RESEARCH ARTICLE Open Access

The potential role of network-orientedinterventions for survivors of sexual andgender-based violence among asylumseekers in BelgiumEmilomo Ogbe1* , Alaa Jbour1, Ladan Rahbari2, Maya Unnithan3 and Olivier Degomme1

Abstract

Background: Social support and social network members have been identified as an important factor in mitigatingthe effects of sexual and gender-based violence (SGBV) and improving the coping process for many survivors.Network oriented strategies have been advocated for among domestic violence survivors, as they help build onimproving social support and addressing factors that alleviate repeat victimization. There are opportunities toimplement such strategies among asylum seekers who are survivors of SGBV in asylum centres, however, this hasnot been fully explored. This study sought to identify key strategies and opportunities for developing peer-led andnetwork-oriented strategies for mitigating the effects of SGBV among asylum seekers at these centres.

Methods: Twenty-seven interviews, were conducted with service providers (n = 14) / asylum seekers (n = 13) atthree asylum centres in Belgium. A theoretical model developed by the research team from a literature review anddiscussions with experts and stakeholders, was used as a theoretical framework to analyse the data. An abductionapproach with qualitative content analysis was used by the two researchers to analyse the data. Data triangulationwas done with findings from observations at these centres over a period of a year.

Results: Many of the asylum seekers presented with PTSD or psychosomatic symptoms, because of different formsof SGBV, including intimate partner violence, or other trauma experienced during migration. Peer and familysupport were very influential in mitigating the effects and social costs of violence among the asylum seekers byproviding emotional and material support. Social assistants were viewed as an information resource that wasessential for most of the asylum seekers. Peer-peer support was identified as a potential tool for mitigating theeffects of SGBV.

Conclusion: Interventions involving asylum seekers and members of their network (especially peers), have thepotential for improving physical and mental health outcomes of asylum seekers who are SGBV survivors.

Keywords: Social support, Asylum seekers, Violence, Network theory, Sexual and gender-based violence

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: emihoms@gmail.com1International Centre for Reproductive Health, Ghent University, CorneelHeymanslaan 10, 9000 Ghent, BelgiumFull list of author information is available at the end of the article

Ogbe et al. BMC Public Health (2021) 21:25 https://doi.org/10.1186/s12889-020-10049-0

BackgroundSocial support and the positive influence of social net-work members are important factors in mitigating theeffects of sexual and gender based violence other formsof violence and life stressors, as well as improving thecoping process for many survivors [1, 2].In this article, we refer to social support as ‘comprising

both the social structure of an individual’s life and thespecific functions served by various interpersonal rela-tionships’ [3] We also define sexual and gender basedviolence (SGBV) as any act that is perpetrated against aperson’s will and is based on gender norms and unequalpower relationships [4]. Sexual and gender-based vio-lence also encompasses threats of violence and coercion.It can be physical, emotional, psychological, or sexual innature, and can take the form of a denial of resources oraccess to services. It inflicts harm on women, girls, men,and boys. There are currently knowledge gaps on theprocesses through which peer-support mitigates conse-quences of sexual and gender-based violence, amongasylum seekers, in existing peer-support interventions.Many asylum seekers experience sexual and gender

based violence during their migratory journey from thecountries to Europe, as well as in the destination coun-tries [5], men, women and young children are all victimsof SGBV but women and children are the most vulner-able [6]. The consequences of sexual and gender-basedviolence are limited not only to physical consequences,but also psychological effects as well, like injuries, gynae-cological disorders and mental health disorders, mostcommonly post-traumatic stress disorder [7–9]. In thispaper, we define PTSD within this study as ‘a mentalhealth condition that’s triggered by a terrifying event —either experiencing it or witnessing it. Symptoms mayinclude flashbacks, nightmares and severe anxiety, aswell as uncontrollable thoughts about the event’ [10].For asylum seekers, the added layer of vulnerability dueto their experience of escaping a humanitarian settingand stressful experiences of migration, makes disclosureand help seeking difficult, especially considering they arein a different context without their regular sources of so-cial support and assistance [6].The mechanisms and processes through which social

support affects coping processes is complex and timedependent. It is also reliant on the structure of the socialnetwork and inherent capabilities of the individual [11].A study comparing the social networks of women inabusive relationships with their domestic partners, com-pared to ‘non-abused’ women, found their social net-works to be smaller, with fewer reciprocated ties. Thesewomen were also more likely to provide support thanreceive it, compared to non-abused women of the samesocio-economic group [12]. Although abused womenoften played a ‘central’ role in their networks, mostly

serving as a link between different members of their net-work and as a resource person, they had few people theydiscussed their problems with.Survivors of SGBV will seek help first through infor-

mal sources (friends and families) before more formalsources like medical centres and legal assistance [13].Several reasons are often cited for this, some of these in-clude sociocultural beliefs around sexual and gender-based violence, and the stigma and shame associatedwith seeking help from formal sources. Other reasonscited is the feeling that these formal sources (judicial,health centres and shelters) might not provide the re-quired support needed. In these cases, survivors of vio-lence were more likely to discuss their experiences ofviolence with close friends and family [14, 15]. This, elu-cidates the need for closer attention to network mem-bers of survivors of violence when developinginterventions [2]. This is especially true for asylumseekers, refugees and undocumented migrants, with thesame national and ethnic identity, among whom stron-ger ties might exist than with service providers or mem-bers of the destination country [16]. Smith’s work onfemale refugee social networks revealed an evolving so-cial network structure, with strong homogenous tiesamong people with similar national identities, and weaksocial ties with people from the host country. Weak tiesrefer to social network members that do not have astrong influence, live far from the survivor of violence,are not part of their everyday lives, especially relation-ships that are not reciprocal and the asylum seeker doesnot consider high value. The importance of this state-ment is related to asylum seekers, refugees and Intern-ally displaced persons who due to migration ordisplacement have been separated from family andfriends with strong social ties and now live-in countrieswhere they have weaker social ties/ connections withpeople around them.Network-oriented strategies have been advocated for

among SGBV survivors, as they help build on improvingsocial support and addressing factors that alleviate re-peat victimization [17]. They have also been used amongother vulnerable populations like intravenous drug users[18], for HIV risk reduction strategies [19] and to pro-vide support for individuals with chronic conditions likediabetes [20]. There are opportunities to implementnetwork-oriented strategies among asylum seekers, forexample, involving family members and peers in mentalhealth interventions, group therapy sessions [21] for in-terventions similar to mentor mothers [22]. There arealready existing network oriented interventions, specific-ally family-oriented interventions, focused on the mentalhealth of asylum seekers and refugees’ which have beenfound to be successful [23]. These strategies could alsobe implemented in different humanitarian settings. In

Ogbe et al. BMC Public Health (2021) 21:25 Page 2 of 15

this study, we have defined asylum seekers as ‘someonewhose request for sanctuary has yet to be processed bythe host country [24] .This study sought to understand the social network

and support characteristics of asylum seekers and refu-gees at three different asylum centres in Belgium. Con-sultations with different stakeholders and findings fromthe interview were used to develop a theoretical modelthat explains the motivating factors and thought pro-cesses involved in decision making and factors associ-ated with their social network that affect disclosure ofintimate partner violence survivors. The aim was toidentify key strategies and opportunities for developingpeer-led and network-oriented strategies for mitigatingthe effects of sexual and gender-based violence amongasylum seekers at these centres. In this paper, networkinterventions are defined as ‘purposeful efforts to use so-cial networks or social network data to generate socialinfluence, accelerate behaviour change, improve per-formance and/ achieve desirable outcomes among indi-viduals, communities, organizations or populations [25].We also refer to ‘peer-led’ interventions or ‘peer to peer’support as interventions led by, or support from otherasylum seekers, who have experienced sexual andgender-based violence. This could be in the form ofmentoring and providing information and referrals, orthrough online or group forums [26]. As a result of con-sultations with experts and findings from interviews withasylum seekers and service providers, we developed atheoretical model to explain the ‘pathways’ and factors

that determine how actions of network members influ-ence the decision to access health care services and thedifferent outcomes of these processes [27].

Theoretical modelThe development of the theoretical model was based on:

i) a literature review of network and social supporttheories and interventions among survivors ofsexual and gender-based violence

ii) In-depth discussions with asylum seekers who weresurvivors of violence, experts in the field of migranthealth, intimate partner violence and other forms ofsexual and gender-based violence, as well as eco-nomic theorists with expertise on network effectsand game theory.

The added value of this approach was to ensure thatthe model reflected the realities of support structures ofmany asylum seekers, refugees, and sexual based vio-lence survivors, as well as the important factors that in-fluenced their decision making. The model andinfluencing factors is depicted in Fig. 1 [27].The proposed model discusses the way actions and ef-

forts made by network members can positively or nega-tively influence decisions to access sexual and gender-based violence. We have explained the different factorsof the model. The underlying assumption of this theoret-ical model is that different factors influence decisionmaking regarding reporting an incident of sexual and

Fig. 1 Model explaining network effects on reporting behaviour of intimate partner violence survivors

Ogbe et al. BMC Public Health (2021) 21:25 Page 3 of 15

gender-based violence, at the interpersonal level, withina survivor’s social network. For example, a survivor, whohas more access to resources, is literate and is situatedwithin an asylum centre, with SGBV reporting policies,screening and referral availability, is more likely to havemembers of their social network within the asylumcentre, who will support reporting the incident of SGBV.The effort made by the social network member to en-courage the survivor of SGBV to report or not report,will have a large influence on the decision as well, how-ever, this is highly determined by the power and influ-ence, this network member has. So, the level ofinfluence of a close friend or relative is determined notonly by the existence of the relationship but by the qual-ity of the relationship, and how well connected the net-work member is.The network factors outlined in the theoretical model

are discussed below:

Factor A. survivors and network members’ attributesThese refer to ‘intrinsic’ characteristics of the survivorand network members, for example, gender, age, ethni-city/ race, and other related characteristics that could bedefined as sociodemographic. An additional factor, weincluded into this category, is the concept of ‘resilience’-which we define as the ability of asylum seekers who aresurvivors of sexual and gender based violence to copewith the psychological consequences of their experiencesand trauma during migration, and navigate the chal-lenges of adapting to a host country in a hopeful yetpragmatic way [28].

Contributing co-factor, a: contextual effectsThese are ‘extrinsic’ attributes for example the refugeecamp or centre, existing laws and regulations regardingaccess to SRH services for asylum seekers, availability ofinfrastructure and sufficient staff to address these issues,as well as a reporting mechanism for reporting cases ofgender-based violence.

Factor B. network members’ reaction to the survivorreportingThis refers to the probability or chance that networkmembers will react positively or negatively to the deci-sion of the refugee to seek out health care services.

Contributing co-factors B

i) Effort required by the network members to supportor oppose: We assume that the network membersof a survivor of SGBV are rational in thought.Hence, if it takes too much effort to support thesurvivor to seek healthcare services, this willinfluence their decision to provide support. Hence,

the higher the personal effort or cost to support thesurvivor of violence, the more likely they will beneutral or oppose the decision of the survivor toreport or seek healthcare. An example of effortcould be the financial cost, time cost or emotionalburden of providing support.

ii) Degree and centrality measures of networkmembers: Degree and centrality measures refer tothe ‘power’ or level of influence, the networkmember has within the refugee’s social network.High degree (highly influential and connected)members who oppose or support the refugee toaccess health care service, will have more influenceon the decision making and the actions of othernetwork members, than network members with fewstrong ties and lower levels of influence.

Factor C: constraint and cohesiveness of the networkIn our model, we assume that within a network, the ex-tent to which, network members’ actions and percep-tions can prevent the refugee from reporting oraccessing health care is dependent on how cohesive thenetwork is; by ‘cohesiveness’ we refer to the strong tiesbetween groups, that ensure the members of the groupremain linked.; A constrained ego (network member)within a cohesive network, is one in which the otherpeople in the network are connected to each other, andthe ego’s actions and perceptions are controlled by hisor her personal network [25].

Threshold and resilienceIn our model, we propose that the additive and detri-mental effect of these factors will result in several out-come scenarios based on the idea of a threshold.Survivors of violence will seek health care with positiveconsequences if the additive effects of Factors A, B andC and their co-factors exceed this required thresholdlevel. Below this threshold level the benefits of reportingwould be non-existent, or reporting might cause therefugee such negative consequences, that it is not intheir interest to seek health care services.In developing this concept, we also take into account

unexplained characteristics like resilience, which weunderstand is difficult to measure. When we define re-silience, we refer to the innate ability of a survivor ofsexual and gender-based violence to cope with externalstressors and challenges, in spite of the absence of re-sources and support. By mapping out these factors, wehope to provide a way to map out with qualitative andquantitative factors, the way social networks affect deci-sions to access health care among asylum seekers, notonly in cases of sexual and gender-based violence butother stigmatizing situations, and for example when

Ogbe et al. BMC Public Health (2021) 21:25 Page 4 of 15

refugees are dealing with mental health issues or infec-tious diseases like HIV/AIDS.

Outcomes from network effectsWe describe several potential outcomes based on theconcept of a ‘threshold effect’, looking at the summationof ‘positive’ and negative influences of network mem-bers, as well as intrinsic and extrinsic factors that mightinfluence decision making, already explained above. Wehave divided these outcomes based on whether the levelof support is equal to, less than or more than the levelof conflict and the decision the survivor takes.

� Outcome 1:Survivor reports, and the level ofsupport is greater than conflict, which would be thebest outcome for the survivor. In this scenario, thesurvivor will require less effort to report (hence, lessindividual cost), as their network members willprovide sufficient support and resources(information, emotional and monetary support) tomitigate whatever stigma or negative consequencesthey will experience, after reporting.

� Outcome 2: The level of support and conflict isequal, but the decision to report is based onsurvivors’ perceived benefit of reporting, as opposedto the actual benefit. In this scenario, there areseveral challenges to reporting their experience ofsexual and gender-based violence and seeking healthassistance. These challenges are equal to whateversupport or benefit the survivor might gain fromseeking care. Hence, the decision to report is moreheavily influenced by the ‘perceived’ personal cost tothe survivor of violence, and less on the existingchallenges or benefits. We assume that most peoplein this situation, do not report or seek health care,unless there is an intervention.

� Outcome 3: The level of support is less than thelevel of conflict caused by reporting, but thesurvivor decides to report. In this scenario, theconsequences of reporting, for example stigma, lossof resources and support network, etc., far outweighthe ‘social’ benefits of reporting. However, thesurvivor goes ahead and reports their experience ofviolence. In this situation, this survivor of violencerequires more support from health workers, as wellas psychosocial counselling and follow up. Thesesurvivors might be viewed as having more resilience,but are actually in a more vulnerable situation, as aresult of seeking care.

� Outcome 4: The level of support is less than thelevel of conflict caused by reporting, but thesurvivor decides to not report, in this scenario, thesurvivor of violence makes a rational decision to notseek health care because of the negative

consequences of reporting. However, in so doingthey are unable to get treatment and the neededpsychosocial counselling required. Also, in aninstance where the perpetrator(s) are part of thefamily, there might be repeat incidents of abuse.

MethodsDifferent qualitative research methods were triangulatedto cross-validate research findings. A combination ofethnographic methods, specifically observations werecombined with key in-depth interviews between Novem-ber 2016 to February 2018. The total number of hoursspent on observations, was 862 h. Interview guide ques-tions and themes are attached to this manuscript as anappendix. The observations were conducted in threecentres, two of these centres were located in East Flan-ders and the third was located in Brussels. See Table 1which provides more detail about the centres and timeallocated to each centre. See Table 2 which provides spe-cific information about service provision at the centres.Ethnographic methods were employed to help us under-stand the pathways of care and the daily life experiencesof people who lived in the different centres selected forthe research. Observations involved following-up withconsultations, assisting with daily tasks required in thecentres’ and attending social events with the refugees.Selection of the centres was purposive and done in col-laboration with the Director of Medical services for theFederal Agency for the Reception of Asylum seekers(Fedasil), as well as with researchers and service pro-viders working with asylum seekers. The purpose ofchoosing different types of centres was to assess how thestructure and organization of asylum centres and pol-icies influenced the perception of support by the refu-gees in the centres and the relationship between theservice providers and the asylum seekers. Ethics approvalfor the study was gotten from the Committee for Med-ical Ethics, University of Ghent teaching Hospital. Ap-proval to conduct the study at the asylum centres, wasobtained from FEDASIL. Purposive sampling was doneto ensure that research participants were a mixed groupof service providers (social workers (2), psychologist (1),nurses (3), education workers (2), medical doctors (4)and asylum seekers (13) (men, women). Informed con-sent was obtained from all participants and permissiontaken for audio recording. See Table 3 for summary ofresearch participants” information.We stopped interviewing more research participants

when thematic saturation was reached. Studies with asimilar focus, have found thematic saturation to bereached at 12 participants [29]. In this paper, thematicsaturation refers to a point, where analysis of new inter-views or data reveal no new findings or insights that dif-fer from that of prior interviews [30]. Research

Ogbe et al. BMC Public Health (2021) 21:25 Page 5 of 15

Table 1 Summary of information about centres and observation activities at study sites

Name ofcentre/Location

Description of centre Type of centre Activities done/observed Length ofobservation

General description

Centre 1 Located by the port, in anold ship. Capacity: 250people. Majority of theresidents were of Syrian,Iraqi, Iranian and Afghanorigin. A combination offamilies and single persons.Rooms were for 4 to 6people in bunks. No specificdemarcation of male andfemale spaces

Open-access centre Consultations with thedoctors, nurses, socialworkers, and educationworkers. Provided supportfor clinic consultations andspoke with and interviewedrefugees at the centre

6 weeks/ 6–9 hper week:November toDecember 2016(Centre closedFebruary 2017)

Medical and social serviceswere located within thecentre. However specificopening hours wereallocated for serviceprovision. The nurses andeducation workers weremore accessible to therefugees, the doctors muchless so. Free entry into thecentre by refugees (i.e.,entrance not manned bysecurity officers or nobarriers or gates), howeverthey were allowed onlyspecific days to live outsidethe centre. Privateconsultation rooms wereavailable that allowed for acertain level of privacyduring consultations.Translation services wereoften required duringconsultations, as majority ofthe respondents were Iraqiand Afghan speaking. Therewere some drug stock-outs,however nurses often hadpainkillers and flu- medica-tion and gave this to pa-tients. No specific protocolfor addressing GBV, case wasdiscussed in team meetings,transfers done if required,and the survivor was oftenreferred to a psychologist.Living rooms, consisted ofbunks of 4–6 people, withmales and females andmixed groups of people. Nocase of GBV consultation ob-served during duration ofethnographic work. How-ever, there were reportedcases handled earlier priorto commencement ofobservation

Centre 2 Located in the centre of thecity in Gent, Capacity of 85Majority of the population,unaccompanied minors of|Afghan origin. Mostly singlemales, no family presentduring the duration ofobservation

Open-access centre Consultations with socialworkers and educationworkers, engaged in socialactivities with the refugees,cooking and outdooractivities, organized a sexualhealth workshop/ focusgroup discussion at thecentre

9 months: May2017 to March2018, 5–8 h perweek

An external mode ofdelivery for health careservices, as medical servicesare not located in thecentre. Most of therespondents had receivedpositive responses for theirasylum procedure and somewere also classified as‘medical cases’ with chronicdiseases like Diabetes,Chronic Kidney failure orAIDS. Referrals to clinics wasdone and to GPs, as nomedical service wasavailable ‘in-house’. Socialassistants were easilyaccessible, as their officeswere located within the

Ogbe et al. BMC Public Health (2021) 21:25 Page 6 of 15

participants approached for an interview, were encour-aged to take their time to review the informed consentform or think about the research, before agreeing to signthe informed consent form and be interviewed. For theasylum seekers recruited at the clinics, the research

project was always introduced by a service provider, afterthe consultation was finished. They were assured thatparticipation in the research project was voluntary andwould not influence their asylum procedure or access toservices. Information about the research was also made

Table 1 Summary of information about centres and observation activities at study sites (Continued)

Name ofcentre/Location

Description of centre Type of centre Activities done/observed Length ofobservation

General description

centre,

Centre 3 Located in Brussels, has acapacity of 850 people,population is mixed and haspeople from Asia (includingthe middle east) sub-Saharan Africa, Latin Amer-ica, and Eastern Europe

The centre has gates, and abadge is used to enter andleave the centre, refugeeshad to take permission toleave the centre and wereallowed to stay outside thecentre for only a certainnumber of days. In manyways felt like a closed gatedcamp

Consultations with healthcare providers, multi-disciplinary team meetings.Informal discussions withrefugees at the waitingroom and the courtyard

1 year: May 2017to May 2018: 6–10 h/ week

Medical centre availablewithin the refugee centre,refugees who want to usethe medical service areexpected to come to thecentre and bookconsultations between 10and 12. ‘Less serious cases‘are seen by the nurses,which means things likecolds, cuts and bruises thatneed to be sutured etc., andmore serious conditions thatrequire treatment withprescriptions or a morethorough medicalassessments are given datesfor consultation with thedoctor.

Table 2 Key characteristics of the centre

Typeofcentre

Serviceprovidersavailable‘in house’

Availabilityof protocolto addressviolence

GBV / Torture referralpathway

Commonly used GBV / Tortureinterventions

Key challenges

Centre1

Yes No Reports to doctor/ Socialassistant, reviewed and thenreferred to psychologist

Referral to psychologist, transfer toanother centre, to separate theperpetrator from the survivor in casesof domestic violence/ interpersonalviolence

No defined protocol for addressinggender-based violence or torture.Clear pathways and action plans notdefined. Made harmonization of prac-tices and responses difficult across dif-ferent service providers

Centre2

No No Discuss with the socialassistant and then refer to apsychologist if needed/requested

Referral to specialists, transfer survivorto a quieter centre, if survivor hassymptoms of PTSD or other mentalhealth problems

Disclosure was difficult and rare,especially as this centre had mostlymales, stigma around gender-basedviolence and PTSD in males, madehelp seeking behaviour rare. No de-fined protocol and pathway of carewas available

Centre3

Yes Yes Refer to the doctor for physicalbruises and then to thepsychologist or an externalorganization for psychosocialsupport

Refer to psychologist, discussexperience of violence in amultidisciplinary team, transfer thesurvivor to another centre in the casesof domestic violence

Rates of disclosure was very low.Language translations served as abarrier as well during consultation,though efforts were made to employtranslators and use on-line translationservices. Consultation hours were spe-cific and few service providers, andnot all patients could see a doctorwhen needed Before the end of theobservations, they had employed apsychologist ‘in-house’ that saw survi-vors of violence during consultationhours. It was hoped this would im-prove access to psychosocialcounselling.

Ogbe et al. BMC Public Health (2021) 21:25 Page 7 of 15

available in Arabic, French, Dutch, Farsi, Pashto, andDari and placed in common areas in the different asylumcentres. Translation of the research information andback translation was done with an Afghan refugee, whohad practised as a medical doctor and was now workingwith refugees as a medical translator, he participated insome of the interviews and discussions of findings. ASyrian refugee was also employed as a research assistantto ensure there was reflection and reflexivity on some ofthe findings and we were able to incorporate the view-points of refugees and asylum seekers in the interpreta-tions of the qualitative research. An additional FocusGroup Discussion was done based on the request for asexual health workshop by one of the centres. The work-shop was done in English, Dari, and Pashto with fivemale asylum seekers at the centre, who were also inter-viewed individually. It was co-facilitated by an Afghanrefugee who was a medical doctor and worked at theUniversity as a medical translator. See Additional file 1,which provides details of the interview questions used.For the analysis, we used an abduction approach,

which focuses on finding explanations from observedfacts’, using a combination of inductive and deductivemethods [31, 32] qualitative content analysis [33] wasdone based on pre-identified codes based on the re-search questions developed by the researchers. For thedata analysis, we used Atlas.ti, a qualitative research soft-ware that allowed us to classify our themes into codefamilies and codes (categories and subcategories). Thisensured that both researchers (EO and AJ) were able tocode using the same frame of reference, discussionsabout codes and their meanings were discussed betweenthe researchers [34]. We developed the theoreticalframework and research hypothesis from a literature re-view and discussion with experts, we then proceeded todevelop codes and code families to reflect the main con-cepts behind the theoretical framework. However, duringthe coding process, we recognized that our codes andcode families were not necessarily sufficient to captureall the differing concepts. In those cases, we did opencoding and then subsequently categorized the codes intocode families that already existed or created new codefamilies. Triangulation of qualitative data generated fromthe different qualitative research methods, information

from the interviews and findings from observations doneat these centres over a period of a year, was used tounderstand the pathways and ways social network mem-bers influence decision to access sexual and genderbased violence services for SGBV survivors at the asylumcentre [35].

ResultsWe have described the key findings based on the theor-etical framework described above.

Survivor’s and network members’ attributes (factor a)We classified several factors related to respondents’ fam-ily situation, their experiences of sexual and gender-based violence before and during their migration toBelgium, as well as, the structure of the asylum centre,including service provision and health system factors, ascontextual factors. Twenty-seven respondents wereinterviewed during the research projects. All respon-dents were above the age of eighteen and were able togive informed consent. The service providers consistedof social workers, education workers (focused on lifeskills and supervising daily activities in the centre), med-ical doctors, nurses, and psychologists. The asylumseekers were from East and West Africa and West Asia.A third of the asylum seekers had at least a bachelor’s levelof education and cited political unrest and economic reasonsas some of their reasons for migration. Specific details aboutthe countries they come from have been excluded to protecttheir anonymity and prevent stigmatization that might arisefrom conclusions of the study. During the interviews, issuesaround integration were identified as important by all the re-spondents but more by the social workers. This was definedas being more than just understanding the local languagebut also behaving in what was considered a ‘culturally ac-ceptable manner’. The term ‘culturally acceptable’ was de-scribed in terms of adhering to an acceptable dressing style,manner of speaking, ‘ways of conducting oneself’ and hy-giene. However, one could argue that these integration issueswere not cultural per se, but more related to ideas aroundpropriety in Belgium and conflicts with different behaviouralattitudes and diversity.

‘ … social network with local people. It is not an easytask. Lots of cultural differences, first they have acultural shock, a lot of differences, … , you need toomuch time to integrate.’ (Medical translator anddoctor, Refugee)

‘ … you walk on the street and you see, a lot ofpeople say. We see these people (refugees) and we areafraid … that’s a small thing, I think the way youdress is less important than the way you conductyourself.’ (Social worker)

Table 3 Information about research participants

Type of respondent Number

Social worker 4

Medical doctors and psychologist (1) 5

Nurses 3

Asylum seekers 13

Medical directors 2

Total 27

Ogbe et al. BMC Public Health (2021) 21:25 Page 8 of 15

The social worker discussed the underlying tension orfear among the local population, as what could be re-ferred to as ‘the fear of difference’, specific issues raisedwere the ‘loud manner’ of some migrants, which wereperceived as aggressive, or the unruly behaviour of mi-grant children from specific backgrounds.The duration of stay in Belgium varied from 3 months

to 7 years among the research participants, who wereasylum seekers. However, there was no reported associ-ation between length of stay in Belgium and perceivedlevel of integration. It is important to point out the com-plexities of integration in Belgium, which are heavily in-fluenced by linguistic and regional politics and can beether broadly defined as assimilationist or multi-culturist. The multi-culturist-interventionist type of pol-icy and approach, which is more common in the Flemishregion is characterized by compulsory civic and languageclasses, and a focus on migrants adhering to the Flemishidentity. The assimilationist colour blind approach ismore common in the Walloon region and has a policythat allows room for diversity, hence the lack of compul-sory language classes. These differences may add layersof complexity to the definition of cultural integration inBelgium.Most of the asylum seekers and health workers inter-

viewed for this study were reflective while describingtheir experiences providing or accessing healthcare atthe centres. Most of the refugees expressed an appreci-ation for the services they were provided at the differentcentres, while also expressing dissatisfaction at barriers,which are described later in this paper. The service pro-viders also seemed to understand the budgetary and hu-man resource challenges encountered in their provisionof services and described different strategies for dealingwith this.

Prior and current experiences of sexual and gender-basedviolencePhysical violence was the most reported type of sexualand gender-based violence among the respondents. Mostof the respondents discussed this situation with the socialworkers. One of the most common barriers discussed wasthe cultural expectation or shame linked with sexual andgender-based violence (physical or sexual). Responses toreports of physical violence were varied, from ‘no actiontaken’ to provision of psychological counselling.

Physical mostly, physical violence is often [reportedby] men and women, but sexual violence either peopleare not disclosing, (or there are) rare cases, I have seenmyself. I think this exists but might be because ofshame, taboo, or cultural differences they are not goingto disclose it. (Research assistant, Male)

Some of the service providers reported instances oftorture among the male refugees. They also discussedthe difficulties with getting these men to share theirexperiences of trauma. While all the service providersrecognized the importance of providing counsellingand psychological care to the asylum seekers, mostcentres had no in-house psychologists present. Exter-nal referrals were often required, as some of the asy-lum seekers had symptoms of post-traumatic stressdisorder (PTSD).

Yes, of course I would never say, this one has beentortured, but I could say to the reception or to thenurses, don’t disturb us now, because it is a heavyconversation. So that would create like a kind ofbubble … Especially because we had men who hadbeen raped, they would never talk about this in theirinterview, because of the shame and trauma, it wastoo big. And in this way, a psychologist … we had aconversation about torture, and I would never stop itat that, because then the story is out, but the evilspirit is also out. So, we need to provide counsellingand afterwards … There were some particularlygood psychologists, (with) whom I would make surethat the people would go there for follow up and fortreatment. (Medical doctor, Female)

From conversations with service providers, it seemedthat men were more likely to report their experiences ofsexual and gender-based violence as torture and womenas experiences of sexual and gender-based violence.Sexual violence: Though there were instances of sexual

violence, disclosure was difficult and often dependent onthe attitude of the health professional. Health care pro-fessionals who probed deeper for sexual violence risk,were more likely to have patients disclose theirexperiences.

… I see a lot, and I think not all are … I try to ask,it is not easy to ask directly, for women it’s not easyto answer … I am clear that lot of people (have ex-perienced) sexual violence … not only women, wehave a lot of young men from Afghanistan (have ex-perienced) sexual violence too. So, I try to askwhenever it’s possible. But I see a lot, more than nor-mal with my consultations... (Medical doctor,Female)

The medical doctor quoted above repeatedly stressed onthe sensitive nature of screening for SGBV, a strategyshe used, was to ask a lot of general questions beforediscussing sexual violence. Another medical doctoraffirmed:

Ogbe et al. BMC Public Health (2021) 21:25 Page 9 of 15

… A lot. Oh, they were very open about it. But never,almost never from the beginning, of course. That'swhy I think this intake was ok, because we wantedto give them the feeling that there was an opportun-ity to talk about it. And for many times we opened,we were very active in starting a conversation aboutthis (Medical doctor, Female).

This comment reaffirms the importance of screening forexperiences of sexual and gender-based violence, as thisprovides an ‘opening’ for asylum seekers to discuss theirexperiences.

Common health problems: psychosomatic symptomsSome of the most common health problems, the respon-dents presented with at the health clinic were psycho-somatic, we use the term ‘psychosomatic’ to refer tophysical conditions and symptoms that are an expressionof the emotional or psychological state of an individual’.For example persistent body aches, with no other under-lying causes or explanation apart from repeated psycho-logical trauma or stress [36], it was rare for them topresent at the clinic and directly report their experiencesof SGBV They only agreed to share their experiences ofviolence after several discussions. Psychosomatic symp-toms were often related to experiences of trauma, duringtheir migration journey or in their home country, andsymptoms of post-traumatic stress disorder.

… it is mostly combination of anxiety related prob-lems including sometimes Post Traumatic Stress Dis-order, and sometimes more severe problems likepsychosis. Sometimes stomach pain, breast pain, andanxiety related problems like flashbacks, and depres-sion of course. Often related to a combination oftraumatic experiences and losses, born in uncertainsituations, difficult events... (Psychologist, female)

… long time, long time. But support here (inBelgium) because sometimes I couldn’t sleep, I woulddream about it, but they gave me some tablets tohelp me sleep. I used to take them but after sometime I stopped because I wanted to sleep in a nat-ural way. I am afraid, still have them with me.Sometimes it happens, I can spend one week withoutsleep, morning, evening I don’t sleep, and I amstrong. But that is not life... (Asylum seeker, SGBVsurvivor, female)

These findings show that service providers need tospend sufficient time discussing with their patients/ cli-ents and probing for experiences of violence, as dis-cussed above. Survivors of SGBV, might be more

vulnerable to repeat experiences of SGBV, especially asthey are far from home and live-in asylum centres. Italso requires that most medical centres ensure that theyhave the right referral pathways, so they can ensure sur-vivors of violence identified have the right access to psy-chosocial support. Survivors of SGBV, might be morevulnerable to repeat experiences of SGBV, especially asthey are far from home and live-in asylum centres.

Co-factor a: contextual factorsContextual factors such as cultural norms and healthsystem factors were also reported by most intervieweesas influential in their decision making to access health-care services.

Family support and cultural norms around SGBVFamily members of a survivor of violence could influ-ence their coping strategies and attitudes towardsreporting their experience of violence. In a case of a fe-male survivor of sexual and gender-based violence, hermother’s support was highly valued as it gave her thepsychological support required. Her mother told her tocope with the experience of domestic violence, as it wasa cultural norm for husbands to sometimes beat theirwives. This example outlines the complexity of family re-lationships and reporting patterns. Family membersmight be able to provide functional support to survivorsof violence and aid them in coping with stress and psy-chological effects, and still discourage them from report-ing. In some cases, the family member might be themain aggressor, and more interested in preventing thereporting of violence. Hence, network interventions thatfocus on key players (very influential network members)would have to take into account the complexities thatexist in social networks with family members.

Asylum application processThe asylum application and process arose from most ofthe interviews as a crucial component and an indicatorof the well-being of asylum seekers. Most of the respon-dents (asylum seekers and service providers) spoke ofthe difficulties of being ‘in transition’ being moved fromone centre to another, while awaiting the decision ontheir asylum. This was a factor that had a significant ef-fect on their psychological well-being. These changesand frequent movement among people still within theasylum process, might make it difficult for sexual andgender-based violence survivors to access needed care,as well as needed follow up, psychosocial counsellingand medico-legal procedures.

‘there’s a huge difference, in terms of the challenges,the uncertainty, you often see it in the chain fromthe asylum procedure, to obtain a status, that makes

Ogbe et al. BMC Public Health (2021) 21:25 Page 10 of 15

a huge difference both in the positive and the nega-tive sense, it impacts your mind … positive is whatgives security and safety, the feeling that I can nowstart my life, Negative (asylum status) is that youbegin to lose many support structures in terms of theasylum centre and that feeling of stability … ’(Ser-vice provider, psychologist, female).

Availability of health service providers and treatmentIn general, health service providers, social workers,nurses, and doctors who provided services to SGBV sur-vivors referred the survivors to psychologists, with theirconsent. Among the three centres that the observationsand interviews were carried out, none had ‘in house’ spe-cialized treatment and forensic services for SGBV ser-vices, so all survivors had to be referred to externalservices. We have classified health services as part of theconcept of ‘context’ because they are sometimes the onlyformal source of support and help, which SGBV survi-vors can access. The health service providers had specificopening times, and these were sometimes identified as abarrier to accessing health care.There was a reported disconnect between refugees and

service providers’ expectations about availability andopening hours. The working hours of the centres weresometimes perceived as a barrier for access to healthcarefor most of the asylum seekers. However, for the serviceproviders it was especially important for them to havethat structure to enable them function effectively. Whenthe opening times were not respected, this was oftenviewed as ‘crossing boundaries’ or ‘being disrespectful’.

… But I always give the signal that it is possible tocome, if they want something, and I keep remindingthem. But they also have to follow the rules, becauseit is not because you are a loner and one time youmake a decision you come and ask for help, if youdo it in the break, it is break time, you are not get-ting special treatment … (Social worker, female)

… yeah, yeah, it’s been easy (to access healthcare).The problem is that they just open for two hours.But the service is good when they try to do every-thing, and when they can’t they transfer you to thebig hospital. If you don’t have an appointment, theycan’t. But they do their best’ (Asylum seeker, female)

It is important to note that the concept of availability isnot the same for service providers and for asylumseekers (service users), and this could influence how sur-vivors of violence perceive the availability of support forthem. It is important that service providers take into ac-count that specific vulnerable groups, for example, survi-vors of violence might require access to support services

that extend beyond daily working hours. Creating alter-native services, like chat lines or emergency supportcould make a difference in access to healthcare for thesegroups and mitigate harmful consequences. Also, fromthe human resource perspective, understanding the needfor extra hours and more staff, referral pathways and ad-equate compensation for staff, can prevent burn out andmotivate service providers.Some of the respondents reported difficulties in acces-

sing services due to the lack of sufficient human re-source. This problem also limited the ability of serviceproviders to provide sufficient assistance and support tothe survivors of violence

… I know a lot of people came once or twice to thenurses and then say I don’t want to come back be-cause it not good. Lots of people think that medicalservices (are) not good because it’s difficult to accessthe doctors because there are lot of people, we don’thave sufficient spaces and workers … (Medical doc-tor, female)

Lack of trust and ambivalence from service providersTrust arose as an important factor, that could also beenabling and encourage disclosure of experiences of vio-lence. It was also a barrier when there is a lack of trustpresent.

… Many are willing to discuss but there are partsthat are hard to express. And it largely depends onthe situation they were in. if they are at peace to talkin a quiet stable situation. For some it’s hard to talkabout because it reveals lots of emotions. Sometimesthey feel like avoiding those emotions because theyare too tough to feel. It depends. I feel there is lot ofdistrust preventing them to talk about it. Protectingthemselves. It depends … (Psychologist, female)

In some cases, when the survivors of violence reportedtheir experience of violence, they were met with ambiva-lence from the service providers which discouragedreporting of violence.

‘[breathes] last time I was passing by the block F, Ihad come to see my assistant, I heard in one officeone lady telling that one guy was abusing her. Butsometimes these things happen. [And even if theytalk to the assistant, they do nothing]. I don’t know… they just give them advices … like I heard even be-fore I came to PC [centre] one lady was telling thatone guy was abusing her, the assistant was laughing,did nothing [reports of abuse taken very lightly, noredress l [sic] … but I heard that later they changedher room. (Asylum centre, Male)

Ogbe et al. BMC Public Health (2021) 21:25 Page 11 of 15

Medical centres that provide care to asylum seekers orundocumented migrants, often have a huge demandwith limited resources, making it difficult for many asy-lum seekers and undocumented migrants to develop re-lationships of trust with their service providers.However, it is possible for these relationships to be

built over time. For example, most asylum seekers inter-viewed developed good relationships with their socialworkers because of sustained interactions over time. Incentres, where asylum seekers saw a particular healthprovider over a long period of time, there was also moretrust between the provider and asylum seeker.

Factor and co-factor B: Network’s member reaction toreporting and effort required by the network members tosupport or opposeFrom the interviews, efforts required by family members,friends, and service providers, did not come up as anissue or factor that influenced the level of support. How-ever, in one interview with an asylum seeker, she men-tioned that it was impossible to get support from herfather because contact (via phone) would put him atrisk. In this case, the effort and personal cost requiredby her father to provide emotional or financial supportto her, was too high. The same fear of persecution offamily members, arose from other conversations withpolitical asylum seekers who had survived other forms oftrauma and whose families were still living in their homecountry. In most of these cases, there was no contactfrom family members.From interviews with service providers, the personal

cost of working extra hours or providing care during‘lunch hours could serve as a barrier to access. Some ofthem were unwilling to do this. Hence, our earlier rec-ommendation for training, recognition, and compensa-tion of extra working hours for service providers.

Factor C: costs of effort for the survivor to report or not

‘Yeah. And also, if the, for example, there is abuse inone family, ehm, and the family is here, there ismore pressure from the family members not to tellanything instead of, there is woman, or a man, com-ing here and has been abused, but here she is alone,maybe there is less pressure from the family’ (SocialAssistant, Female)

In many situations, especially if the asylum claim ismade by a whole family, and there is an incident ofSGBV, where the perpetrator is a family member, itwould be very difficult for the survivor to disclose andseek help for the incident because of the implications(the asylum process) for the whole family. In other in-stances, the dependence many asylum seekers have on

family and social networks for emotional and financialassistance, can also negatively influence their ability todisclose incidents of SGBV within the family circle. Un-derstanding these dynamics can be helpful for serviceproviders and researchers, in understanding the barriersto access to healthcare.Family members of a survivor of violence could influ-

ence their coping strategies and attitudes towardsreporting their experience of violence. In a case of a fe-male survivor of domestic violence, her mother’s supportwas highly valued as it gave her the psychological sup-port required. Her mother was very influential withinher network, but her mother discouraged her fromreporting and seeking help for her experience of SGBVfrom formal sources. Her mother told her to cope withthe experience of violence, as it was a cultural norm.This example outlines the complexity of family relation-ships and reporting patterns. Family members might beable to provide support to survivors of violence, which ishelpful with coping with stress and psychological effects,and still discourage them from reporting. In some cases,the family member might be the main aggressor or animportant influential member of the family. Hence, thecost of the survivor reporting the incident, would have anegative impact on the family relations, as well as a per-sonal cost to the survivor and family member.

Co-factor C: degree and centrality measure of networkmembersAmong asylum seekers interviewed, it was difficult to as-sess which asylum seekers were ‘central’ to their networkand were key players. However, it was clear from some in-terviews, that certain people had more authority and morecontacts with different asylum seekers than others. Also,during collection of pilot data and ethnographic work, itwas clear that some family members’ or friends’ opinionswere more valued than others in decision making. In someinstances, especially when it was about navigating the legaland social system in Belgium. The perspective of the socialassistant was more valued, or another asylum seeker withmore years of experience of living in Belgium. The impli-cation this has for SGBV survivors, is that if SGBV inter-ventions are directed to individuals, and influentialmembers of their network oppose their decision to accesshealth care, this will make it very difficult for the asylumseeker tor receive the necessary emotional and physicalsupport required and might even result in isolation fromother members of their network.

The bridgeDuring the interviews, we identified people whomValente (2012) refers to as people with bridging proper-ties within a network, they were often people who hadbeen in the centres for less than 6 months, had few

Ogbe et al. BMC Public Health (2021) 21:25 Page 12 of 15

social network members, were bi-lingual and had friend-ship networks that were heterophilic. In a microsystem,were most people sought friendships with people theyviewed as being similar, bridges were often people whohad friendships across ‘cliques. Though they had closefriendships with people from their own country, theywere likely to identify people from different countries asbeing part of their friendship network. They would notbe identified as key players/ opinion leaders in a networkanalysis, but during my interviews and subsequent infor-mal conversations with them, they were the ones whoexpressed more of an interest in our research projectand proffered specific recommendations to addressgender-based violence and its effects, that were based onpeer-support. I ended up engaging some of these peopleas volunteers in my research project. I think these arethe people with the greatest potential to effect change,especially in complex network structures, like thosefound in the centres we worked in.

‘No, no [responds to question about having friendsfrom the same country] … . from other places likeRwanda, Congo, Niger, Ivory Coast, Kenya, Morocco,yeah, [the friendships are helpful]...One day, wastalking to a staff at PC [centre] regarding as we arecoming from different countries, we have differentcultures, many things, I was telling them like to doone meeting for all people at PC … for some peoplewho, how to say it, who in their life had difficulttimes, they want to be consulted [and speak aboutit].. because talking about it, you will feel well …(Male, asylum seeker)

The asylum seeker we spoke with above supported theidea of getting asylum seekers of different nationalitiestogether and consulting with them to jointly develop so-lutions to address their past experiences of violence andtrauma and develop sustainable solutions.

Limitations of the study This study focused on the ex-periences of asylum seekers who had formally lodged anapplication to the Belgian government and hence had ac-cess to social services pending the result of their applica-tion, and in so doing we were unable to document theexperiences of many undocumented migrant that alsohave experiences of SGBV. In most of the centres therewas a mix of asylum seekers from Asia, sub-Saharan Af-rica, and Latin America. Difficulties in ensuring that wedid not generalise some of their stories because of the dif-ferences in culture and migration experiences were en-countered. We discussed some of the initial findings withtwo asylum seekers who were part of the analysis and datacollection, and had lived in one of the centres, to ensurethat we were reflexive about our interpretations.

DiscussionNetwork –oriented interventions have been widely usedin public health for different types of interventions in-cluding but not limited to smoking cessation, cervicalcancer screening, diet and weight management and HIVprevention with different target populations, for ex-ample, sex workers and intravenous drug users [37].However, there is limited evidence of the use of networkinterventions among vulnerable groups like asylumseekers and refugees. The use of network theory or so-cial network-based interventions involving asylumseekers and refugees requires an understanding of thecontext and the different factors within network interac-tions, which might influence decisions to access healthcare. This aligns with other findings from a study doneby UNHCR on intimate partner violence interventions,which found that implementing a peer based interven-tion without effective community engagement and un-derstanding of the context, would negatively affect thesuccess of the intervention [38]. Our research findingsindicate that the quality and perceived importance ofconnections is a key factor to developing peer based ornetwork interventions, as compared to the number ofconnections. The popular assumption that, the presenceof friends and family confers a protective barrier to sex-ual and gender-based violence is not always correct asprovided by examples from our interviews, and this kindof information can be teased out from respondents dur-ing the screening process. This finding is similar toLlyod’s work on refugees in Australia, which shows thatfamily and friends can be important sources of informa-tion and support, but specific harmful cultural beliefsshared among close knit or cohesive networks can be adeterrent to accessing health care [39] . Although, insome cases where family and friends are supportive, thismight provide the survivor of violence with enough im-petus to report their experience and seek health care.Context, specifically the existing asylum policies and

processes, health system barriers as well as other barrierslike language are of equal importance in developingnetwork-based interventions. Peer support might be usefulin providing information, emotional support, and re-sources but challenges experienced during the asylumprocess, could have a deterring effect on the willingness toaccess health care. The psychological distress experiencedby many refugees during their migration process, as wellas the uncertainty regarding their status in the new coun-try can take its toll on their psyche, and ability to utilizeexisting Services [40] The language barrier is an oftenoverlooked factor but is significant in ensuring access tohealth care, information and resources [41]. In some set-tings, translators where used when available, as well asinter-cultural communicators, but these interventions arenot systemic or widely used in all asylum centres [42].

Ogbe et al. BMC Public Health (2021) 21:25 Page 13 of 15

Expanding the definition of networks and incorporat-ing service providers, like social workers, advocates, doc-tors and nurses into developing support interventions isimportant as discussed earlier in the paper, and identi-fied in other studies done with refugees in high incomecountries [43]. For some refugees, these contacts serveas the first and only source of information and re-sources. Also, addressing values and assumptions aboutrefugees among social workers and doctors is important.This is an overlooked step in many asylum centres, asrefugees might have specific challenges, which are differ-ent from the general population, which social workersand doctors in the host country might be unfamiliarwith. Understanding concepts like resilience and theneed for better screening processes especially during theintake process at asylum centres might improve identifi-cation and adequate referral processes for survivors ofdifferent forms of violence at the centres, especially formental health issues like depression and post- traumaticstress disorder arising from experiences of SGBV [44].

ConclusionThis study describes some of the network factors that in-fluence the decision to seek formal care by asylum seekerswho are SGBV survivors. Our findings draw attention tothe importance and role of peer support, in access tohealth care, and the importance of understanding the na-ture of the social network of asylum seekers, before imple-menting a peer support or peer-led program. Theeffectiveness and applicability of such interventions isheavily influenced by the context: existing asylum policies,availability of health services and the ‘centrality’ of theirclose social contacts, among other factors.Through the interviews with asylum seekers and ser-

vice providers, we identified pathways, through whichsocial network members influence the decision makingof SGBV survivors. This has implications for communityand peer based interventions, as it is not sufficient towork with peers, without effective community engage-ment to understand the context of the target population[38]. For example, understanding the personal and soci-etal cost reporting would have not just for the survivor,but for the close network members that would supportthe survivor’s decision to report, will also have implica-tions on the survivor’s decision to seek help and utilizeexisting peer-based interventions.The context of the survivor which includes the avail-

ability of supportive asylum related health policies,SGBV care services for the survivor at the asylum recep-tion centres or through referral, is also an important fac-tor, as well as the availability of trained counsellors, andstaff that have the skill sets, time and ability to screenfor SGBV survivors. This will have an impact on disclos-ure rates and also utilization of SGBV care services [6].

Our model proposed earlier, can provide a way ofmapping these different factors and evaluating the differ-ent ways a peer-based intervention can address thesefactors to ensure that the survivor of SGBV is able toovercome challenges to reporting their experience ofSGBV and seeking the required help. Especially for asy-lum seekers, who may likely not have as much socialsupport in their host country, understanding these dif-ferent factors would help in developing more responsiveand effective programming to address their needs forcare, especially for SGBV survivors.

Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s12889-020-10049-0.

Additional file 1. Interview guide for asylum seekers and serviceproviders. Interview guide used in interviews of asylum seekers andservice providers.

AbbreviationsFEDASIL: Federal Agency for the Reception of Asylum seekers; PTSD: Post-traumatic stress disorder; SGBV: Sexual and gender-based violence;IPV: Intimate Partner violence

AcknowledgementsWe would like to acknowledge Vincent Vannetelbosch, Ana Mauleon andSimon Schopohl for their input into the development of the theoreticalmodel. Dr. Khalid Zurmati for his technical insights into the medical andpsychosocial needs of refugees and asylum seekers, Ines Keygnaert forproviding technical information on recruitment strategies, Anne-Marie Hoog-weys for technical insights into the research and for facilitating the fieldwork,Kris Vanduffel, Dr. Alexandra Moonaas and Servaas Congreacht for assistingwith the coordination of fieldwork, Rukoundo Vincent and Gloria Ima-nishimwe for being excellent volunteers for my research.

Authors’ contributionsEO designed the study, developed the analytical framework, conductedinterviews, analysed the data and drafted the manuscript, AJ conductedinterviews, analysed the data and reviewed the manuscript, LR and MUreviewed the data and provided technical inputs into the manuscript andanalysis. OD supervised the development of the study, co-conceptualised theanalytical framework, reviewed the paper and provided technical insight intothe manuscript. ‘All authors read and approved the final manuscript’.

FundingThis project was funded by the University of Ghent BOF Starting Grant(BOF.STA.2016.0031.01). The funding body had no role in the design of thestudy, data collection, analysis, interpretation of data or in writing themanuscript.

Availability of data and materialsThe datasets generated and/ analysed during the current study are notpublicly available, as the data for this study are transcript interviews withasylum seekers (a vulnerable group) and service providers withpseudonymized information that might be re-identifiable. However, they areavailable from the corresponding author on reasonable request.

Ethics approval and consent to participateWritten Informed consent was obtained from all participants in this study.The consent process involved the research assistant informing the researchparticipants about the study with an information sheet and if they wereinterested, sharing an informed consent form. The consent form was thenshared/ read out and explained, as required. Each participant had the choiceto take the consent form with them, to review and discuss with friends orfamily and schedule the interview for another day, or to give consent the

Ogbe et al. BMC Public Health (2021) 21:25 Page 14 of 15

same day and participate in the interview. Each participant signed on theresearchers’ copy of the informed consent form with their initials orthumbprint, depending on what they were comfortable with and kept acopy, that had the contact of the lead researcher and the secretariat of theethics committee. Ethics approval to conduct this study and obtain writteninformed consent was obtained from the Committee for Medical Ethics,Ghent University Teaching Hospital (EC/2016/1252).

Consent for publicationNot applicable.

Competing interestsThe authors declare no competing interests.

Author details1International Centre for Reproductive Health, Ghent University, CorneelHeymanslaan 10, 9000 Ghent, Belgium. 2Centre for Research on Culture andGender, Ghent University, Blandijnberg 2, Ghent 9000, Belgium. 3Departmentof Social Anthropology, Sussex Centre for Migration Research, InternationalDevelopment, University of Sussex, BN1 9RH Brighton and Hove, UnitedKingdom.

Received: 16 July 2020 Accepted: 10 December 2020

References1. Levendosky AA, Bogat GA, Theran SA, Trotter JS, Eye AV, Davidson WS. The

social networks of women experiencing domestic violence. Am JCommunity Psychol. 2004;34(1–2):95–109.

2. Sullivan CM, Bybee DI. Reducing violence using community-based advocacyfor women with abusive partners. J Consult Clin Psychol. 1999;67(1):43.

3. Uchino BN, Trettevik R, Kent de Grey RG, Cronan S, Hogan J, Baucom BR.Social support, social integration, and inflammatory cytokines: A meta-analysis. Health Psychol. 2018;37(5):462.

4. UNHCR S. Gender-Based Violence prevention and response. Available inhttps://emergency.unhcr.org/entry/60283/sexual-and-gender-based-violence-sgbv-prevention-and-response, vol. 26; 2017.

5. Freedman J. Sexual and gender-based violence against refugee women: ahidden aspect of the refugee “crisis”. Reprod Health Matters. 2016;24(47):18–26.

6. Keygnaert I, Vettenburg N, Temmerman M. Hidden violence is silent rape: sexualand gender-based violence in refugees, asylum seekers and undocumentedmigrants in Belgium and the Netherlands. Culture Health Se. 2012;14(5):505–20.

7. Butchart A, García-Moreno C, Mikton C. Preventing intimate partner andsexual violence against women: taking action and generating evidence:World Health Organization; 2010.

8. Garcia-Moreno C, Pallitto C, Devries K, Stockl H, Watts C, Abrahams N. Globaland regional estimates of violence against women: prevalence and healtheffects of intimate partner violence and non-partner sexual violence; 2013.

9. Ellsberg M, Arango DJ, Morton M, Gennari F, Kiplesund S, Contreras M, et al.Prevention of violence against women and girls: what does the evidencesay? Lancet. 2015;385(9977):1555–66.

10. Mayo Clinic. Post-traumatic stress disorder (PTSD): Mayo Clinic,; 2020[updated Ausut 2020. Available from: https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967.

11. Schwarzer R, Leppin A. Social support and health: a theoretical andempirical overview. J Soc Pers Relat. 1991;8(1):99–127.

12. Katerndahl D, Burge S, Ferrer R, Becho J, Wood R. Differences in socialnetwork structure and support among women in violent relationships. JInterpers Violence. 2013;28(9):1948–64.

13. Hatcher AM, Romito P, Odero M, Bukusi EA, Onono M, Turan JM. Socialcontext and drivers of intimate partner violence in rural Kenya: implicationsfor the health of pregnant women. Culture Health Sex. 2013;15(4):404–19.

14. Kaukinen C, Gover AR, Hartman JL. College women’s experiences of dating violencein casual and exclusive relationships. Am J Crim Justice. 2012;37(2):146–62.

15. Fugate M, Landis L, Riordan K, Naureckas S, Engel B. Barriers to domestic violence helpseeking: implications for intervention. Violence Against Women. 2005;11(3):290–310.

16. Smith J, Ho L, Langston A, Mankani N, Shivshanker A, Perera D. Clinical carefor sexual assault survivors multimedia training: a mixed-methods study ofeffect on healthcare providers’ attitudes, knowledge, confidence, andpractice in humanitarian settings. Confl Health. 2013;7(1):14.

17. Goodman LA, Smyth KF. A call for a social network-oriented approach to servicesfor survivors of intimate partner violence. Psychol Violence. 2011;1(2):79.

18. Latkin CA, Sherman S, Knowlton A. HIV prevention among drug users: outcomeof a network-oriented peer outreach intervention. Health Psychol. 2003;22(4):332.

19. Kelly JA, St Lawrence JS, Diaz YE, Stevenson LY, Hauth AC, Brasfield TL, et al.HIV risk behavior reduction following intervention with key opinion leaders ofpopulation: an experimental analysis. Am J Public Health. 1991;81(2):168–71.

20. Vissenberg C, Stronks K, Nijpels G, Uitewaal P, Middelkoop B, Kohinor M,et al. Impact of a social network-based intervention promoting diabetesself-management in socioeconomically deprived patients: a qualitativeevaluation of the intervention strategies. BMJ Open. 2016;6(4):e010254.

21. Hogan BE, Linden W, Najarian BJ. Social support interventions: Do theywork? Clin Psychol Rev. 2002;22(3):381–440.

22. McFarlane J, Wiist W. Preventing abuse to pregnant women:implementation of a'mentor mother’advocacy model. J Community HealthNurs. 1997;14(4):237–49.

23. Weine S, Kulauzovic Y, Klebic A, Besic S, Mujagic A, Muzurovic J, et al.Evaluating a multiple-family group access intervention for refugees withPTSD. J Marital Fam Ther. 2008;34(2):149–64.

24. UNHCR. Asylum-seekers 2020 [cited 2020 16 July ]. Available from: https://www.unhcr.org/asylum-seekers.html.

25. Valente TW. Network interventions. Science. 2012;337(6090):49–53.26. Solomon P. Peer support/peer provided services underlying processes,

benefits, and critical ingredients. Psychiatr Rehabil J. 2004;27(4):392.27. Ogbe E, Jbour A, Degomme O. The potential role of network oriented interventions

for GBV among refugees in Belgium. Eur J Public Health. 2018;28(suppl_4):446–7.28. Pooley JA, Cohen L. Resilience: a definition in context. Aust Community

Psychol. 2010;22(1):30–7.29. Ando H, Cousins R, Young C. Achieving saturation in thematic analysis: Development

and refinement of a codebook. Comprehen Psychol. 2014;3:03 CP. 3.4.30. Walker JL. The Use of Saturation in Qualitative Research. Can J Cardiovasc

Nurs. 2012;22(2):37–46.31. Charmaz K, Belgrave LL. Grounded theory. The Blackwell encyclopedia of

sociology. 2007.32. Richardson R, Kramer EH. Abduction as the type of inference that characterizes

the development of a grounded theory. Qual Res. 2006;6(4):497–513.33. Mayring P. Qualitative content analysis. Companion Qual Res. 2004;1(2004):159–76.34. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis.

Qual Health Res. 2005;15(9):1277–88.35. Triangulation DS. The use of triangulation in qualitative research. Oncol

Nurs Forum. 2014;41(5):545–7.36. Lipowski ZJ. What does the word “psychosomatic” really mean?. In Psychosomatic

Medicine and Liaison Psychiatry. Boston: Springer; 1984. pp. 119-137.37. Shelton RC, Lee M, Brotzman LE, Crookes DM, Jandorf L, Erwin D, et al. Use

of social network analysis in the development, dissemination,implementation, and sustainability of health behavior interventions foradults: a systematic review. Soc Sci Med. 2019;220:81–101.

38. Tappis H, Freeman J, Glass N, Doocy S. Effectiveness of interventions,programs and strategies for gender-based violence prevention in refugeepopulations: an integrative review. PLoS currents. 2016;8:1–19.

39. Lloyd A. Building information resilience: how do resettling refugees connectwith health information in regional landscapes–implications for healthliteracy. Aust Acad Res Libr. 2014;45(1):48–66.

40. Laban CJ, Gernaat HB, Komproe IH, Schreuders BA, De Jong JT. Impact of along asylum procedure on the prevalence of psychiatric disorders in Iraqiasylum seekers in the Netherlands. J Nerv Ment Dis. 2004;192(12):843–51.

41. Asgary R, Segar N. Barriers to health care access among refugee asylumseekers. J Health Care Poor Underserved. 2011;22(2):506–22.

42. Robertshaw L, Dhesi S, Jones LL. Challenges and facilitators for healthprofessionals providing primary healthcare for refugees and asylum seekersin high-income countries: a systematic review and thematic synthesis ofqualitative research. BMJ Open. 2017;7(8):e015981.

43. Burnett A, Peel M. Asylum seekers and refugees in Britain: health needs ofasylum seekers and refugees. BMJ. 2001;322(7285):544.

44. Stenmark H, Catani C, Neuner F, Elbert T, Holen A. Treating PTSD in refugeesand asylum seekers within the general health care system. A randomizedcontrolled multicenter study. Behav Res Ther. 2013;51(10):641–7.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Ogbe et al. BMC Public Health (2021) 21:25 Page 15 of 15