Violence Against Children Survey Haiti: Report for the Comité de Coordination on Focus Groups to Inform the Survey

Violence against Children Survey (VACS) Haiti Report for the Comité de Coordination Focus Groups to Inform VACS Haiti Conducted July 2011 Julia Smith-Easley, MPH, CHES CDC International Emergency and Refugee Health Centers for Disease Control and Prevention (CDC) The Interuniversity Institute for Research and Development (INURED)  Findings of Focus Groups to Inform the Violence against Children Survey (VACS) in Haiti Table of Contents Page Executive Summary…………………………………………………………………………………………….3 Background ............................................................................................................ 8 Purpose ................................................................................................................ 10 Lead Institutions Conducting Qualitative Study ................................................... 10 Methods ............................................................................................................... 11 Results 1. Perception of Household and Family Pre- and Post-Earthquake………….12 2. Recall of Events ....................................................................................... 13 3. Perception of Authority and Authority Figures....................................... 14 4. Children in Situations of Domestic Servitude ......................................... 15 5. Experiences of Violence .......................................................................... 17 6. Drug Use .................................................................................................. 23 7. Sexual Health .......................................................................................... 24 8. Condoms ................................................................................................. 25 9. Sexual Taboos ......................................................................................... 26 10. Services ................................................................................................... 27 Discussion and Recommendations ....................................................................... 29 Limitations and Strengths ..................................................................................... 35 Conclusion ............................................................................................................ 36 Acknowledgements .............................................................................................. 36 References………………………………………………………………………………………………………..37 Focus Group Guide – Children and Youth ............................................. Appendix A Focus Group Guide – Parents and Practitioners ................................... Appendix B Page 2 of 64 EXECUTIVE SUMMARY Background Violence against children is a global human rights concern that affects millions of children worldwide. In addition to immediate injury and trauma, children who experience physical, emotional, and sexual violence suffer both short and long-term health and social consequences. These include sexual and reproductive health problems, mental health issues, social ostracism, and increased incidence of chronic disease in adulthood. The gravity of these issues indicates the critical need to understand the magnitude and nature of violence against children in order develop effective prevention and response strategies. On a worldwide index of 60 failed states, Haiti ranked 12 behind such countries as Sierra Leone and North Korea, increasing the vulnerability of all children to violence. Throughout the past decade, Haiti has experienced deteriorating economic, political, and social conditions. In addition, there are a large proportion of children who may be particularly vulnerable to violence because many are either orphans, not attending school, or working as unpaid domestic servants. Although there are no nationally representative data on the prevalence of violence against children in Haiti, available studies done prior to the January 2010 uncovered high incidence of child victimization in Port-au-Prince, particularly among girls. The earthquake further disrupted the political and social landscape of Haiti and may have exacerbated the problem of violence against children. Chaotic conditions and breakdown of social infrastructure, separation from parents or parental death, and displacement of families have further increased the vulnerability of children in Haiti; it is estimated that 500,000 children currently live in extremely vulnerable circumstances. In order to better address this problem, the Comité de Coordination, consisting of the Ministries of the Government of Haiti, members of the United Nations, and international and local civil society organizations in collaboration with the United Nations Children’s Fund (UNICEF), the Interuniversity Institute for Research and Development (INURED), and the Centers for Disease Control and Prevention (CDC), are providing guidance for a nationally representative violence against children survey (VACS) in Haiti. The proposed study will describe the magnitude, nature, and potential risk and protective factors of violence, especially sexual violence, against children, as well as associated health outcomes. To inform and strengthen the planned VACS Haiti, a qualitative study was conducted. The main objectives of the study were to: Identify types of violence against children, with a particular focus on sexual violence, that may be common in Haiti and the circumstances under which they may occur Identify correct and understandable terminologies and clarify various concepts that will be used in the questionnaire Identify specific cultural perceptions and practices relevant to violence against children that may be unique to Haiti Summary of Methods The qualitative study was conducted in neighborhoods of greater Port-au-Prince, Haiti from July 8-11, 2011. Page 3 of 64 Qualitative teams were selected by INURED and trained by INURED and CDC staff. Recruitment of participants occurred in five neighborhoods of greater Port-au-Prince in order to obtain a sample with varied social and socioeconomic backgrounds. A total of nine focus groups were conducted separately among male and female children and youth aged 13-14 years, 15-17 years and 18-24 years; mothers and fathers of children in this age group; and practitioners who work with youth. Groups were segregated by gender and age group, and neither parents nor providers involved in focus groups had any connection to participating children. INURED staff obtained parental consent for all child participants, and all participants provided their own verbal consent before the start of the focus group. Focus group questions concentrated on determining the child’s perspective on subject matter areas with relevance to VACS, including questions both directly related to violence against children and questions formulated to improve the comprehension and acceptability of the quantitative questionnaire. These areas were: 1) the perception of what constitutes a household pre- and post-earthquake; 2) recall of events; 3) perception of authority and authority figures; 4) children in situations of domestic servitude; 5) experiences of violence, with a particular focus on sexual violence; 6) drug use; 7) sexual health; 8) condoms; 9) sexual taboos; and 10) services for victims of physical and sexual violence. Participants were informed not to provide any personal information about themselves or people they know, however when personal experiences were provided by choice, they were included as part of the results. All sessions were conducted in Haitian Creole, and were recorded, transcribed, and translated into English in Haiti. Analysis of qualitative data was completed by trained research personnel from CDC and academic institutions. Key Findings In brief, the participants reported the following key results: The definition of the household has changed since the earthquake as a result of family separation and displacement, especially into camps. This has implications on child vulnerability due to reduced parental supervision and multifamily cohabitation. Participants recall dates and events by traumatic experiences (earthquake, cholera outbreak), political occurrences (riots, presidential terms), public celebrations (holidays), and births and deaths. Authority figures have a high measure of influence over children, which may be misused in an abusive manner. Authority figures were identified as parents and older relatives, teachers, political and religious figures, or those with money or power over others; the ability to inflict punishment was an important marker of authority. Physical, emotional, and sexual violence against children is perceived to be widespread. It was agreed that all forms of violence impact both boys and girls, but respondents tend to believe that physical violence disproportionally impacts boys while sexual violence disproportionately impacts girls, including very young girls. Children in situations of domestic servitude were reported to be at increased risk of violence and neglect. These children were generally not considered to be part of the household by the families for whom they work. Respondents indicated that extra precautions need to be taken when conducting the study in order to avoid targeting them for further violence. Page 4 of 64  It was reported that violence can occur any time, but evenings, holidays, and elections are most dangerous. Streets, camps, and other areas with tents were identified as especially dangerous places for children. According to respondents, the earthquake and resulting displacement has resulted in increased sexual violence and transactional sex. Parents believed that strangers were the primary perpetrators of all types of violence; however, children believed that parents were the primary perpetrators of physical and emotional violence against children. The distinction between forced, coerced, and transactional sex was not always clear, nor were they similarly described by all respondents. Participants largely did not understand terms used to describe sexual coercion, such as “harassed, “coerced” and “tricked,” but they were familiar with the varying circumstances under which sexual coercion or unwanted sex occur. Use of marijuana and cocaine are common in Haiti and are well recognized by children. Participants had very low familiarity with genital health terms and symptoms. Knowledge of condoms was universal among participants but acceptability of children using condoms is low as a result of stigma associated with sexual activity among youth. Children caught with condoms are reported to be physically punished by parents. Issues of homosexuality and non-traditional sexual practices, such as felatio, were identified as taboo topics in Haiti. Children and parents rarely discuss issues related to sexual behavior and sexuality, and such discussions are reported to result in physical punishment from parents. Participants stressed the importance of interviewers being age and gender-appropriate and building trust with respondents in order to obtain accurate responses for sensitive topics (sexual taboos, sexual violence). Children recommended being clear and direct when discussing sensitive issues, including sexual violence, sexual taboos, and condom use. It was widely known that medical services are available for victims of sexual and physical violence; knowledge of psychosocial, legal, and protection services are low although providers reported that they are available in Port-au-Prince. Key Implications of the Findings for Survey Design and Implementation The findings suggest that physical, emotional, and sexual violence against children are common in Haiti and may have increased since the January 2010 earthquake. It is therefore both critical and timely to conduct a nationally representative study on violence against children to accurately describe the magnitude and nature of the problem. Although respondents indicated the varying (and sometimes contradictory) circumstances under which they believed violent incidents occur, a nationally representative study is necessary to accurately describe the problem in order to develop and guide effective prevention and response strategies. It is Page 5 of 64 important that the study also collects information about transactional sex and the most recent violent incidents, in particular regarding sexual violence, since the findings suggest that the prevalence and nature of these events have changed since the earthquake. The findings of this qualitative study indicate that a national quantitative study of violence against children should be successful in obtaining accurate responses to questions on a variety of sensitive topics from children in Haiti. First, participants in the focus group discussions were largely willing to discuss a number of sensitive topics and openly shared personal experiences of violence despite being asked not to. Second, participants identified several feasible strategies that, if incorporated into the study, would help child respondents feel safe and at ease in order to provide truthful responses. These included identifying enumerators who appear young, are gender-appropriate, and prioritize building a rapport with the respondent before highly sensitive questions are asked; this result therefore stresses the importance of the selection and training of enumerators. In addition, emphasis should be placed on confidentiality and privacy during the administration of the interview. Lastly, the questions themselves should be asked directly and clearly, after having established good rapport. Results indicate that questions related to violence, particularly sexual violence, should use explicit language that is clear and direct. Children themselves recommend the use of direct and clear questions when discussing these sensitive issues to help obtain more truthful responses. In addition, in order for the study to measure the problem accurately, it is critical to use precise language that will be interpreted similarly by all respondents. Many respondents described the various forms of sexual violence dissimilarly, did not have clear distinctions between the various forms of sexual violence, or did not understand various terminologies typically used to reference sexual coercion. The findings reveal that child participants identify parents as the most common perpetrators of violence. Moreover, physical violence was reported to be a common result of children found discussing sensitive topics related to sexual behavior and sexuality. This again emphasizes the importance of confidentiality and privacy during the administration of the interview. As an extra measure of caution, careful consideration should be given to the parental/caregiver consent form in Haiti in order to protect children, especially child domestic servants, from possible violence from their parents or caretakers. The parental/caregiver consent form therefore should be careful in how sensitive topics included in the study are addressed, particularly those related to violence or sexual behavior, including condom use or HIV testing. It is also important for the quantitative study to assess potential cofactors associated with survivors of childhood violence, such as substance abuse, high-risk sexual behavior, and acquisition of sexually transmitted infections (STIs). Results indicate that questions on drug and condom use should be understood well by respondents but genital health and homosexual behavior may be problematic to assess. However, with appropriately selected and trained enumerators, it may be possible to solicit more accurate responses. In addition, findings suggest that decreased parental supervision as a result of displacement and increased vulnerability of children to recognized authority figures may be important cofactors to violence in the post- emergency phase. Respondents’ accurate recall of events indicates that chronology of experiences of violence after the earthquake should be accurate with help of a calendar of events. Results further suggest that a gap exists between existing psychosocial, legal, and protection services and Page 6 of 64 public knowledge and utilization of these services after experiences of violence. Although medical services were recognized as a resource in this population, the extent to which they are used in situations of violence is not known. It will thus be important to measure awareness and utilization of these services in Haiti to develop effective response strategies and improve access to critical care for victims of violence. This report represents a unique collaborative effort to conduct formative research for a nationally representative study on violence against children. Although the information presented here cannot be generalized to all children in Haiti, the results can still effectively inform question development, survey design, and training of data collectors in the field. These findings provide important insights into the feasibility of carrying out the survey in a particularly challenging post-emergency setting and inform on the cultural appropriateness and acceptability of discussing such sensitive topics among children. The findings also highlight the need for both a better understanding of the scope of violence against children and services available to victims of violence in this setting. The goal of VACS Haiti is then to collect this much-needed information with the intention of effectively using the findings to define the gravity of the problem and to inform a national prevention and response strategy. Key Recommendations for VACS Haiti Enumerators should be selected based on gender-appropriateness, youthful appearance, and ability to build rapport quickly with respondents. Questions on sensitive topics should use explicit language that is clear and direct. Topics that could easily be misunderstood should be explained in careful detail; this includes questions on the distinctions between forced and pressured sex, genital health and STI symptoms, and services that may be used following experiences of violence. Particular attention must be given to the population of domestic servants in order to identify them as potential study participants in household listings and to ensure their protection and safety. A calendar of events for events following the January 2010 earthquake should be developed for ease in determining accurate dates of experiences of assault. In addition to informing the national quantitative study on violence against children, findings from the qualitative study can be utilized more immediately to begin to develop intervention strategies to better address this problem. Some examples of intervention strategies are provided below: 1. Develop information, education, and communication (IEC) campaigns to educate parents and caregivers about the negative consequences of parents and caregivers abusing their children, even if these incidents are considered acts of corporal punishment. 2. Strengthen promising programs that prevent child sexual abuse. Such programs may include those that strengthen the relationships between mothers and their children; improve communication between parents and children on sexual and reproductive health and violence; and/or improve social, health, and economic asset building of high risk adolescent girls and boys. 3. Better publicize the availability of existing services for victims of violence to improve knowledge and utilization. 4. Consider policies and laws regarding child labor, including children in situations of domestic servitude. Page 7 of 64 BACKGROUND Violence against children is a global human rights violation that spans every country worldwide and affects millions of children each year. The impact of violence against children goes far beyond the initial incident, and victims of emotional, physical, and sexual violence can experience severe medium to long-term health and social consequences [1]. Common health-related outcomes of sexual violence, in particular, include unintended pregnancy and gynecological complications, infection with HIV and sexually transmitted infections (STIs), mental health problems such as depression and post-traumatic stress disorder (PTSD), and social consequences such as ostracism [2]. Further, neurobiological and behavioral research indicates that early childhood exposure to violence can affect brain development and thereby increase the child’s susceptibility to a range of mental and physical health problems that can span into adulthood including anxiety or depressive disorders, cardiovascular health problems, and diabetes[3-5]. Given the serious and lasting impacts on children, it is critical to understand the magnitude and nature of violence against children in order to develop effective prevention and response strategies. Without integrative research into the breadth and depth of the problem and investigation into why violence is so highly stigmatized and hidden, current response options may be ineffective, leaving children with limited access to services and protection. On a worldwide index of 60 failed states, Haiti ranked number 12 behind such countries as Sierra Leone and North Korea, [6], consequently making all children more vulnerable to violence and abuse. Over the past decade, deteriorating political, economic, and social conditions have resulted in a high level of vulnerability among Haitian children [7]. The 2006/2007 Demographic and Health Survey found that 5 percent of girls and 3.9 percent of boys aged 10-14 were not in school and not living with either parent [8]. Furthermore, it was estimated that 380,000 children were orphans and 150,000-500,000 children lived with non-relatives as unpaid domestic servants [9, 10]. Children who are not attending school, are orphans, or working as unpaid domestic servant constitute a particularly vulnerable population of children. Haiti thus deserves particular attention due to the variety of social, political, and economic factors that may be influencing the prevalence of violence. Prior to the January 12, 2010 earthquake, several studies done in Haiti concluded that violence is a common occurrence, particularly among girls. A study in 2004-2005 found that more than half of the estimated 35,000 sexual assaults in the Port-au-Prince area were among girls under 18, and domestic servants were a significant proportion of all victims [11]. Another study found that, among victims of sexual violence seeking help in a Port-au-Prince clinic from 2000-2008, 42% were found to be under 18 years old, and nearly half of these were 12-14 years old [12]. However, these figures can be considered underestimates due to the established discrepancy between numbers of children who experience violence and numbers of those seeking services [13]. Finally, a study of youth violence in Cité Soleil, a slum community of Port-au-Prince, found high rates of gang violence among youth, and young people reported that violence was a driving force in their lives [14]. The situation in Haiti was critical before the earthquake, and the disaster has likely worsened the issue of violence against children in Haiti [15]. Related research suggests that violence against children is likely to increase following natural disasters as a result of social disruption, stress, and increased vulnerability of youth [16, 17]. Parental loss of life or economic standing, separation from family members, crowding in camp Page 8 of 64 conditions, and lack of safe places to sleep and play can influence a child’s susceptibility to violence. Moreover, children who are in chaotic or unstable environments and lack adequate supervision are at increased risk for sexual violence specifically [18]. The situation with an already vulnerable population of children in Haiti was exacerbated following the earthquake, which led to a complex, protracted humanitarian crisis with significant societal disruption over a large population. UNICEF estimates that 1.5 million Haitian children have been affected by the earthquake with approximately 500,000 children living in extremely vulnerable circumstances [19]. The subsequent cholera outbreak and bursts of political violence preceding a transition to a new government have caused further instability in the country, and potentially child victimization. Anecdotal evidence indicates that children have been more likely to experience violence and sexual violence following the earthquake, cholera outbreak, and political problems [20-22]. Despite the range of studies from both before and after the earthquake, there have been no nationally representative studies to date investigating the scale, magnitude, or social epidemiology of violence against children in Haiti. Furthermore, there is very little in the literature about Haitian children’s perceptions of violence. Although collaborations between governmental, international and local agencies are now addressing violence, the lack of nationally representative data poses a significant barrier to the development of effective program prevention and response strategies. To this end, key Ministries to the Government of Haiti, members of the UN, and international and local civil society organizations have come together to form the Comité de Coordination in collaboration with United Nations Children’s Fund (UNICEF), the Interuniversity Institute for Research and Development (INURED) and the Centers for Disease Control and Prevention (CDC) to galvanize support for and provide guidance on the national violence against children survey (VACS) in Haiti. The key objectives of this quantitative national study are to: Describe the epidemiologic patterns of sexual and other forms of violence against children Identify potential risk and protective factors for sexual violence and other forms of violence Assess the health consequences of sexual violence and other forms of violence Assess the knowledge and utilization of medical, psychosocial, legal, and protective services available for victims of sexual and physical violence Assess the impact of the January 12, 2010 earthquake and the complex, protracted humanitarian crisis on sexual violence and other forms of violence Identify areas for further research Make recommendations to the Government of Haiti and international and local partners on developing, improving and enhancing prevention and response strategies to address violence against children as part of a larger, comprehensive, multi-sectoral approach to child protection. CDC has demonstrated technical expertise in conducting national violence against children surveys in developing countries, including Swaziland, Tanzania, Kenya, and Zimbabwe. We expect that the success and impact of these surveys will be replicated in Haiti. Since this is the first time a national VACS study will be implemented outside of sub-Saharan Africa and due to the unique challenges of conducting VACS in a post- disaster setting, a qualitative study was conducted in Haiti in July 2011 to inform the national quantitative study and guide the appropriate development of the questionnaire. The results of this study are summarized in this report. Page 9 of 64  PURPOSE To inform and strengthen the planned VACS Haiti, a qualitative study was conducted. The main objectives of the study were to: Identify types of violence against children, with a particular focus on sexual violence, that may be common in Haiti and the circumstances under which they may occur Identify correct and understandable terminologies and clarify various concepts that will be used in the questionnaire Identify specific cultural perceptions and practices relevant to violence against children that may be unique to Haiti To address study objectives, the following topics were explored using a focus group methodology: The acceptability of children and youth participating in a survey on violence Definition of a household and how this changed after the earthquake Identification of recognized categories of authority figures among Haitian children Haitian children’s recall and memory of important events and the utility of developing a calendar of events The role and perception of children in situations of domestic servitude in Haiti Knowledge and exposure to substance abuse among Haitian children Understanding of sexual health terminology among Haitian children Knowledge and attitudes about condom use in Haiti Sexual taboos in Haitian society and strategies to discuss sensitive topics with youth The types of services available for children who have experienced violence LEAD INSTITUTIONS CONDUCTING QUALITATIVE STUDY CDC, in collaboration with INURED, jointly conducted the qualitative study to inform VACS Haiti. INURED is a research and higher education institute based in Haiti. The institute’s mission is to contribute to the development of high-level research and scientific training in Haiti with the aim of improving the educational, socioeconomic and political conditions of Haiti’s people. INURED seeks to accomplish its mission through three types of activities: higher education research and training; production, centralization and diffusion of knowledge; and community intervention. [23] CDC is a United States federal agency within the Department of Health and Human Services. CDC’s mission is to collaborate to create the expertise, information, and tools that people and communities need to protect their health – through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. CDC seeks to accomplish its mission by working with partners throughout the nation and the world to monitor health; detect and investigate health problem; conduct research to enhance prevention; develop and advocate sound public health policies; implement prevention strategies; promote healthy behaviors; foster safe and healthful environments; and provide leadership and training [24]. Page 10 of 64  METHODS A qualitative research methodology was used to allow for open-ended exploration of the variety of experiences among young people in Haiti. Focus groups are one qualitative technique that can be used to efficiently gather information from individuals within vulnerable populations, such as children in post- emergency settings. The group forum allows input from several individuals at once and allows participants’ responses to build on each other. This emphasis on interaction among group members also allows participants to explore difficult subjects among the group. The study team consisted of three qualitative teams, each with one facilitator, one note taker, and one observer. These qualitative teams were recruited and selected by the INURED Project Coordinator. A 2-day training led by instructors from CDC and INURED was held with the qualitative teams prior to recruiting participants and conducting focus groups. Study participants were then identified and recruited by INURED from home and camp settings in Cité Soleil, Bel-Air, Martissant, Delmas 2, and Place Boyer, all neighborhoods of greater Port-au-Prince, with the intent of obtaining participants from a variety of social and socioeconomic backgrounds. An equal number of participants were recruited for each group in all locations, resulting in approximately 7-12 participants recruited per focus group for a total of 64 participants. INURED staff obtained parental consent for child participants, and each parent received a letter from INURED to ensure the child’s safety, proper treatment, and respect for their rights. Transportation was provided by INURED for focus group participants and an equivalent allowance was provided to mothers, fathers, and practitioners. A total of nine focus groups were conducted with females and males between the ages of 13-24 years, parents of similarly aged children, and practitioners who work with children and youth within this age range. Participating parents and providers had no connection to participating children. From July 8 – 11, 2011 three focus groups were held each day, and qualitative teams met daily to coordinate activities and provide summaries, discussions and debriefings. Focus groups were separated by gender and age as indicated in Table 1, and focus group facilitators were gender-matched to child and parent groups. All focus groups were conducted in Haitian Creole and lasted 1-2 hours. Table 1: Focus group schedule of participants Fri – July 8, 2011 Sat – July 9, 2011 Mon – July 11, 2011 Girls 13-14 (6 participants) Girls 15-17 (5 participants) Mothers (5 participants) Boys 13-14 (8 participants) Girls 18-24 (8 participants) Fathers (5 participants) Boys 15-17 (8 participants) Boys 18-24 (12 participants) Practitioners (7 participants) Focus groups began with an introduction and overview of the qualitative study, followed by a review of the verbal consent form. At the time, participants were informed not to provide any personal information about themselves or people they knew. However, as rapport developed, respondents sometimes offered personal information and this was included in results. Focus group questions concentrated on the child’s perspective on 12 subject matter areas (see Appendix A). For parent and provider groups, participants were asked about the questions as they apply to children in the community (see Appendix B). At the conclusion of each group discussion, participants were provided with details about local available resources for themselves or others. Page 11 of 64 All focus group discussions were conducted in Haitian Creole, and were recorded, transcribed, and translated into English in Haiti to provide primary source data for qualitative analysis. Analysis of the data by qualified research personnel including an anthropologist with two decades of experience in Haiti produced line-by-line coding of the transcripts using inductive and deductive codes. This was followed by discussion for concurrence of codes and classification of all recordings using the guideline questions and conceptual frameworks as initial categories. CDC International Review Board (IRB) and in-country ethics review through the National Ethics Committee and INURED designated this study as not involving human subject research and therefore not IRB review. RESULTS Perception of Household and Family Pre- and Post-Earthquake The definition of the household is important to correctly identifying eligible children in the home at the time of the survey. Further, it is important to determine if the earthquake had a significant effect on household composition. To address these issues, participants were asked who they currently live with and how they generally think of a household or family. They were also asked how these definitions and concepts have changed after the earthquake. Respondents mostly considered a family to be a nuclear unit consisting of a mother, a father, and children. When prompted, most respondents agreed that a family could include other relatives, although a distinction was made between a nuclear “family” and extended “kin” among some participants. Several groups, particularly children, included friends and neighbors and cited the multiple support networks they considered as part of their immediate family. I can say that in my community, we have three types of family. You have your biological family…. The second one is your family in Christ, your Christian brothers and sisters, which usually calls you brother or sister, and the third one is the person that surrounds you, your friends for example. (Boys 18-24) There was some difficulty distinguishing between a family and household, indicating that this might not be a meaningful distinction in this population. When asked about this issue, most participants reported that their own household consisted of their immediate family, but when prompted it was revealed that they lived with extended family members, “neighbors”, boyfriends, and friends. This confusion was alleviated when respondents were asked who they lived with rather than who was in their household. All respondents had very strong ideas of how families and households had changed after the earthquake. While not all respondents were separated from their families, it was widely agreed that the main effect of the earthquake was to disrupt the home and split up families. This was reported to occur most frequently when the family was displaced due to damage or destruction to their home, particularly into the camps or into areas with tents. A variety of problems were attributed to this phenomenon, most commonly an increase in the vulnerability and/or promiscuity of girls and criminal activity among boys. With children living under a different roof, parents lost their capacity to protect and subsequently lost authority over the behavior of children, resulting in the child becoming independent earlier than normal. Page 12 of 64  The earthquake caused everybody to be divided. In the camps we find each child living in a tent and the mother and father is living in another tent, so the household is really divided. (Fathers) Everything is spread out under tents. Multiple young women have gotten pregnant, children 13-14 are pregnant, and so living under the tents changed the concept of family. You live under a tent, the child has no room to stay so you send him or her under another tent, and so … from there the child begins to wander around. Thus, the child becomes an adult before his or her time. This becomes a problem for the family…. Before the earthquake we used to have control over the child. After the earthquake families are broken and misery increases. (Mothers) Children and providers also reported that it has become more common and acceptable for multiple families to live together, thus increasing reliance on people outside the traditional family unit. This belief was not expressed among parent groups. After January 12, I’ve come to trust these people more, because after January 12 the way we’ve been living with one another, all that we shared … we all became aware that united we stand, divided we fall, and we are all brothers and sisters, so I’ve realized that it was way more important than what I had in mind. My entourage is my family, and I trust them more. (Boys 18-24) Recall of Events Participants were asked how they remember important events. The recall of events plays an important role in retrospective questioning. It is therefore important to define how participants might remember important events and whether these recollections are chronologically accurate. According to participants, cutting across all age groups and genders, recall of dates and events is marked primarily by catastrophes (floods, the earthquake, etc.), public celebrations, past presidents’ terms, or simply through mental “markings” of certain days such as the day a person was born or died. Some groups referred to looking at calendars or documents such as birth certificates. Another example that helps people recall the date of a specific event, and said to be more common to rural households, is the use of agricultural harvesting seasons for coffee, maize or beans. Nonetheless, all participants expressed the idea of how things are “engraved” in the memory. I think a person can use a calendar . . . [or] with their memory. When I say their memory, I mean it can be engraved in that person’s memory. (Providers) Events people remember easily in the community are natural catastrophes that cause lots of damage. . . With public events, I saw that you . . . focus on elections only, you could also talk about Christmas. (Boys 18-24) Recall of events is often marked by trauma, as one mother indicates: Yes, usually when an event that was good for us is followed by one that did not do us any good, we remember it. (Mothers) Weaving both trauma and catastrophe into one, participants from the Providers group affirmed that everyone would remember the cholera outbreak following the earthquake in 2010. It is important to note that Page 13 of 64 discussions on recall did not address personal traumatic events (such as sexual assault) but rather more publically shared events. Perception of Authority and Authority Figures In order to provide a complete list of potential perpetrators of violence as part of the response choices for the questionnaire, focus group participants were asked who they considered to be authority figures, how this authority was conferred, and how a person might lose their authority. The main persons reported as authority figures across all groups were parents and other family members, political and religious figures, teachers, police, and people with wealth. However, the perceived source of this authority varied widely by age and gender among the respondents. Some described the basis of one’s authority as rooted in an acknowledged respect for the figure’s position and authority. With this view, parents have authority because of their role as a caretaker, politicians have authority because they were entrusted with governance by the people and the State, and other adults could have authority as “moral figures” in the community by taking an active role in a child’s upbringing or education. This would include, for example, “someone who is telling us we are on the right path” (Boys 15-17). Age and maturity were also important components of this viewpoint among children, whereas among adults, the ability to provide protection was deemed important. My mother. If she asked me to do something I do not make a fuss, I just go and do it. She is my mother after all and I can’t misbehave. (Girls 13-14) In the community that I live, I consider my president, the senators and the deputies, the mayor that I voted for…. Since it’s someone that I send to do the job in my place, I have a lot of respect for that particular person…. I also consider as authorities the grownups because they were born before me, they can teach me lots of things about life. I think they have an important role in one’s life. (Boys 18-24) I consider people who have a certain authority, people that do what he or she is supposed to, and [who] also respect themselves. (Boys 18-24) According to participants who ascribed authority to be based on respect, it was felt that people can lose their authoritative status by losing this respect, being corrupt, or for failing to uphold their commitments to the community. Examples include shamed public figures and parents who were maimed or injured in the earthquake and can no longer provide for their children. When parents cannot pay the tuition or put food on the table or take care of his children, he automatically loses this authority. That also happened after the earthquake. When a parent loses a limb and you have to see his young child taking care of them, the parent can no longer discipline the child. (Providers) An alternative belief posited that the source of authority comes from one’s measure of power over others. This was a unique perspective among adult males and older boys and was not expressed among other groups. For these respondents, authority figures are those that have the ability to control and make decisions for other people, ranging from family members to the population in general. Fathers or husbands, politicians, religious figures, and police are people seen to possess this kind of authority. Notably most of these authority figures Page 14 of 64 refer to males, reflecting gendered norms. Specifically, as related to children, this type of authority would constitute the ability to influence children or tell them what to do. This kind of authority was not perceived to be affected by the opinion or agreement of others. Instead, this type of authority can be lost if someone loses their power over others through weakness, loss of public office, or loss of wealth. If I get married to a girl, I am her commander…. Because she is my wife and I got married to her, I have an authority over her and in the household. (Fathers) The archbishops, the fathers, and even virtually the voodoo priests, because they are a certain [type of] authority figure. For example, the Pope who represents God on Earth, he has a lot of power, the whole world. In the five continents he is a powerful figure. (Boys 18-24) A person with power is the number one of a country. The number one of a country is the president. It’s Michel Martelly, so he has a lot of power, he can do whatever. (Fathers) Me I say for children it’s whoever can exert some kind of pressure on the children, whether it’s physical or psychological, even in school. If there is a person that is always giving pressure who is saying I’m you big brother, your boss. I won’t hit you, but you have to be nice to me. (Providers) As a variation of the previously described viewpoints, several of the groups described authority figures as those with the ability to punish or instill fear. This opinion was seen specifically among children (13-17 years) of both genders. Among respondents who held this opinion, persons with this type of authority were described as the most feared people in the child’s life and included parents, family members, and police. Physical punishments especially were described by these respondents as a common means to exert one’s authority over a child. They have authority when I do something wrong they can punish me. But if it is the President he can punish me by law. (Girls 15-17) Any person who is older has authority over you. If they tell you not to do something and you still want to do it they might hit you for not listening. (Boys 15-17) One day, my mother asked me to mop the floor. I hold her I would do it when I get back from an errand…. She got up and hit me over the head with a pan. I fell unconscious. When I woke up my mother was throwing water on me to wake me up and I was bleeding out of one ear. (Girls 15-17). Children in Situations of Domestic Servitude Participants were asked about the life of child domestic servants in Haiti and their role in the household in order to better determine if this population is at higher risk for violence. The most common names for these children were “sentaniz” for a girl and “ti joel” for a boy. The word restavek was also commonly used, but this was reported to be a derogatory term referring to “child slaves.” Other less common names for servants include ti jocelyn, san famni (no family), ti bon (little maid), tifi lakou (little girl of the compound), domestic (domestic), tisal (little dirty one), tisalop (little prostitute), ti sansal, ti malpwop (little shameless person), and kokorat (hood rat). Many participants reported that the servant was generally called one of these names or Page 15 of 64 something more insulting and that it was unlikely to hear the child’s name ever spoken in the home. According to respondents, child domestic servants are typically between 8 and 15 years of age. According to respondents, the role of the domestic servant in the home is to work without compensation and do all chores, many demanding physicality beyond the means of small children. Girls are responsible for cooking, cleaning, laundry, and taking care of the other children in the house. Boys are responsible for errands outside of the home, such as getting water and marketing. In many groups, it was reported that the servant works long hours daily while the homeowners and other children in the house have no responsibilities within the house. They clean and get water. They make them work very hard. They even bathe the children of the homeowner, cook the meals. If the person is mean they will have the child do all the chores around the house. The homeowner just lies around like a fat cat and the child does everything including throwing away the trash. (Boys 15-17) They are the motor of the house. Everything depends on the ‘sentaniz’. The later they sleep, the earlier they wake, they have so much work and no leisure time. For me it’s another form of slavery. (Providers) Among all participants, it was universally acknowledged that children in domestic servitude are in a position of extreme vulnerability in Haitian society. They are under the full jurisdiction of their employers and risk being abandoned or beaten for any infraction. Circumstances reported to lead a child to become a domestic servant are the death of a parent, the poverty of the parents, and the inability of the parents to care for their children. One respondent added that if parents in a rural area wish their child to have a better life and access to good schools, they might mistakenly send their child to be a servant in the city, resulting in a much harder life for the child when they arrive and are subjected to potentially severe mistreatment by household members. It was a common theme among respondents to speak disparagingly about the treatment of the servant by the home-owning family. These people were referred to as the “master,” and a myriad of abuses were reported by all groups. Descriptions of emotional abuse and neglect included the child servants being kept from attending school, forced to sleep on the floor or in a shed, not having enough to eat, and not having suitable clothes. It was also reported that child servants are frequent victims of physical and sexual abuse as a result of their accessibility to the homeowner and other males in the home and their lack of access to legal or police protection. Physical punishments included being beaten while naked and being forced to kneel on the ground or on gravel. Respondents also reported that child servants are vulnerable to sexual violence. Perpetrators of sexual violence included any males within the home including male children, in addition to neighborhood boys who know the servant has no familial protection. Respondents agreed that the homeowners should not neglect and abuse the servant in this way but should rather treat them like their own children. *The master’s+ role is to hurt the child, beat them and not feed them until they finish their chores …. The child has to eat what is left in the pot. They are not allowed to eat on a table. (Boys 15-17) Knowing that the slave was considered as an object, the master has a life and death power over that child-slave. No one can say anything about it…. He can decide if he’ll send that kid to school or not. He can treat him like a human being or like a slave. It will only depend on that person’s good heart, who Page 16 of 64  will decide if he will take good care of that child or treat him like a slave. (Boys 18-24) They have them sleep in the street instead of inside the house. They do not take care of the child, they do not comb the child’s hair or send them to school. The child would sleep on the porch or with the animals. They would feed this child with the animals and like the animals. They would leave the small child alone in the house at night knowing they are scared of all sorts of things in the dark. (Girls 13-14) In keeping with these reports of abuse, participants discussed the resulting mental health issues of the child servants. These children are subject to discrimination in society due to their position in the home, and they are thus increasingly vulnerable to violence from the community. Another particularly difficult problem described in groups was the integration of this vulnerable population into general society once they leave work in the home-setting. It was reported that these children typically become homeless and move to the streets where delinquency, promiscuity and prostitution are common. Attempts to seek revenge on the abusive family were also described. Even if these children are properly fed all the abuse affects them even mentally. People would take these children from their family home and promise they will be living in luxury. Instead once they get to their own home they start beating them with a horse whip. A lot of children who live in people home do not go to school and it affects their moral. They feel alone. (Boys 15-17) If he’s in the streets other kids can tease him, hit him, or get into a fight because they’re aware that he’s younger, and that he is not living with his parents, he has no one, not even an older brother that would come and fight for him. (Boys 18-24) All in all, domestic servants were identified as an extremely vulnerable population in Haitian society who are at high risk for experiencing violence during childhood. Experiences of Violence In order to ask children about experiences of violence, it is important to understand how they interpret emotional, physical, and sexual violence in their communities, in their home, and within their differing age groups. The very broad theme of violence was explored from several aspects during the focus group discussions. Respondents were asked what hurtful things can happen to children and youth, what violence they expect to occur among girls and boys specifically, why violence might occur, when and where violence is most likely to occur, and whether incidents of violence had increased since the earthquake. Throughout this discussion, many respondents offered to share their personal experiences with violence and others talked in more general terms. Violence was generally viewed by participants as omnipresent in Haiti and to have peaked over the years during times of political unrest and social disorder. As Haiti rebuilds in the post-earthquake era, violence remains a significant part of the landscape. As one provider summarized: Everywhere where there are people in power, everywhere there are people who want to dominate, [and everywhere] you find violence. Everywhere in the house, the streets, in every community. (Providers) Page 17 of 64 The Circumstances Surrounding Violence: Time, Place, and Perpetrators Children were very specific as to when and where violence takes place in Haiti today. Both boys and girls expressed feelings of vulnerability and these feelings were heightened during the evening hours. Walking alone at night for girls was noted as highly dangerous, but when probed, there was agreement that no time of day is entirely safe for children. For all participants, specific events were marked by both boys and girls as times that violence was more likely to occur, most notably the winter holiday season around Christmas, Carnivale, and elections. However girls emphasized that violence could occur any time. *It’s the+ thieves, we might want to go to school and can’t because of violence in the streets. At night things are even worse. (Boys 15-17). There is no special time of day or season. Whenever they want to they can put their hands on children. (Girls 15-17) They beat them, kill them and rape them. When they are passing by they can just grab them in an alley way in the middle of the day. (Girls 15-17) Violence was also reported to occur in a variety of places, such as the community, the school and the home. Participants reported that violence had increased significantly after the earthquake, and that previously safe activities, such as running an errand for a parent, were now fraught with risks. Both boys and girls described strong feelings of vulnerability in the community. Notably, the streets and tents in resettlement areas were identified as the most dangerous locations. In these settings, girls described being under constant fear of attack. When your mother sends you on an errand and you become a victim in the police and robbers crossfire. (Boys 15-17). If there is a thirteen-year-old child living in a camp, if they go out at night to buy something, sometimes they would get trapped by thugs who can hurt them. (Girls 13-14). Interestingly, there was a wide divergence of opinion on perpetrators of violence between children and parents. While parents unanimously reported that strangers and criminals could be perpetrators of violence, children clearly voiced that parents and other family members were the most common perpetrators of physical and emotional violence. Others reported perpetrators were peers and people with money who might coerce a child into engaging in activities they otherwise would not do. Parents, however, reported that perpetrators of all types of violence against children were criminals or vagabonds (general societal misfits) exclusively, despite admitting that they inflicted corporal punishment on their children. Providers believed that perpetrators of violence could be both the community and family members. Types of Violence by Gender Respondents agreed that both boys and girls are potential and likely victims of violence. Girls reported that boys are victims of theft, kidnapping and killing, and can be involved both as victims and by being pulled in, sometimes unwillingly, as perpetrators. Page 18 of 64  They [the boys] go not knowing they are going to kill someone then they end up killing the person ... and if *they+ don’t have family, they die in prison. (Girls 15-17) Boys conversely characterized girls’ experience of violence as being either a victim of sexual violence, becoming promiscuous, or being subject to unwanted pregnancy, often because they were no longer under parental care. “Moving to the street,” or leaving parental care either by force or by choice, was seen to put girls at enormous risk for sexual exploitation and unwanted pregnancy. Some girls can be talked into leaving home for the streets, most of them do not have a father and their mother does not have the means to take care of them. These girls end up pregnant since they can’t get any support from their mothers they face so many problems that most of them end up having abortions. (Boys 15-17) Physical Violence Girls and boys both referred to physical violence occurring in romantic relationships and between peers, with special emphasis on contexts involving dating or intimate relationships. Bullying or the threat of bullying were both reported to be commonplace among boys, as were disagreements among peers and disputes over illegal drugs. For example, if I disagree with someone and they tell me ‘I will meet up with you later’ it says a lot. It means [he is] getting ready to beat me. When you have a friend and all of the sudden this person starts blaming you for things and start using all sorts of insults. That is hurtful. If someone lies about you, can call you names. (Boys 15-17) However, most remarkable were the frequent comments about physical violence inside of families. Perpetrators were identified as fathers, mothers, siblings, and uncles. Sticks, belts, whips, and other objects were described as typical instruments of beatings. Mothers, specifically, figured centrally in reports of household physical violence. Mothers themselves reported the practice of corporal punishment of children, especially daughters, with punishments including beating and burning their children and forcing them to kneel on the ground or on gravel for long periods. Fathers were referred to as perpetrators of physical violence within the home by both boys and girls, but not as frequently as mothers. In some cases, violence was associated with discussing taboo subjects, such as sexuality, at home. Several girls in all of the age groups talked about how they could be beaten for talking about their boyfriends or being found with condoms as evidence of their sexual activity. It was also mentioned by the adults, and notably the provider group, that the frequency of violence within the home can have long-term impact on both boys and girls. While girls can become promiscuous or become subject to sexual abuse, boys can rather enact the violence they have experienced. [My uncle] would use a leather belt with a buckle to beat me. My mother does not like it when he does so they argue. But when he is drunk and hungry is when he beats me the most that is how he gets rid of all his frustrations. (Girls 13-14). When [my mother] is beating me, if the switch happens to break, she starts to punch, kick and bite. If Page 19 of 64  she happens to be holding a knife she would throw it. I use to fear my father more but when my mother gets in that state I fear her the most. (Girls 13-14) So boys when they see violence, they reproduce violence because that’s the model they have at home. Tomorrow, God willing, the boy becomes the violent husband beating their wives. You see, what I mean is, if someone is raised in an environment filled with violence, they will later reproduce violence one way or another. (Providers) During many of the discussions there were references to other forms of parental corporal punishment, including forcing children to eat hot peppers (or hot pepper oil), placing hot peppers in their vaginas, or by putting pepper oil in the eyes. Girls also described various ways mothers can burn children by placing hot coals in their hands, placing children’s hands on hot coals directly, or likewise forcing a child to hold a hot egg in their mouth with the intention of burning. Mothers indicated that the hot pepper practice was more common in the rural areas but this was not verified by any other groups. There were several references among children and adults to the use of leaves prepared in a powder or liquid form, which are added to food to cause a child to have diarrhea and used as a form of punishment. Finally, there was discussion of parents drugging their children with cough syrup or other medicines to calm them down or get them out of the way. There was little if any discussion around violence in schools but this could be due to the focus group composition, facilitators’ biases or a lack of questions on education. Emotional Violence Emotional violence was also reported to be prominent in the lives of young respondents. Boys mentioned experiences of verbal violence a few times, but girls, particularly young girls, reported this experience frequently. Mothers especially were reported to say “mean things” and make their daughters feel “very badly.” Most noteworthy were girls’ descriptions of their mothers insulting them, making them afraid, and insinuating that they will end up on the streets or that they deserved to be raped. Girls indicate that this sort of ridicule begins as early as 10 years of age and continues throughout adolescence. Girls reported that these comments can have a significant impact on them. Providers also reported that that these experiences can have long-term effects. It is painful to me when my mother tells me that I should get raped and pregnant by these guys in the street. (Girls 13-14) When they call you a dog and treat you badly [it affects you]. Also when they tell you to go and get pregnant by any thug in the street. If a child does not understand they might end up getting pregnant and suffering a great deal since they did not finish school and have no money. (Girls 13-14) You tell him hurtful words, violence can be psychological, you letting him know he will never be anything, calling him a vagabond, you’re hurting his soul. You can beat him and hurt his body, but by not giving him affection, you are making him a bitter person who will commit violence in society. When a parent hurts their child by not giving him affection, he will never learn how to give any love because you can’t give what you never received. (Providers) Page 20 of 64 Sexual Violence Sexual violence, understood as unwanted or forced sex or sexual acts, was reported by participants to be a very common occurrence in Haiti. Incidents of sexual violence were said to occur most frequently in the street or in a tent, although the home was also mentioned as a potential location where sexual violence can occur. Girls, particularly in the 15-17 group, were very conversant on the topic of rape. As one girl expressed, “they can be aggressive,” referring to perpetrators of such acts. After the earthquake and primarily in camps, girls reported a heightened level of aggression and violence. It was often described that tents were high-risk places, especially for girls who lived separately from their parents. In these situations it was not uncommon for one or several men to slip inside and force the girl to have sex. Mothers corroborated this opinion. They can give the kid pressure, tell the kid if “you don’t have sex I’ll kill you. After, they tie you up. It’s not just one person, it can be 5, 6, almost 13 people. (Girls 15-17) They pressure you, intimidate you, some would even use a gun and say if you do not have sex they will shoot you. [They] hold a knife to your side and say if you do not take your clothes off I will stab you. (Girls 13-14) Boys and providers also reported that sexual violence commonly occurred in situations involving the dissolution of the family after the earthquake, among female domestic servants, and during interactions where a woman or girl refuses to have sex. This could occur either in a relationship or on the street as an attempted sexual transaction. This case mostly presents itself when the child loses her/his mother or father. At that moment, the mother has another man. The stepfather then proceeds to rape the daughter or the son, because that happens nowadays. (Providers) You sometime see 14/ 15 year olds in a house being abused by the master’s child, or the master himself since the child has no one they can do whatever they want to her. That child lives with the scars in their head, their body also and he/ she won’t find any pleasure because they are forcing them. (Providers) If they do not do it for money, they get raped. (Boys 13-14) Many of the participants also reported that sexual violence disproportionally affects girls as opposed to boys solely based on their female status and the resulting power differential in Haitian society. In reference to the lack of protection and resulting vulnerability of female children, “a girl is always more neglected than the boy” by virtue of her gender alone. There were few references to boys suffering from sexual violence, although this could be due to the sensitive nature of the topic. A provider summarized the vulnerability of girls due to their gender by reporting that ‘sex,’ referring to a woman or girl’s sexuality or more broadly her sexual assets, leads to both physical, emotional, and sexual abuse and violence. They prepare the hot spices and they say it is so that it may stick or so that it may be thrown in the eyes or in the mouth or in other place because most of the time in the Haitian community when they want to humiliate a women whatever she age may be they use her sex in order to do so. They also use her sex as a mean of exchange as in I have to sleep with you in order to give you a job. (Providers) Page 21 of 64 Societal reactions to rape were asked of all participants and responses varied. Young boys (13-14 years) spoke of strong peer pressure among female friends to make survivors of rape feel bad by insinuating that the girl deserved it or even went ‘looking for it’. Older boys (18-24 years) also noted the intense peer shame that can result from a rape, indicating that girls who suffer as survivors can lose their reputations and be shunned by peers. A girl who had been gang raped suffers even greater shame. The community sometimes puts the person in quarantine. This could lead [a]young lady to feel discouraged. . . This can cause a person to have mental problems, the way to avoid that is to get moral support, attention from her friends and family. (Boys 18-24) Let’s say if I was in love with that girl . . . *and+ there are 4 other men who had raped that girl, this could discourage you. I will tell you that I was wrong, and the thing I was waiting for is no longer here. I could say to myself 4 other men did that to her. There’s absolutely no hope. I’d probably love her very much, but after what happened I probably wouldn’t appreciate her that much. (Boys 18-24) In order to help researchers correctly formulate questions around this clearly stigmatizing issue, facilitators asked the group: How can I ask someone your age about forced or unwanted sex in order for them to tell me the truth? Young girls in the 13-14 years group suggested asking in a straightforward manner. Other respondents confirmed that asking questions directly would likely open girls up to ‘admit’ if in fact they have been victims of forced sex. You could ask why, did they have sex with so and so. What did they ask you? Why did you accept to have sex with that person? (Girls 13-14) Sexual Coercion Issues around sexual coercion, as distinct from physically forced sex, were discussed in considerable detail with focus group participants. Definitions of coerced sex were largely voiced by adults rather than youth and were framed around sex without consent, forcing someone to do something they would otherwise not do, or “being greedy.” The child groups who most strongly voiced their perceptions of sexual coercion issues of sex against one’s will were girls and boys (13-14 years and 15-17 years), perhaps because this age cohort has less sexual experience or feels the most vulnerable. Boys perceived ‘sex against will’ to be a direct result of family separation and poverty and framed the issue in terms of survival. Older girls (18-24) mentioned their boyfriends and childhood friends as perpetrators of unwanted sex. Mothers also reported that sexual coercion was not confined to childhood but could happen among young women and adults. The parents can’t afford taking care of the children so they close their eyes. (Boys 15-17) A mother might have a child but she has no money so she uses the child but she should not be the one to do such thing. (Boys 15-17) There may be a little quarrel between the two of you, and the guy invites you to the restaurant, and then forces you to have sex with him. Sometimes there are people who you grow up with in a neighborhood, you consider that person a friend, then one time that friend forces you and even gets on you to get what he needs (Girls 18-24) Page 22 of 64  Even your husband in the house who’s asking for something and you don’t want forces you and might even fight with you, and you end up . . . obliged, it’s called forced. (Mothers) Although participants made clear distinctions between physically forced sex and sexual coercion, there was considerable confusion about words used to describe coerced sex. While “forced” was widely understood and distinct from other forms of unwanted sex, participants were unable to define or provide an example for “harassed,” “coerced,” and “tricked,” indicating that these words are not known in this population. Exceptions include providers, who understood all terms, and girls 18-24 who were able to define “tricked” in terms of their personal experiences. Yes, the guy can say that he will lease out a home for you. He pays the house in front of you then takes the money [back] without you knowing and has sex with you. (Girls 18-24) It is important to note that, although participants had clear opinions about what constitutes coerced rather than forced sex, these distinctions varied between participants. Respondent understood that “rape” fell under the category of forced sex and described these experiences to be more brutal and associated with weapons or physical assault. However, some participants, particularly boys, believed that transactional sex due to poverty represented forced sex, as it would normally not be a person’s choice to enter into such a transaction. Further, depending on the nature of the relationship between the perpetrator and victim, ideas about what constituted forced sex versus sexual coercion seemed to vary. A frequent example of this was depictions of physically forced sex when asked about sexual coercion; this occurred mostly when the perpetrator was a boyfriend or husband. In such cases, where sex is ‘obliged’ by culture or circumstance, the experience was described by the respondent as coercion despite the physical element. Drug Use Identifying the types of drugs specifically used in Haiti is important for informing the study since drug use is a high-risk behavior that is considered an important health outcome associated with childhood exposure to violence. Participants were asked what drugs young people use to become intoxicated and to distinguish between legal drugs from a pharmacy and illegal street drugs. Knowledge and exposure to drugs was universally acknowledged among this population. Legal drugs mentioned included alcohol, tobacco, and caffeine, and it was reported that some youth abuse legal household products such as tea, toothpaste, and cement powder. The most commonly reported illegal drugs were marijuana, cocaine, and crack, the first two of which were mentioned in every group. Several of the younger children had witnessed cocaine use, and all respondents were familiar with marijuana use. Terms participants used to describe drug use were “getting high,” “going to Africa,” “going to Jamaica,” and “getting fat.” Participants identified drug users to be criminals, artists, and older kids (if the respondents were younger children). All respondents had a clear comprehension of the difference between legal and illegal drugs. Legal drugs were perceived to come from pharmacies and be regulated, while illegal drugs are found on the street and can have unintended side effects, such as causing people to “lose control.” It was commonly reported that illegal drugs are “not good for their brains” and can make one sick. Some respondents also reported that illegal drugs are bad because they cannot be returned if they do not work or because they “sit under the sun” all day. Respondents recognized that some drugs that are legal in the pharmacy are no longer legal when sold on the Page 23 of 64 street, such as painkillers. The drugs you get at the pharmacy are to cure you are legal but the ones the police do not want you to use since they make you sick are illegal. If you are not use to taking them they can affect your skin and sometimes even make you vomit. It can make you vomit until you die. (Boys 13-14) Participants also identified illegal drugs as an underlying cause of violence towards one’s family and the community. Several children recalled getting into street fights with other youth who were under the influence of drugs. Other participants recalled stories of youth attacking their parents while under the influence of drugs or putting drugs in their parents’ mouths while they were sleeping. Other outcomes participants associated with illegal drug use included becoming a criminal, getting arrested, homelessness, and prostitution. I have a sister, when she started smoking marijuana she would steal my mother’s money to buy it. She would hide in the bathroom from my mother to smoke. When my mother found out she started smoking they argued and she left the house. Now, she lives on the park. (Boys 13-14) This thing can make them loose their minds. It turns people into thieves. It also plays with your mind. If you take without eating it can make you crazy and start stealing stuff. When they do not have money to pay it they walk into businesses to steal. For example, recently after smoking, this man went and stole a man’s wallet and killed him. (Girls 13-14) When you smoke these things it confuses your brain and you feel like you are in another world. That is when you can do any act on someone. For example, after smoking they would sit and wait for someone’s child to walk by so that they would grab and then rape. (Boys 13-14) Sexual Health To assess the accuracy of self-reported history of sexually transmitted infections (STIs), which have been demonstrated to be an important health outcome associated with childhood exposure to violence, participants were asked about their familiarity and knowledge of the symptoms of genital health problems. Girls and women were asked what they knew about vaginal discharge; boys and men were asked what they knew about penile discharge, and all participants were asked to describe genital warts. Overall, knowledge of these genital health symptoms and terms was very low among all groups. Providers were the only group with working knowledge of both genital discharge and genital warts. Parents had a better comprehension of discharge than child groups, but overall their knowledge of these terms was also poor. Among parents, only mothers recognized the term for genital warts. Providers described them as “buttons” or “ulcers.” Well normally we talk to people and we ask them if they give out some type of yellow or white water in their panties. Once you tell them they understand. (Providers) A little yellow liquid that’s coming out of the head of the guy’s penis, but it’s a sickness. (Fathers) Child groups had very rudimentary understanding that discharge meant something was wrong with their genitals, but symptoms described by boys seemed to confuse STIs with urinary tract symptoms or ejaculation. Girls frequently referred to vaginal discharge as “water in your underwear” or “water down there.” Symptoms Page 24 of 64 sometimes seemed to describe urinary tract problems, yeast, or other non-sexually transmitted infections. Genital warts were unknown in boy groups, and among girl groups they were described as “pimples” or with symptoms more indicative of genital herpes. STIs in general were reported to occur if one has sex and does not wash afterwards. It means when your pee it comes out red; it means you are having sex with someone and it gets inside a person and forms a baby. (Boys 13-14) Yes, it is when a person has difficulties to urinate and when it finally comes out it is hot and burns. (Boys 15-17) It leaves a liquid in the person’s underwear and then it causes itchiness. (Girls 18-24) Condoms To assess the accuracy of self-reported history of condom use, the lack of which has been shown to be an important high risk behavior associated with childhood exposure to violence, participants were asked about the acceptability of condom use among youth, how best to broach the subject of condoms with youth, and why a young person might lie about condom use. All respondents were familiar with condoms, and both boys and girls thought it was appropriate for young people to use condoms. It was widely understood that the purpose of condoms is to prevent pregnancy, HIV and other types of STIs; many different respondents emphasized these issues individually in each group. There are a lot of diseases out there, besides AIDS, there are a lot of things that you can catch, and there is pregnancy. You can get all of that if you don’t use protection. (Girls 15-17) I don’t think that it has to do with sickness, for the person that is opening to me, I could tell him, since you just earned your High School Diploma, I think you should manage your life, because I don’t want the guy to start college and not finish with a young girl that could get pregnant. (Boys 18-24) The most common suggestion for discussing condoms with youth was to utilize their existing knowledge on the topic. Participants suggested raising the topic of HIV and pregnancy prevention, and to express concern about them and their future. It was also commonly said that young people would be more comfortable talking about these issues with others their own age than with adults. First thing to do is to increase his awareness, so the person could know what type of disease he could catch and the diseases that can be sexually transmitted. And I would ask him to tell me, how he can prevent these diseases. Once you ask these questions, he should open to you easily. (Boys 18-24) The main barrier to discussing condoms with youth was identified to be the child’s shame and the stigma of admitting they are sexually active. It was remarked several times that Haitian children do not discuss sex with their parents and that there is little formal sexual education for youth. In keeping with this trend, child groups frequently stressed that they did not want to discuss condoms with their parents or other adults for fear of judgment or punishment, and that open discussion about sexual activity was not generally acceptable even among peers. Page 25 of 64  We can’t mention the word because the older one with tell our parents, who in return will spank us. (Boys 13-14) Because you are not of the age to be having sex, if your parents know you will get in trouble. They will say you need to be married or legal (Boys 15-17) This viewpoint was confirmed among parents and providers, who agreed that it is inappropriate for young people to be sexually active and therefore not acceptable for them to use condoms. Mothers reported that children would not discuss condoms with adults because it would “confirm that they’re being bad” and that this would give them license to hit the children. Providers were concerned that bringing up the topic of condoms too early would encourage children to become sexually active. If I have a 15 year-old kid and I find a condom in his hands, I’m going to take my ‘bout makak’ (stick - used to hit) to ask where he found the condom. Is it the best way to ask? Yes. (Mothers) This is not a kind of question you should be asking a kid, things concerning condoms. That would mean that it’s okay for them to have sexual relations at a young age (Providers) I have problems with parents that just leave the kids to themselves early and give them condoms, because you have to help the kids not get pregnant, and when you just give them a condom too early it’s as if you told them to go do something. (Providers) To address this barrier, it was suggested by several groups that persons wanting to discuss this issue should be as close as possible to the child’s age and must make the child feel comfortable by building a rapport with them beforehand. An additional obstacle to condom use that arose throughout the conversations was a link between the negotiation of condom use and forced sex. Several groups discussed how requests for condoms often resulted in forced sex, or that unprotected sex was pressured by boyfriends’ threats to leave. These results have important implications for both experiences of sexual violence and its association with other health outcomes, such as HIV and STIs. After he gave her money, she still did not want to do it without a condom. So the man gagged and tied her and had sex without a condom. (Boys 13-14) If they use a condom with the guy, the guy might not stay their boyfriend. (Girls 15-17) Sexual Taboos Participants were asked about sexual taboos to better inform the study about topics that may be especially sensitive. Findings around these broad issues were generally consistent across all participants regardless of age of gender. Nearly all of the discussion around taboo subjects was oriented towards sexuality (notably homosexuality) or around specific sexual acts such as felatio or anal sex. Older boys and young men, for example, reported that certain issues are generally not discussed amongst each other, including acquiring a sexually-transmitted infection or having sex with a very elderly person. Intra-generational boundaries were also discussed in terms of sex and sexuality, and it was commonly reported that children receive very little Page 26 of 64 sexual instruction or education from their parents. Some guys have the tendency when they have their girlfriend to sodomize her, and since they find it kind of immoral, even when their talking to their friends they won’t mention it. (Boys 18-24) It *sex+ is just is too big of a word; I can’t say it in front of my mother or sisters. I could get punished or even spanked for saying that I am having sex. They might have me explain and then spank me for using such expressions. Parents will start asking you questions such as, where have you learned that word, what you know about such things and if you do not tell the truth they will start spanking you. (Girls 13- 14) However, upon closer analysis of the narrative it is clear that the younger age groups talk about sexuality amongst peers except when it involves issues of morality or immorality. This was corroborated by both children and providers. Kids speak with kids, kids don’t talk with adults they talk with kids, they don’t want to bring up the sex subject with adults and adults don’t want to bring up the sex subject with kids. (Providers) Clearly, these are sensitive issues that have the potential to incite physical violence against children by parents and other caretakers if they were brought up in their presence. Circumstances where children are ‘caught’ in one way or another expressing issues around sexuality or engaging in some sort of sexual activity are often resolved with physical violence. These topics were frequently mentioned in all of the age groups of youth but notably so among the younger groups. Children confirmed that girls would be more willing to speak with a provider than with their mother if they ever experienced sexual assault. Our education shows us that talking about sex is a dirty act . . . as something sordid. Sexual relations are viewed as something wretched, and that is not good. (Providers) Services Participants were asked what services children and youth could use if they were forced to have sex, and which services they were familiar with overall. Providers were very knowledgeable about all services, to an extent that exceeded all other respondents. Services listed by non-provider participants included the hospital and other medical services, followed by the Ministry of Women’s Affairs. If the victim is male, it was agreed that he should go to the police; however, going to the police was generally mentioned for a female victim only if the perpetrator was caught or they otherwise had proof of the assault. Other services identified were Doctors without Borders and the church. Participants overall were familiar with medical services that one might seek after a sexual assault, such as a hospital or gynecologist but no one specifically mentioned the need for such care within 72 hours (for emergency contraception or post-exposure prophylaxis for HIV). Only providers discussed how medical services were necessary after forced sex in order to get a medical certificate to be used in court. Only a doctor can do a physical examination for the person. Thanks to that examination, she can prepare a medical certificate. Then they do many medical tests for the person like HIV or syphilis, then Page 27 of 64  for her pregnancy. (Providers) Some participants were familiar with the purpose of mental health or psychosocial services, but children more often connected these with the earthquake and large traumatic events rather than sexual violence. For example, a respondent reported that mental health services are to “help get in a better mood” or for “people who lost a lot of relatives in the earthquake who tend to be a little loopy.” However, most child groups did not understand the concept of mental health services and mischaracterized them completely, including boys in the 15-17 year age group and all girls. They [mental health services] help the people who live under the tents by giving those tents and tarps, water and food. (Boys 15-17) Fathers and providers had a better conception of mental health services after an assault. She could see a doctor to get first aid and that person would need to see a psychologist as soon as he suffered from the violent act. That person wants to kill herself. The person might think society would take it badly that she’s been raped so she would need someone to boost her spirits. (Fathers) Police and protection services were mentioned as people whose role it is to protect the community, but unprompted, they were only described as services for victims of sexual violence among female respondents. Legal services were similarly characterized as helping people in reasonably accurate ways but were rarely linked to sexual or physical assaults. Boys 18-24 were the only children to describe legal action in terms of violence, and only mothers and providers mentioned that legal action could help a victim get a warrant for the arrest of the perpetrator. Participants were also asked why youth might not seek services if they are sexually assaulted. Answers from children included that they would be ignored, that they wouldn’t be believed, that they would be ashamed, and that other people would treat them badly. Groups frequently mentioned that their friends and community would stigmatize an assaulted girl, and so it was better to keep the information to themselves. The opinion was also expressed that a girl who had been raped was no longer desirable and would be unsuitable for marriage. Fear of retaliation from the perpetrator, fear of punishment by their family, and lack of known or acceptable services were other less common reasons to avoid seeking services. Because they would not want others to know their business, so that friends don’t tease her, and to stop other girls from being raped, these are the reason she’ll hide that. (Boys 18-24) They do not want their parents to know. The aggressor would threaten to kill them if they told anyone. (Girls 13-14) Kids re-victimize themselves because their parent hit them, their friends bother them, his neighborhood is calling him names. So to sum it all up there are some thing that make the kid not want to talk to people about anything. (Providers) Altogether, there was very little familiarity about the use of non-medical services to help victims of sexual assault. This could be due to an overall lack of services, a lack of familiarity with services, particularly those Page 28 of 64 that have only been established since the earthquake, or a lack of belief that these services will provide meaningful support. The infrequency of descriptions about police, legal, and mental health services indicate that these are not well-utilized recourses for assistance among this population and that it is unlikely for these services to be sought after an assault. DISCUSSION The focus groups presented an opportunity to discuss a variety of sensitive topics with children and their caretakers in post-emergency Haiti. Although these groups were not representative of all children across the country, the data is useful to inform the upcoming national VACS in Haiti and ensure that it is conducted in a culturally appropriate manner and understood by this population. This current work provides insights on issues not typically asked of Haitian children and gave them an opportunity to voice their concerns and beliefs on violence and other key issues in their lives. Willingness to Discuss Sensitive Issues Overall, participants were willing and able to cooperate with facilitators to answer questions asked, and many participants discussed their personal experiences unsolicited. Boys of all ages, fathers, and providers were the most forthcoming and outgoing with their responses, while girls and mothers were more reticent and introverted. The youngest group of girls was reported to be the most difficult to elicit responses from due to the shyness of participants. Child groups consistently voiced their preference for discussing sensitive topics with people their own age rather than adults, and the need to establish trust and a good rapport with participants was mentioned frequently in all groups. These finding indicate that enumerators for the national study should appear to be young and be gender-matched and that strategies for approaching boys and girls during the survey should be well-thought out in order to maximize comfort and thereby sharing of information. Furthermore, enumerators must be selected and trained on the basis of their personal comfort with sensitive topics and their ability to set the respondent at ease. The findings suggest that, given the appropriate selection of enumerators, children would be willing to openly answer questions on sensitive topics related to violence and even sexual taboos. Experiences of Violence The participant’s perceptions of sexual violence and other forms of violence are particularly relevant to inform VACS Haiti. Based on participants’ responses, it is clear that violence is prominent in Haitian society. The respondents suggest that there are very few ways that Haitian children can be protected from both calculated and random acts of violence. The level and frequency of violent experiences described by the participants indicate that it is an omnipresent factor in their lives and affects their daily activities. The respondents themselves reported that they could not run errands, go to school, or walk alone without the fear of being attacked. And as noted at the start of this report, these issues can have long-term impact on the health and wellbeing of girls and boys. Overall, respondents have an appreciation for the impact of sexual, physical, and emotional violence on Page 29 of 64 children in Haiti. While it was agreed that all of these forms of violence impact both boys and girls, respondents believed that physical violence disproportionally impacts boys while sexual violence disproportionately impacts girls, including very young girls. An exception to this gender-specific pattern of violence was the repeated reference among girls to the frequent physical violence they experience in the home as perpetrated by their mothers. If mothers are then the main perpetrators of physical violence against girls, this represents a potentially significant source of daily violence and fear among young girls as 70% of households in Haiti are female-headed [25]. Furthermore, girls reported that mothers would threaten them verbally with the idea of being raped on the street if they were disobedient or promiscuous; this is an indication of both verbal violence within the home and of the emotional impact of past violence that mothers themselves may carry with them. The extreme nature of this context underscores the importance of conducting VACS to provide nationally representative and reliable data that can describe the magnitude and nature of violence experience by children in Haiti, which can inform effective prevention and response strategies. Equally, the findings suggest that children will be both familiar and forthcoming on the subject in general. A finding of particular note is the distinction between parents’ perceptions of the common perpetrators of violence and the perceptions of children. As mentioned, children reported that their parents are the main perpetrators of physical and emotional violence against children, while parents reported that strangers were the primary perpetrators of all forms of violence. This contradiction emphasizes the importance of conducting a nationally representative study to accurately describe the common relationship between the perpetrator and victim in this population. In addition, given that child participants identified parents as one of the most common perpetrators of violence, emphasis should be placed on confidentiality and privacy during the administration of the interview. Further, the parental/caregiver consent form should be careful in how the issue of violence is addressed. Finally, it is also important to consider the potential underlying causes of violence. The respondents frequently referred to poverty as a root cause of violence in Haiti. Therefore, the quantitative study should consider structural risk factors for violence, particularly measures of socioeconomic status (SES), to determine to what extent poverty or low SES is associated with experiences of violence. Also, acknowledging the importance poverty may have in the lives of Haitians may help in building rapport with respondents and preparing them for survey questions. For instance, this topic may be included in the participant consent process. Sexual Violence: Sexual Coercion versus Physically Forced Sex Sexual violence was reported to be both common and expected among the respondents, suggesting that this type of violence against children may be an increasingly normal part of Haitian society. Based on the respondents’ descriptions, forced sex and coercive sex have blurred boundaries in the Haitian urban context. As previously described in the results, distinctions between forced sex and sexual coercion vary among participants, and there appears to be some confusion between these categories, particularly when dealing with intimate partners and cultural expectations. Also, while respondents understood many of the circumstances under which sexual coercion or otherwise unwanted sexual experiences occur, they largely did not understand terms like “harassed,” “coerced,” and “tricked,” to capture sexual coercion. Based on these findings, in order for VACS to accurately describe the problem of sexual violence and disentangle the nuances Page 30 of 64 between forced, coerced, and transactional sex, it is critical that questions related to sexual violence be direct and explicit so that respondents clearly understand what is being asked and interpret the questions as intended. According to nearly all participants, the earthquake and resulting displacement have resulted in an increase in the incidents of sexual assaults as well as transactional sex. It is, therefore important for the survey to try and capture the impact of the earthquake on sexual violence. The impact of being forced into sexual relationships, whether indirectly through poverty (leading to transactional sex) or directly through sexual assault has profound social impact on survivors as reported by both girls and parents. Social castigation and isolation of survivors is common, and victims are reported to conceal their experiences as a result of this social stigma. These findings again point to the need to respect child survey participants’ sensitivity in both divulging and explaining these acts of violence. As mentioned above, participants overall felt that asking questions clearly and directly, after having established good rapport, would help children express these events truthfully. Authority Figures and Vulnerable Populations In order to clearly define the range of potential perpetrators of violence, it is important to understand who within Haitian society may be acknowledged as authority figures. Authority is important specifically because people identified with this kind of power have a high measure of influence over children and this can be potentially misused in an abusive manner, emotionally, physically, and sexually. Also, certain people with widely recognized authority over children may have more freedom to be physically violent towards children, such as parents and teachers. Some authority figures identified by groups fit into the above categories. These include parents and teachers in addition to other family members, religious figures, police, and people with wealth. Political figures were also frequently identified as a type of authority figures; however, there is a lower likelihood of these people coming into contact with most children, except at local level politics. Due to the absence of the centralized government in the rural areas, political figures are likely to be considerably more important to rural children. In the survey, it will be important to measure the frequency of victimization by all the people mentioned above in order to better understand the circumstances under which children may be at greater risk for violence in Haiti. Data on households and domestic servants, perhaps the most vulnerable of children in Haitian society, also yielded critical information for VACS regarding the importance of defining the household for identification of eligible children. Findings suggest that Haitian children and parents do not view the concept of the household as distinct from the nuclear family, and that requests for household rosters could produce an inaccurate household listing. An incomplete household listing can be made by omitting extended family or non-related children living under the same roof, including both domestic servants and the children of other families cohabiting with the identified head of household. Further, including children in the household that in fact live in their own residence or tent could also result in errors. Therefore, care must be taken to explicitly define the intended scope of the household to the respondent to avoid any confusion. Furthermore, it was clear that domestic servants are rarely considered part of the household or family, and so it is recommended to specifically ask whether any children work and sleep in the home in order to include them in the household Page 31 of 64 listing. The information on children in situations of domestic servitude also revealed the extreme vulnerability of this population in Haitian society and indicated some limitations to accessing this population. As previously mentioned, household listings are not likely to include these children unless participants are given explicit instructions, so special reference to them may be required. Still, even after requesting them specifically, homeowners may be less willing to allow servants to participate in the survey. Reasons for this might include that the child would stop working for the duration of the survey so household tasks would not be completed, or that the homeowners would rather their own children be involved. According to qualitative respondents, the domestic servant is also more likely to experience violence than other children in the household and the homeowner may consequently be less willing to allow them to participate for fear that they would share their experiences of abuse. Child servants participating in the study may also provide less reliable information on their experiences for fear of retaliation by the home-owning family. This issue raises concern that seeking out domestic servants for the survey may target them for further abuse, regardless of their responses. Additional precautions should therefore be taken to ensure their safety as a particularly vulnerable population, to explain that their responses are confidential, and to ensure appropriate communication with homeowners in order to minimize these risks. A final concern with domestic servants involves questions they may confuse their biological family versus their residential household. When questions are asked of these children, it must be made explicit whether the question is referring to their biological family or the home-owning family with which they live. Substance Abuse, Condoms, Genital Health and Taboos as Cofactors associated with Violence While defining the scope and magnitude of violence are the primary objectives of VACS Haiti, another important objective of the survey is to demonstrate the impact of childhood violence on health outcomes and high-risk behaviors. The literature demonstrates that the experiences of violence in childhood impact risk behaviors and health outcomes later in adolescence and adulthood; victims of childhood violence frequently exhibit more sexual and drug-related risk behaviors, which impacts their susceptibility to HIV, STIs, unintended pregnancy and abortion, and other negative health outcomes [1-5]. Participants were not asked about personal substance abuse, but all groups were very familiar with a variety drugs that can be abused and had a solid understanding of the difference between legal and illegal drugs. Even the youngest respondents were familiar with which drugs are used medicinally versus those used for recreational purposes. There also appears to be a clear connection between drug-use and violent behavior or crime, and respondents were willing to discuss these issues at length. This high level of understanding indicates that questions relevant to drug-use behavior will be both understood and well-received among this population. However, the universally negative connotation of drug-use among respondents may indicate that this behavior is stigmatized and personal use may be under-reported due to social desirability issues. It will be important for data collectors to assure respondents of their confidentiality. As a corollary, marijuana and cocaine were both frequently mentioned but the study participants did not identify injectable drugs as a problem. Therefore, targeted questions on injection drug use may not be relevant for this population. Participants were also widely familiar with condoms and their use to prevent pregnancy, HIV and other STIs. Page 32 of 64 However, there was a fair amount of stigma associated with their use, particularly among children under 18. Children, parents, and providers reported that it was not acceptable for youth to have condoms as it would be an admission that they were sexually active. Children identified the fear of punishment and violence from parents as the most limiting factor to condom use. Mothers confirmed that they would beat their children if they found them with condoms, emphasizing again that respondents’ answers on the national survey must be kept strictly confidential from their parents. . Another identified barrier to condom use was that the male partner often does not comply and that this was sometimes linked to sexual violence. These issues indicate that there may be both over and underreporting of condom use in this population due to knowledge that they are supposed to be used and the stigma associated with their use, respectively. Potential ways to address these concerns would include developing rapport and a sense of trust with the respondent, reminding them of the confidentiality of their responses, and impressing upon them the importance of accurate information. The issue of genital health symptoms and terminology is expected to be particularly difficult to measure in the national survey. The findings show that knowledge of STIs both by symptoms and by actual name is very poor among the younger cohorts. Child respondents overall were either entirely unfamiliar with signs and symptoms of STIs or appeared to associate them with non-sexually transmitted infections such as yeast and urinary tract issues. Genital warts particularly were unknown among child respondents. This could present problems when asking questions about general reproductive health, and inquiries around these issues will need to be carefully worded in a very descriptive way. Other potential solutions could include using slang terminology suggested by respondents, or using a more detailed description of the condition including symptoms to rule out. Indirect questioning could also be used to see if respondents had ever taken pills or received an injection to treat a genital health issue. In addition to the specific issues of drug use, condoms, and genital health, this qualitative study shows that other taboo subjects are common in Haiti. Participants appear to classify them similarly, regardless of age and gender, and largely around issues of sexuality (homosexuality and differing sexual practices such as felatio). To partly explain this phenomenon, children reportedly perceive adults as holding authoritative power over them in terms of these issues and so, in response, children keep things “in their hearts” as one young girl (15-17 years) noted. Several children also emphasized that their parents would physically punish them for attempting to discuss these topics. However, generally in Haitian culture, talking about sexuality is not a forbidden issue on a one-to-one basis, and among same-age groups, the discussion of taboos was open and frank. Children interviewed are likely to discuss things from the level and perspective they best understand it. Boys especially confirmed this perspective by reporting that they perceived providers to be open to hearing about these issues, but girls did not mention any adult figures with whom they could speak frankly about such things. The findings suggest that girls may have a more difficult time discussing taboo topics with adults due to issues of shame, stigma, and fear. It is, therefore, critical that enumerators for the study develop strong rapport with participants, in particular female respondents, and preface questions on sensitive topics with considerable confidentiality to ensure that young people feel free to report. As previously mentioned, it is particularly important for these issues that enumerators are gender-matched to respondents and appear to be reasonably young. Furthermore, in order to avoid children being targeted for physical abuse from their parents, careful consideration should be given to the language of the parental/caretaker consent form related to how these sensitive topics are addressed. Page 33 of 64 Service Utilization Another important objective of the VACS survey is to assess the availability and utilization of services for victims of physical and sexual violence. While there are several service providers that offer medical, mental health, and legal services, the respondents were generally unfamiliar with most of these services, with the exception of medical services for victims of violence. There was wide recognition that one could seek help at a hospital or clinic; however, there was considerable confusion on what mental health services actually are and what these services might be used for. The Ministry of Women’s Affairs was frequently cited as a resource for female victims, however child groups did not discuss legal services and according to respondents, there are no designated advocacy services for males. Police and protection services were only cited as resources for males or for females only if there was proof or the perpetrator had been caught. These results demonstrate the need for improved advocacy around services and education among this population highlighting the need to further investigate this issue in the national survey. However, care must be taken to avoid confusion among participants unfamiliar with the range of assistance they can seek. Here too, very literal descriptions of the services, especially related to mental and psychosocial services, may be needed to ascertain if respondents are familiar with or have actually used the services themselves. These findings also indicate to the need to establish appropriate service referral pathways for child respondents prior to the actual survey. Calendar of Events In order to ascertain if violence peaked following the earthquake and to help inform preparedness efforts for future emergencies following natural disasters, the researchers would like to track the occurrence of sexual violent incidents by time. Consequently, defining accurate recall strategies among children is essential for the accuracy of retrospective questioning. In Francophone countries, learning by rote is standard course. For this reason, so too is recall of events—either traumatic or pleasant—in Haitian culture. Questions to participants were oriented around general recall of birthdays and basic life events, but also around specific events, such as the earthquake, to determine the potential for a detailed recall process. In order to create an epidemiological curve of sexual violence following the earthquake, researchers may need to document, as probes, various events that followed the earthquake in the immediate, medium and longer term. Creating a list of events that happened such as ‘when cell phone service resumed’ or ‘when food and water first arrived’ might enable respondents to recall their own terms of security based in a chronological manner. Creating such a timeline would then be the tool to help researchers probe for detailed questions of physical and sexual violence. Ensuring the Safety of Study Participants Due to the wide range of circumstances in which children are reported to receive corporal punishment from family members in Haiti, ensuring the safety of study participants is an integral aspect of the survey. Therefore, emphasis should be placed on the importance of confidentiality and privacy during the administration of the interview. As an extra measure of caution, careful consideration should be given to the parental/caregiver consent form addressing violence and sexual behavior in Haiti in order to protect children, especially child domestic servants, from possible violence from their parents or caretakers. Page 34 of 64 Key Recommendations for VACS Haiti Enumerators should be selected based on gender-appropriateness, youthful appearance, and ability to build rapport quickly with respondents. Questions on sensitive topics should use explicit language that is clear and direct. Topics that could easily be misunderstood should be explained in careful detail; this includes questions on the distinctions between forced and pressured sex, genital health and STI symptoms, and services that may be used following experiences of violence. Particular attention must be given to the population of domestic servants in order to identify them as potential study participants in household listings and to ensure their protection and safety. A calendar of events for events following the January 2010 earthquake should be developed for ease in determining accurate dates of experiences of assault. In addition to informing the national quantitative study on violence against children, findings from the qualitative study can be utilized more immediately to begin to develop intervention strategies to better address this problem. Some examples of intervention strategies are provided below: 1. Develop information, education, and communication (IEC) campaigns to educate parents and caregivers about the negative consequences of parents and caregivers abusing their children, even if these incidents are considered acts of corporal punishment. 2. Strengthen promising programs that prevent child sexual abuse. Such programs may include those that strengthen the relationships between mothers and their children; improve communication between parents and children on sexual and reproductive health and violence; and/or improve social, health, and economic asset building of high risk adolescent girls and boys. 3. Better publicize the availability of existing services for victims of violence to improve knowledge and utilization. 4. Consider policies and laws regarding child labor, including children in situations of domestic servitude. LIMITATIONS and STRENGTHS There were several limitations to this study, many of which were due to limited time and financial resources. First, FGDs were held only in urban Haiti and therefore are not representative of the largely rural general population. Second, while facilitators were generally matched to each group, the quality of the facilitation varied, making the responses less consistent across the different groups. Third, a limited data team was tasked with transcription, translation of recordings in Haiti, and coding and analysis of the data, leading to a range in the quality of translation and thereby limited efficacy of the analysis team. Due to a poor recording one of the focus groups (Boys 13-14) was not fully transcribed or translated. Finally, the section on the variety of sexual Page 35 of 64 partners was not included in written results due to misunderstanding of the question by respondents and lack of usable information. Despite these limitations, this qualitative study represents the first time the VACS process has used a qualitative methodology to inform the quantitative survey and the findings show that undertaking this sort of formative fieldwork is an important step for informing the quantitative survey tool. This qualitative study incorporated opinions and beliefs from a wide variety of child respondents aged 13-24, broken down by gender and from different urban settings. It also included the perceptions of parents and service providers. This range of opinions and beliefs has provided unique information on how children comprehend issues related to violence in Haiti that will lead to more appropriate and culturally sensitive research methods. This will, ultimately, improve the quality of the quantitative survey tool and help ensure the psychological well- being and physical safety of survey respondents and data collection personnel. CONCLUSION This report reflects the results of a qualitative investigation designed to better inform VACS Haiti prior to its implementation. Undertaking this type of qualitative study was a unique collaborative effort between CDC and INURED in an effort to generate formative data on the topic of violence. If properly applied, information gleaned in this report could be effectively used in the design of the survey questions as well as during the training of data collectors. Although the findings from this study are limited, they provide important insights into the feasibility of carrying out the survey in a particularly challenging post-emergency setting where understanding of vulnerability and safety have taken on dynamic meaning. Participants ranging in age and gender provided a wide array of responses on numerous subjects related to violence and, overall, seemed generally at ease when discussing these sensitive issues. That said, while violence—physical, emotional and sexual—were all acknowledged as significant part of children’s lives, there is a very poor understanding of the services that should be made available to survivors of such violence. The goal then is to implement VACS Haiti and, in turn, effectively use the findings to properly define both the gravity of the problem and a just national prevention and response strategy that provides Haitian children with the protection they so deserve. ACKNOWLEGMENTS CDC Laura Chiang, Associate Service Fellow, Division of Violence Prevention Jean Wysler Domercant, M.D., Development Assistance Specialist, CDC Haiti Kimberley Freire, Senior Service Fellow, Division of Violence Prevention Marisa Hast, MPH, Epidemiologist, Health Systems Reconstruction Office Avid Reza, MD, MPH, Principal Investigator/Epidemiologist, International Emergency and Refugee Health Julia Smith-Easley, MPH, CHES, Behavioral Scientist, International Emergency and Refugee Health John Vertefeuille, PhD, MHS, Country Director, CDC Haiti Angela Wood, MPA, Public Health Analyst, Office of Public Health Preparedness and Response Page 36 of 64 INURED Dr. Calixte Clerismé, Professor, Université d’Etat d’Haïti & Senior Research Associate, INURED Agr. Jacob Jonas, Academic and Research Liaison Manger, INURED Jean-Elie Larrieux, Ph.D., Vice-Recteur of Université Notre-Dame D'Haïti & Research Fellow, INURED Louis Herns Marcelin, Ph.D., Professor of Social Sciences, University of Miami & Chancellor, INURED Olivia Paul, MA, Assistant Liaison Académique et Recherche, INURED UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Catherine Maternowska, PhD, MPH, Bixby Center for Global Reproductive Health MEMBERS OF THE QUALITATIVE TEAM Loutie Compere, Student Assistant Jean Dider Deslorges, BA, Assistant Liaison Académique et Recherche, INURED Eddy Junior Dorveus, Student Assistant Benjamin Deusmar, Student Assistant Evens Jean-Pierre, Student Assistant Sherley Jean-Pierre, MA, Assistant Research Administration, INURED Stanley Joseph, BA, Translator, INURED Francette Lubin, Student Assistant, INURED Wilkens Pierre, BA, Research Assistant, INURED Habaccuc Sigue, Student Assistant REFERENCES 1. United Nations' Secretary General Study on Violence Against Children. Available from: http://www.unicef.org/violencestudy/presskits/2%20Study%20findings_Press%20kit%20EN.pdf. 2. Jewkes, R. and et al, Sexual Violence, in World Report on Violence and Health, E. Krug, et al., Editors. 2002, World Health Organization: Geneva. p. 147-82. 3. National Research Council and Institude of Medicine. From neurons to neighborhoods: the science of early childhood development. in Committee on Integrating the Science of Early Childhood Development. Board on Children, Youth, and Famillies, Commission on Behavioral and Social Sciences and Education. 2000. Washington, DC: National Academy Press. 4. Felitti, V., et al., The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventative Medicine, 1998. 14: p. 245-58. 5. Kendall-Tackett, K., Treating the lifetime health effects of childhood victimization, 2003, Civic Research Institute, Inc: Kingston. 6. 2009 Failed States Index. Available from: http://www.foreignpolicy.com/articles/2009/06/22/2009_failed_states_index_interactive_map_an d_rankings. Page 37 of 64 7. IMPACT, The situation of orphans in Haiti: A Summary Assessment. 8. Population Council, The Haiti adolescent experience in-depth: Using data to identify and reach the most vulnerable young people: Haiti 2005/06, 2009, Population Council: New York. 9. UNICEF Haiti. Statistics at a glance. Available from: http://www.unicef.org/infobycountry/haiti_statistics.html. 10. Balsari, S. and et al, Protecting the Children of Haiti. New England Journal of Medicine. 11. Kolbe, A. and R. Hutson, Human rights abuse and other criminal violations in Port-au-Prince, Haiti: a random survey of households. Lancet, 2006. 12. GHESKIO and USAID, Sexual Violence in Haiti: GHESKIO's Response and Recommendations, 2010: Port-au-Prince. 13. Reza, A., Violence Against Children in Swaziland: FIndings from a National Survey on Violence Against Children in Swaziland, May 15-June 16, 2007, 2008, CDC/UNICEF Report. 14. Wilman, A. and L. Marceling, "If they could make us disappear, they would!" - Youth and Violence in Cite Soleil, Haiti. Journal of Community Psychology, 2010. 38(4): p. 515-31. 15. USAID, Gender-Based Violence in Haiti, January 2011. 16. Biwas, A. and et al, Unintentional injuries and parental violence against children during flood: a study in rural Bangladesh. Rural and Remote Health, 2010. 10(1199). 17. Catani, C., Tsunami, war, and culumlative risk in the lives of Sri Lankan School children. Child Development, 2010. 81(4): p. 1176-1191. 18. Breiding, M. and et al, Risk factors associated with the experience of childhood sexual violence among females in the Swaziland, Bulletin of the World Health Organization. 19. UNICEF, Children of Haiti: Milestones and looking forward six months, 2010: New York. 20. Amnesty International, Haiti: After the earthquake - initial mission findings March 2010, 2010, Amnesty International Publications: London. 21. Gupta, J. and A. Agrawal, Chronic aftershocks of an earthquake on the well-being of children in Haiti: violence, psychosocial health, and slavery. CMAJ, 2010. 182(18). 22. Institute for Justice and Democracy in Haiti, Our bodies are still trembling: Haitian women's fight against rape, July, 2010. 23. INURED. Available from: www.inured.org. 24. Centers for Disease Control and Prevention. Available from: www.cdc.gov. 25. Maternowska, C., Reproducing Inequitties: Poverty and the Politics of Population in Haiti2006: Rutgers University. Press: New Brunswick, NJ. Page 38 of 64  Appendix A: Haiti VACS June 2011 Focus Group Discussion Guide CHIDREN AND YOUTH Date: Site: Time Started: Time Ending: Name(s) of Facilitator: Name of Note taker Gender of participants: *Age range of participants  Females  13-14 years  Males  15-17 years  18-24 years # Females: # Males: Page 39 of 64 INTRODUCTION: Hello, my name is __________________ and this is _________________ who will be taking name of Facilitator name of Note taker notes during our talk today. I am with a team from ________________________________ Implementing partner organization We will be here for about an hour today. Are you able to stay with us for the full hour? We are asking questions about how best to discuss health, social practices, and issues related to violence that people your age may be facing. As we talk today, please think about how these things were before the earthquake and how they are now since the earthquake. All the things we talk about in this group will be kept secret. This means that we all agree not to talk to people who are not part of the group about any person in the group or what they said during the group. We do not want to you share your personal experience or to say anyone’s name while we are talking. We want this to be relaxed, so you do not have to wait for us to call on you to talk. If you have any questions, please let us know. We are here to ask questions, to listen, and make sure everyone has a chance to share. We want to hear every one’s view. It is ok if you have different opinions. I would like to hear all of them. There are no wrong answers. It is very important that you do not speak at the same time. I would like to be able to hear each of you. So, please take turns talking. When you speak, please talk with the group as a whole and not in side groups. If we seem to be stuck on a topic, we may stop. If you are not saying much, we may call on you. If we do this, please do not feel bad about it. This is how we make sure we hear from everyone. We are not asking for personal details about you or people you know. Please share only what you feel comfortable saying. I want to make sure I can listen to our talk later to make sure I understand what everyone says so I would like tape record our talk. The tape will be kept safe and no one will be able to listen to it without asking me first. [Facilitator: Please review consent form.] Page 40 of 64 1. QUESTIONS ABOUT HOUSEHOLD To begin, I would like to ask some general questions about households and families. Please think about before and after the earthquake as we talk. 1A. What makes up a typical household in your community? Probe: who is in the house… mother, father, extended family, multiple generations? 1B. What was a household like before the earthquake and now after the earthquake? Probe: how has migration (moving to different places) since the earthquake affected the makeup of a household? 1C. How do people in your community define a household? Probe: people who live and sleep in the same structure? People who eat together? Eat from the same pot? Answer to one person? Other? 1D. How many families are in one household? Probe: Does everyone live in the same structure? 1E. What terms do people usually use for the community? For the household? Probe: settlement, camp, other? Page 41 of 64 2. QUESTIONS ABOUT RECALLING EVENTS (F412) I will now ask how people remember or recall dates and events. 2A. What are ways that people recall when someone is born or dies? 2B. How do people recall birthdays and special occasions? 2C. How do people recall public events such as elections and private events such as a first kiss or special family day? 2D. What kind or events or situations are people likely to recall? Probe: How has the earthquake affected the way people may recall events? 2E. How do people remember and keep track of when other events happen? Probe: use calendar and dates, compare with other events? 3. QUESTIONS ABOUT AUTHORITY FIGURES (F603) My next question is about people who are seen as authority figures. 3A. Who are looked at as authority figures? Think of as many types of people – males and females – that you can. Facilitator: have group free list and write down all they list. Make note of any terms/names they use for specific authority figures. If there is a pause, probe by asking “can you think of any others?” 3B. Why are these people considered to be an authority? At what point do they become an authority? 3C. What are ways that people might lose their authority status and no longer be seen as an authority? Page 42 of 64 Facilitator and Notetaker: The list below if for the note taker and facilitator. DO NOT READ OUT THE LIST TO PARTICIPANTS. Use the list to check off authority figures named by the participants. Please note if they give common terms used to describe a person. For example…other term to describe husband, mother, etc  Possible Male Authority Figures  Possible Female Authority Figures Romantic partner (boyfriend) Romantic partner (girlfriend) Husband Wife Father Mother Step father Step mother Brother Sister Step brother Step sister Grandfather Grandmother Uncle Aunt Other male relative Other female relative Male teacher Female teacher Male police Female police Male military Female military Male employer Female employer Male neighbor Female neighbor Male community leader Female community leader Male religious leader Female religious leader Male friend Female friend Any male adult Any female adult Male stranger Female stranger Male restaveck owner Female restaveck owner Page 43 of 64 4. QUESTIONS ABOUT RESTAVEKS (F15) We would like to ask questions about children who may be sent away to be servants for other people. 4A. What is the term used for this person? Facilitator: List all terms they give and use that term during this discussion. If they give more than one term ask which is most commonly used. 4B. What are circumstances or situations in which a child would be sent away to be a restavek? Probe: How common is it for someone to be a restavek? How often does it happen? 4C. How old are children when they become restaveks? 4D. How long are do they live as a restavek? Probe: what happens when they leave the household? How old are they when they leave? 4E. What is the role of a restavek in a household? Probe: Is a restavek counted as part of a HH? 4F. What is the role and responsibility of the restavek owner? Probe: How is he/she viewed by the restavek? authority figure, owner, employer, caregiver ? 4G. What is life like for a restavek? What do they experience? Probe: What is the difference for girl and boy restaveks? Facilitator: Make note of any type of violence mentioned Page 44 of 64 5. QUESTIONS ABOUT TYPES OF VIOLENCE (F205) I will now ask about types of violence people your age may experience and when the violence is likely to happen. As we talk about this we would like for you to talk about how it was before and after the earthquake. Facilitator: List all responses that participants give to questions below. 5A. What are things that people may do or say to hurt someone in your age group? Probe: physical? emotional? isolation? gangs? Sexual violence? 5B. What kinds of hurtful experiences are likely to happen to boys? 5C. What kinds of hurtful experiences are likely to happen to girls? 5D. Which people do things to hurt someone in your age group? 5E. What are the reasons these people might hurt someone in your age group? 5F. Where are hurtful things that we have talked about likely to occur? 5G. What are specific times that people your age are more likely to experience violence? Probe: times of day, week, month, seasons? Before, during, after specific events? 5H. How has migration (moving to different places) since the earthquake affected violence that people your age may experience? Probe: types of violence, where and when it happens, who does the violence? 5I. Have people ever used hot peppers in the mouth as a way to burn someone? Page 45 of 64 6. QUESTIONS ABOUT DRUGS I now would like to ask some questions about different kinds of drugs. 6A. What are types of substances that people your age use to get high? These can be any kind of substance whether legal or illegal. Facilitator: write down all that they list 6B. What is the difference between drugs that are from a pharmacy and drugs that are illegal 6C. What terms do people your age use to talk about getting high? 7. QUESTIONS ABOUT TERMS SEXUAL HEALTH ISSUES (F107-8) 7A. I now want to ask you to help us understand the best words to use when talking about genital health. If we asked someone your age about the following terms, please say what they may think these words or terms mean. Facilitator: To be asked of females Facilitator: To be asked of males Vaginal discharge Penile discharge Genital ulcer/sore Genital ulcer/sore 7B. Are there other words that are used to describe these? Page 46 of 64 8. QUESTIONS ABOUT SEXUAL PARTNERS (F402) I would now like to ask you about the types of sexual partners that people your age may have. 8A. What are common terms people your age use for “sex” and “having sex”? 8B. What people are considered to be a sexual partner? What terms are used for someone that people your age have sex with? Facilitator: List all responses that they give. 8C. What are circumstances that someone may be considered to be a sexual partner? Probe: in marriage, dating, live-in partner, fiancé, someone of the same gender, casual sex partner, someone meet in a bar, someone of the same gender? Trading sex for food, gifts or other items of value? 8D. When is someone who is a friend also a sex partner? 9. QUESTIONS ABOUT USING A CONDOM (F68-70, F233-4 I would now like to ask you some questions about condoms. 9A. What are best ways that we can ask people your age questions about using condoms so that they will answer truthfully? 9B. What are reasons that people your age may not answer questions truthfully about using a condom? 9C. What are other terms that are used for condom? Page 47 of 64 10. QUESTIONS ABOUT SEXUAL TABOOS I would now like to ask you some questions about sexual taboos. 10A. What are sexual taboos that people your age may not want to talk about? Probe: sex with someone of the same gender, different types of sex acts (ie: anal sex) 10B. What are reasons they may not want to talk about these? 10C. What are ways that we can ask questions so that people would talk about these? Page 48 of 64 11. QUESTIONS ABOUT PEOPLE HAVING SEX AGAINST THEIR WILL (F701) I would now like to ask some questions about people who have sex against their will. As we talk about this we would like for you to talk about how it was before and after the earthquake. 11A. What are words or terms that people your age use to talk about having sex against their will? 11B. What is the best way to ask people your age whether they have had sex against their will? 11C. How are people your age who have been made to have sex against their will treated by their friends, family, communities? 11D. What are situations or circumstances when people your age have been made to have sex against their will? Probe: Have them give examples of the kinds of situations when people may be forced to have sex against their will. Probe: How has migration (moving) since the earth quake affected people having sex against their will? 11E. How likely is someone your age to recall being touched vs recall being forced/pressured to have sex? 11F. I am now going to go through a list of terms. Please say what these words may mean to people your age. It is ok if you think of more than one meaning. What is an example of each? What is an example of someone being pressured to have sex? Pressured Harassed Forced Coerced Tricked 11G. Are there other terms that people your age may use to talk about having sex against their will? Facilitator: Write down all terms they list. Page 49 of 64 12. QUESTIONS ABOUT COUNSELING SOURCES (F218) My next question is about where people your age go for help if they experience violence. 12A. Where do people your age who have experienced violence go to for counseling? 12B. What other people or places offer counseling services? 12C. What are reasons people your age might not seek counseling services? 12D. I will now read out types of services. For each one, please say what they offer or do for people your age? What are reasons people your age would use these? What are other terms people may use for these? Mental health services Pyschosocial services Medical services Legal aid Police Security protection 12E. What are other types of services people your age who have experienced violence may seek? Page 50 of 64 CLOSING QUESTION Thank you for your input. We are almost finished. I have one last question as we end our discussion today. Is there anything more that you would like for us to know about violence among people who are your age? ENDING THE FOCUS GROUP DISCUSSION Thank you for talking with us today. What you have to say is important and will help us better understand concerns about health and social practices as well as issues related to violence among adolescents and youth. The information will also be helpful in developing programs for improving health and safety. If you have any concerns about health and safety and would like someone to talk with in private, there is a list of resources available for you. Please remember, all the things we talked about in this group will be kept secret. This means that we all agree not to talk to people who are not part of the group about any person in the group or what they said during the group. Facilitator: Summarize key points from the discussion Give handouts with resource information ### Page 51 of 64  Appendix B: Haiti VACS June 2011 Focus Group Discussion Guide PARENTS AND PRACTITIONERS Date: Site: Time Started: Time Ending: Name(s) of Facilitator: Name of Note taker: Type of Participants:  Parents  Practitioner # Females: # Males: Page 52 of 64 INTRODUCTION: Hello, my name is __________________ and this is _________________ who will be taking name of Facilitator name of Note taker notes during our talk today. I am with a team from ________________________________ Implementing partner organization We will be here for about an hour today. Are you able to stay with us for the full hour? We are asking questions about how best to discuss health, social practices, and issues related to violence that children and youth may be facing. As we talk today, please think about how these things were before the earthquake and how they are now since the earthquake. All the things we talk about in this group will be kept secret. This means that we all agree not to talk to people who are not part of the group about any person in the group or what they said during the group. We do not want to you share your personal experience or to say anyone’s name while we are talking. We want this to be relaxed, so you do not have to wait for us to call on you to talk. If you have any questions, please let us know. We are here to ask questions, to listen, and make sure everyone has a chance to share. We want to hear every one’s view. It is ok if you have different opinions. I would like to hear all of them. There are no wrong answers. It is very important that you do not speak at the same time. I would like to be able to hear each of you. So, please take turns talking. When you speak, please talk with the group as a whole and not in side groups. If we seem to be stuck on a topic, we may stop. If you are not saying much, we may call on you. If we do this, please do not feel bad about it. This is how we make sure we hear from everyone. We are not asking for personal details about you or people you know. Please share only what you feel comfortable saying. I want to make sure I can listen to our talk later to make sure I understand what everyone says so I would like tape record our talk. The tape will be kept safe and no one will be able to listen to it without asking me first. [Facilitator: Please review consent form.] Page 53 of 64 1. QUESTIONS ABOUT HOUSEHOLD To begin, I would like to ask some general questions about households and families. Please think about before and after the earthquake as we talk. 1A. What makes up a typical household in your community? Probe: who is in the house… mother, father, extended family, multiple generations? 1B. What was a household like before the earthquake and now after the earthquake? Probe: how has migration (moving to different places) since the earthquake affected the makeup of a household? 1C. How do people in your community define a household? Probe: people who live and sleep in the same structure? People who eat together? Eat from the same pot? Answer to one person? Other? 1D. How many families are in one household? Probe: Does everyone live in the same structure? 1E. What terms do people usually use for the community? For the household? Probe: settlement, camp, other? Page 54 of 64 2. QUESTIONS ABOUT RECALLING EVENTS (F412) I will now ask how people remember or recall dates and events. 2A. What are ways that people recall when someone is born or dies? 2B. How do people recall birthdays and special occasions? 2C. How do people recall public events such as elections and private events such as a first kiss or special family day? 2D. What kind or events or situations are people likely to recall? Probe: How has the earthquake affected the way people may recall events? 2E. How do people remember and keep track of when other events happen? Probe: use calendar and dates, compare with other events? 3. QUESTIONS ABOUT AUTHORITY FIGURES (F603) My next question is about people who children and youth see as authority figures. 3A. Who do children and youth look to as authority figures? Think of as many types of people – males and females – that you can. Facilitator: have group free list and write down all they list. Make note of any terms/names they use for specific authority figures. If there is a pause, probe by asking “can you think of any others?” 3B. Why are these people considered to be an authority? At what point do they become an authority? 3C. What are ways that people might lose their authority status and no longer be seen as an authority? Page 55 of 64 Facilitator and Notetaker: The list below if for the note taker and facilitator. DO NOT READ OUT THE LIST TO PARTICIPANTS. Use the list to check off authority figures named by the participants. Please note if they give common terms used to describe a person. For example…other term to describe husband, mother, etc  Possible Male Authority Figures  Possible Female Authority Figures Romantic partner (boyfriend) Romantic partner (girlfriend) Husband Wife Father Mother Step father Step mother Brother Sister Step brother Step sister Grandfather Grandmother Uncle Aunt Other male relative Other female relative Male teacher Female teacher Male police Female police Male military Female military Male employer Female employer Male neighbor Female neighbor Male community leader Female community leader Male religious leader Female religious leader Male friend Female friend Any male adult Any female adult Male stranger Female stranger Male restaveck owner Female restaveck owner Page 56 of 64  4. QUESTIONS ABOUT RESTAVEKS (F15) We would like to ask questions about children who may be sent away to be servants for other people. 4A. What is the term used for this person? Facilitator: List all terms they give and use that term during this discussion. If they give more than one term ask which is most commonly used. 4B. What are circumstances or situations in which a child would be sent away to be a restavek? Probe: How common is it for someone to be a restavek? How often does it happen? 4C. How old are children when they become restaveks? 4D. How long are do they live as a restavek? Probe: what happens when they leave the household? How old are they when they leave? 4E. What is the role of a restavek in a household? Probe: Is a restavek counted as part of a HH? 4F. What is the role and responsibility of the restavek owner? Probe: How is he/she viewed by the restavek? authority figure, owner, employer, caregiver? 4G. What is life like for a restavek? What do they experience? Probe: What is the difference for girl and boy restaveks? Facilitator: Make note of any type of violence mentioned Page 57 of 64  5. QUESTIONS ABOUT TYPES OF VIOLENCE (F205) I will now ask about types of violence children and youth may experience and when the violence is likely to happen. As we talk about this we would like for you to talk about how it was before and after the earthquake. Facilitator: List all responses that participants give to questions below. 5A. What are things that people may do or say to hurt children and youth? Probe: physical? emotional? isolation? gangs? Sexual violence? 5B. What kinds of hurtful experiences are likely to happen to boys? 5C. What kinds of hurtful experiences are likely to happen to girls? 5D. Which people do things to hurt children and youth? 5E. What are the reasons these people might hurt children and youth? 5F. Where are hurtful things that we have talked about likely to occur? 5G. What are specific times that children and youth are more likely to experience violence? Probe: times of day, week, month, seasons? Before, during, after specific events? 5H. How has migration (moving to different places) since the earthquake affected violence that children and youth may experience? Probe: types of violence, where and when it happens, who does the violence? 5I. Have people ever used hot peppers in the mouth as a way to burn children and youth? Page 58 of 64 6. QUESTIONS ABOUT DRUGS I now would like to ask some questions about different kinds of drugs. 6A. What are types of substances that children and youth use to get high? These can be any kind of substance whether legal or illegal. Facilitator: write down all that they list 6B. What is the difference between drugs that are from a pharmacy and drugs that are illegal 6C. What terms do children and youth use to talk about getting high? 7. QUESTIONS ABOUT TERMS SEXUAL HEALTH ISSUES (F107-8) 7A. I now want to ask you to help us understand the best words to use when talking about genital health. If we asked children and youth about the following terms, please say what they may think these words or terms mean. Facilitator: To be asked of females Facilitator: To be asked of males Vaginal discharge Penile discharge Genital ulcer/sore Genital ulcer/sore 7B. Are there other words that children and youth use to describe these? Page 59 of 64 8. QUESTIONS ABOUT SEXUAL PARTNERS (F402) I would now like to ask you about the types of sexual partners that children and youth may have. 8A. What are common terms children and youth use for “sex” and “having sex”? 8B. What people are considered to be a sexual partner? What terms are used for someone that people have sex with? Facilitator: List all responses that they give. 8C. What are circumstances that someone may be considered to be a sexual partner? Probe: in marriage, dating, live-in partner, fiancé, someone of the same gender, casual sex partner, someone meet in a bar, someone of the same gender? Trading sex for food, gifts or other items of value? 8D. When is someone who is a friend also a sex partner? 9. QUESTIONS ABOUT USING A CONDOM (F68-70, F233-4 I would now like to ask you some questions about condoms. 9A. What are best ways that we can ask children and youth questions about using condoms so that they will answer truthfully? 9B. What are reasons that children and youth may not answer questions truthfully about using a condom? 9C. What are other terms that children and youth use for condom? Page 60 of 64 10. QUESTIONS ABOUT SEXUAL TABOOS I would now like to ask you some questions about sexual taboos. 10A. What are sexual taboos that children and youth may not want to talk about? Probe: sex with someone of the same gender, different types of sex acts (ie: anal sex) 10B. What are reasons children and youth may not want to talk about these? 10C. What are ways that we can ask questions so that children and youth would talk about these? Page 61 of 64 11. QUESTIONS ABOUT PEOPLE HAVING SEX AGAINST THEIR WILL (F701) I would now like to ask some questions about children and youth who have sex against their will. As we talk about this we would like for you to talk about how it was before and after the earthquake. 11A. What are words or terms that children and youth use to talk about having sex against their will? 11B. What is the best way to ask children and youth whether they have had sex against their will? 11C. How are children and youth who have been made to have sex against their will treated by their friends, family, communities? 11D. What are situations or circumstances when children and youth have been made to have sex against their will? Probe: How has migration (moving) since the earth quake affected people having sex against their will? 11E. How likely are children and youth to recall being touched vs recall being forced/pressured to have sex? 11F. I am now going to go through a list of terms. Please say what these words may mean to children and youth. It is ok if you think of more than one meaning. What is an example of each? What is an example of someone being pressured to have sex? Pressured Harassed Forced Coerced Tricked 11G. Are there other terms that children and youth may use to talk about having sex against their will? Facilitator: Write down all terms they list Page 62 of 64 12. QUESTIONS ABOUT COUNSELING SOURCES (F218) My next question is about where children and youth go for help if they experience violence. 12A. Where do children and youth who have experienced violence go to for counseling? 12B. What other people or places offer counseling services for children and youth? 12C. What are reasons children and youth might not seek counseling services? 12D. I will now read out types of services. For each one, please say what they offer or do for children and youth? What are reasons children and youth would use these? What are other terms children and youth may use for these? Mental health services Psychosocial services Medical services Legal aid Police Security protection 12E. What are other types of services children and youth who have experienced violence may seek? Page 63 of 64 CLOSING QUESTION Thank you for your input. We are almost finished. I have one last question as we end our discussion today. Is there anything more that you would like for us to know about violence among children and youth? ENDING THE FOCUS GROUP DISCUSSION Thank you for talking with us today. What you have to say is important and will help us better understand concerns about health and social practices as well as issues related to violence among children and youth. The information will also be helpful in developing programs for improving health and safety. If you have any concerns about health and safety and would like someone to talk with in private, there is a list of resources available for you. Please remember, all the things we talked about in this group will be kept secret. This means that we all agree not to talk to people who are not part of the group about any person in the group or what they said during the group. Facilitator: Summarize key points from the discussion Give handouts with resource information ### Page 64 of 64