A growing body of literature has documented an increased risk of gender-based violence (GBV) within the context of COVID-19 and service providers’ reduced capacity to address this vulnerability. Less examined are the system-level impacts of the pandemic on the GBV sector in low- and middle-income countries. Drawing on the perspectives of 18 service providers working across various GBV-related sectors in Guatemala, we explored how the Guatemalan GBV prevention and response system operated during the COVID-19 pandemic. Findings highlight that the pandemic reinforced survivors’ existing adversities , which subsequently reduced access to reporting, justice, and support. Consequently, the GBV prevention and response system had to absorb the responsibility of securing survivors’ essential social determinants of health, further limiting already inflexible budgets. The pandemic also imposed new challenges, such as service gridlocks, that negatively affected survivors’ system navigation and impaired service providers’ abilities to efficiently receive reports and mobilize harm reduction and prevention programming. The findings underscore the systemic challenges faced by GBV service providers and the need to incorporate gender mainstreaming across public service sectors—namely, transportation and information/communication—to improve lifesaving GBV service delivery for Guatemalan survivors, particularly survivors in rural/remote regions. COVID-19-related movement restrictions and adverse socioeconomic impacts have exacerbated the “shadow pandemic” of gender-based violence (GBV) . NumerouThe GBV prevention and response system is the medium through which GBV survivors and service providers interact to facilitate the reporting of violence and/or access to care. Scholarship has detailed how isolation in the home, unemployment, and movement restrictions have magnified GBV risk ,14,15,16Less investigated has been the manner in which GBV prevention and response systems operate as a whole within the wider context of COVID-19. Adopting a complex systems science theoretical position ,21 proviThe interconnected sectors comprising the GBV prevention and response system are acted upon exogenously by the social and political environment. The COVID-19 pandemic can be conceptualized as an exogenous shock to existing GBV systems. Previous research has shown how this shock has magnified GBV, altered reporting, and increased vulnerability to GBV risk factors in high, low-, and middle-income countries (LMICs), as well as fragile states ,22. HoweGuatemala, though classified as an upper-middle income country, consistently ranks among the top nations in the world for malnutrition, and experiences significant inequality and persistent poverty . GuatemaIn Guatemala, services for protection from and prevention of GBV are covered by government institutions and nongovernmental organizations (NGOs) that refer cases of violence to the Public Ministry (autonomous institution) or National Civil Police (government body) for criminal investigation and criminal prosecution. The entity in charge of supervising that all institutions function properly is the Human Rights Ombudsman. The Guatemalan GBV prevention and response system is largely decentralized, meaning that few service providers are able to respond to violence cases across the country. There is a lack of coverage in rural and remote areas and among Indigenous communities, who require linguistic inclusiveness.In March of 2020, Guatemala instituted what was initially proposed as an 8-day national lockdown to attempt to control the spread of COVID-19, which continued through October 2020 due to continued peaks of the virus ,34. The By employing a systems science perspective to conceptualize the Guatemalan GBV prevention and response system, this research qualitatively explored how the COVID-19 pandemic has affected the Guatemalan GBV sector. Drawing on 16 in-depth, semistructured interviews conducted with GBV service providers working in the Guatemalan GBV prevention and response system, we explored how the COVID-19 pandemic has impacted not only individual women, girls, and service providers but also how the pandemic has impacted the broader GBV system and its interrelated sectors.The present analysis, focused specifically on Guatemala, is part of a multicountry project conducted in LMICs that explores the impact of the COVID-19 pandemic on women and girls’ safety, their knowledge of and access to GBV services, and adaptations to service provision in light of COVID control measures .To understand how GBV service providers operated within the context of COVID-19 and to gain insights into survivors’ experiences in navigating the system, we interviewed various individuals working within the Guatemalan GBV prevention and response system as key informants. Key informant interviews are semistructured interviews commonly used in public health research, wherein participants are probed to share their expert perspectives and reflections on the community . A semisAll interviews were conducted virtually using the Zoom platform. Prior to the start of the interview, the researcher reviewed the consent form and allowed the participant to ask clarifying questions. Verbal informed consent was obtained. All KIIs were conducted in Spanish and lasted approximately 60 to 90 min. All study procedures were approved by the Health Media Lab Institutional Review Board (361GLOB21).KIIs were audio-recorded, transcribed, and translated into English. All names, locations, and other identifying information were removed from the transcripts to ensure the confidentiality and anonymity of study participants. The team used a combined deductive and inductive approach to refine a codebook previously employed in a multisite study ,37. Aften = 13) and nongovernmental (n = 5) organizations in Guatemala, including antiviolence organizations (n = 9), branches of the justice system (n = 7), and crisis and support hotlines (n = 2). The antiviolence organizations included political advocacy and anti–human trafficking groups, as well as shelters and child-protective services. The informants from the justice system represented governmental bodies that are in charge of receiving and investigating GBV cases, providing legal representation to survivors, and prosecuting GBV cases. Half of the KIs (n = 9) were part of organizations that primarily offered services to adult survivors, while the other half (n = 9) focused on minors.The research team interviewed 18 KIs from governmental . Second, the pandemic imposed new challenges that negatively affected survivors’ navigation of the system and impaired service providers’ ability to receive reports and mobilize prevention/response. Based on service providers’ reflections, we explored the Guatemalan GBV prevention and response sector within the COVID-19 context through five interrelated themes: (1) addressing immanent SDH, (2) altered patterns of reporting, (3) resource challenges, (4) digitizing service provision, and (5) navigating health–legal–social services.basically the needs [of victims] are the same, but they’ve increased” (KII_16). Moreover, “if a victim was economically dependent before, now even more so” (KII_16).Multiple service providers across sectors unequivocally expressed that the COVID-19 pandemic magnified and reinforced the backdrop of adversity faced by GBV survivors. Considering the absence of robust gender protections, service providers expressed that the pandemic worsened several mutually reinforcing SDH. Specifically, precarious employment, inadequate water and sanitation infrastructure, scarce electricity, malnutrition and food insecurity, and limited public transportation were mentioned. Simply stated by a KI working for the justice system, “victims in rural areas lack access to electricity, and obviously to the internet or a phone line. Poverty and extreme poverty are also obstacles that are exacerbated by the pandemic” (KII_16). Remote regions in Guatemala were described as “hard to reach” in terms of service access because the communities are “eight or nine hours away” and service providers had to “schedule interventions in advance” (KII_15). Discrimination and limited resources in remote areas interacted with the pandemic to further marginalize rural and Indigenous populations:Further, ““The large inequalities that exist are also related to discrimination and the lack of access [to resources]. If we’re talking about rural areas and urban areas, this is also something that has a lot to do with discrimination relating to ethnic groups, our Indigenous population” (KII_18).I know that [organizations that work with trans women] distributed a lot, a lot, a lot of bags with food last year, particularly for trans women who are sex workers and were not able to work during the first months of the pandemic” (KII_12).Service providers highlighted that pandemic-related unemployment had a particularly profound effect on women and girls who mostly relied on informal and gendered forms of employment, such as domestic work and care labor. Gendered economic precarity and food insecurity, incubated within a context of unemployment, underemployment, and inadequate social protections, were described as being particularly striking for sex workers and transgender women. As noted by one service provider, “Service providers working in the child-protection sector reflected on how the pandemic affected child and household malnutrition and food insecurity. Consequently, the governmental child-protection and foster-care sector had to shift their focus from providing specialized services to providing humanitarian aid:Severe child malnutrition increased because … many people and families lost their jobs, they were fired, and this obliged us, as an institution, to coordinate some humanitarian aid, the inclusion of some social programs, but these were very limited, very limited considering the enormous need that was just identified and which was getting worse, it was insufficient, any aid sent was insufficient against the needs, and we don’t have a welfare approach, we are rather focused on providing special care, on being able to provide psychosocial, pedagogical, legal care to restitute the rights of children. (KII_5)Some service providers also mentioned substandard water and sanitation infrastructure, which represents an unmet basic human need that escalated in priority during the pandemic. For example, a service provider working at a GBV crisis and support line noted:During the pandemic we had a lot of complaints about access to drinking water. There was a lot of emphasis about handwashing, but many sectors lack access to drinking water, so the number of complaints about this skyrocketed. In the case of water-related interventions, we labeled them as emergencies, as health-related. The idea is to approach the responsible institution and get a timely response in order to reestablish the people’s human rights. (KII_4)Service providers also mentioned that pandemic-related economic losses increased financial power differentials between abusers and survivors, making it more difficult for survivors to flee abuse. For instance, from the perspective of a KI working for an NGO serving the Indigenous Mayan community in northwestern Guatemala:The economic dependence of women also forces them to endure violent situations. It is frequent, for example, to hear, ‘Look, the thing is, if I leave my husband, who’s going to support my children?’ At the root of COVID-19 grew a more complicated situation. (KII_6)in some cases, there has been an opportunity to be able to sell [products], and also to generate some economic income.” Even families without land were supported to cultivate “inclusive small-scale gardens” in pots (KII_6).The same service provider revealed that in an effort to mitigate pandemic-related food insecurity, the NGO supported women to develop family gardens in the community. She explained that “Another service provider noted that household economic precarity magnified during the pandemic and contributed directly to violence against women and children.“Physical abuse increased because of confinement and the economic crisis. Economic challenges always tend to create tensions, and now that everyone was forced to stay in the house for a long time, these tensions grew even further. In many cases, we saw that the husband would abuse his wife, and then she would abuse her children. Violence became commonplace, a daily event even.” (KII_2)the first thing done was to restrict several rights, mobilization among them one of the most particular things restricted was public transportation services. So, that restriction, in particular, means that the population does not have easy access to practically anything” (KII_9). Service providers’ abilities to mobilize antiviolence programs and initiatives was also impacted by reduced access to public transportation:Lastly, access to affordable public transportation emerged as a key social determinant of health among Guatemalan GBV survivors. As mentioned in an unprobed manner by several KIs, pandemic-related movement restrictions severely limited access to public transportation and resulted in price surges. Weakened public transportation systems negatively affected survivors’ ability to leave abusers and access reporting mechanisms and services. A service provider working with minors in the criminal justice system noted that when the pandemic started, “Teams still can’t access all [regions] … Many of them have mobilized themselves by bus, public transportation, and some even have their own vehicles, or are paid an allowance through transportation lists. However, right now, under the pandemic, there is no access to regular transportation, and when transportation started to reactivate, the cost was double and even triple, which meant that budgets were affected. In the end, if there is no tool to bring the services close to communities, it is a challenge for us to be able to solve it. These are the most significant challenges we face (KII_5).the pandemic increased violence while also reducing the possibility for victims to access justice” (KII_16). Providers believed that reduced access to formal reporting mechanisms was at least partially due to “the many roles that a woman now has to fulfill: they are mothers, sisters, grandmothers, caretakers, or educators of their children at home.” (KII_16).KIs mentioned that GBV reporting during the pandemic was affected by a variety of factors, including movement restrictions, human resource challenges, prioritization of infection control over violence protection, reporting mechanism adaptations, and reduced public transportation. Multiple KIs also noted that when system-level gridlocks decreased reporting and access to justice, cases were less likely to move forward, thereby making it harder to hold perpetrators accountable. Therefore, service providers worried that decreases in reporting reinforced perpetrator impunity. As noted by one key informant, “Confinement forced people to stay inside and stop reporting abuse … They didn’t have any mechanisms or means to escape or file a report” (KII_1). Service providers also expressed that reporting patterns were affected by pandemic-related limits to public transportation. For instance, when asked what groups of women could not access services, a service provider working for an NGO serving child and adolescent survivors of sexual violence stated:Other service providers offering legal and psychological services to survivors noted that movement restrictions and stay-at-home orders reduced formal reporting: “From March to April [of 2020] women who didn’t own a car couldn’t even file a report. The phone line for filing reports hadn’t been implemented yet. Public transport services resumed in September. There was also a curfew. From May onwards, we could go out from 6:00 AM to 2:00 PM, and then the curfew would start. So, we had very little time. We could only open for 4 h, so only people with a car could commute to file a report. Those who didn’t own a car were the most affected. (KII_2)Service providers noted that due to movement restrictions, such as curfews and lockdowns, survivors were not able to report violence or seek help in a timely manner. Consequently, case severity and lethality increased, leading to fatalities. One service provider explained:“Yes, [most cases] were more severe compared to before the pandemic. Women disappeared before the curfew began. Since their family couldn’t get out to activate the alert, these alerts would be sent until later. There was a case in which the neighbors of a missing woman heard her little girl crying. The woman was found dead two days later… [The perpetrators] took advantage of the curfews to get rid of the bodies.” (KII_2)We have the same [violence] figures we had in previous years, the only difference is that there will be more impunity now because people couldn’t go out to file a complaint. That is why we also encourage people to report and to stop normalizing sexual violence.” (KII_14) The reduced ability of antiviolence organizations to mobilize community outreach focused on GBV awareness and reporting contributed to a culture of violence normalization, which in turn further reduced reporting:Further, service providers revealed that a reduction in formal reporting led to perpetrator impunity. For instance, from the perspective of a KI working to monitor and coordinate medical care of sexual violence survivors, “The problem was that lockdown didn’t allow us to deploy people or to organize any mass activities, we couldn’t organize meetings with parents, children or institutions. We had to change the strategies and find ways for the people to stay informed and specially to be made aware because sexual violence, exploitation and people trafficking are crimes that most people have normalized, so there isn’t much of a culture of reporting these crimes, sometimes this happens due to a lack of credibility and of course this creates impunity (KII_14).The impunity of GBV perpetrators was also described as occurring in part due to the concentration of law-enforcement efforts on enforcing pandemic control policies. Thus, even when violence was reported/disclosed, the capacity of law enforcement and the judicial system to hold perpetrators accountable was more limited during a pandemic context:Full lockdown caused an increase of human rights violations and a lack of response from the system. There was an increase of missing girls but a reduction of reports in the system. When we started looking into what was happening, we realized that the police were no longer accepting any reports during lockdown so if people went to a police station to report a missing girl or woman, they said that they were asked to focus on the pandemic and that they couldn’t deal with other types of reports (KII_3).In contrast, one KI working for the justice system who oversaw the investigation of specialized GBV cases noted that the increased police presence intended to enforce pandemic control measures was helpful for more quickly responding to GBV:“Because there are lockdowns and there’s a need to verify that people are staying home during lockdowns, the police became present throughout the whole country, that is, they monitored the streets. Therefore, when there was a violent act, the police were nearby and could aid the victims. So, we do believe that the Public Ministry and the National Civilian Police have helped” (KII_16).Importantly, a few KIs did not feel that GBV reporting decreased during the pandemic. One service provider reported that, in her experience, when multiple avenues to report violence were made available, reporting increased:I think the increase in complaints is a positive thing. It means women feel more empowered to report and they have more trust in the system protecting their rights … In terms of technology, I think that was great progress too. We were able to get a lot of complaints that way. People just have to tag the Procuraduría de los Derechos Humanos [Attorney General’s Office for Human Rights: the governmental body seeking to secure constitutional human rights], and the consultant is monitoring that. They get their information, like a phone number, and they give that to us. And then the officers here can follow up (KII_4).However, while another service provider also noted an increase in crisis and support-line calls, they were often unrelated to GBV, and as a result, the KI encountered challenges in identifying and responding to GBV cases, given the fixed budget and staff:The pandemic has been a challenge for us and for 1555 , because initially we received an overflow of requests. Not all were necessarily related to human rights violations, but there was a lot of uncertainty about the disease, healthcare services, and a large number of cases. People, because they trust us, came to us (KII_4).if something is not in the budget, we cannot get it” (KII_14). For example, KIs conducting specialized investigations of serious GBV cases recognized that existing budgets could not accommodate additional costs associated with purchasing PPE and gasoline for private transportation:Inadequate and inflexible budgets, staffing limitations, and personal protective equipment (PPE) constraints comprised some of the resource challenges faced by KIs during the pandemic. Service providers explained that multiple sectors could not expand their budgets or be flexible in allocating additional expenses within the COVID-19 context. Simply put, ““The pandemic struck the world in March 2020, when there was already an annual operating plan created based on another plan conceived for normal times. Some of the resources had to be used for health security equipment to prevent the institution’s staff from getting infected. Therefore, there was a shortage of other things needed, for example—and this is essential—gasoline for vehicles. By using part of the budget for health security measures, other services lose resources. And one of the resources that has been severely affected was gasoline for transporting prosecutors, victims, in the institution’s vehicles” (KII_16).Working in a digital environment also requires funds because the internet isn’t free. All of this has modified the budget.” (KII_16). As digitized services were not originally planned, organizations suddenly found themselves with unexpected expenses, such as professional Zoom accounts: “At the beginning we hadn’t considered that, Zoom gave you 40 min. but it wasn’t enough, and we had to pay for that” (KII_14). Further, a service provider in the child-protection sector noted that resource constraints during the pandemic impacted their ability to respond to child maltreatment cases in a timely manner:The shift to virtual service provision further limited budgets. As stated by one KI: ““We don’t have ideal resources. With the few investigators, the vehicles that we have, sometimes we are not able to investigate all the cases at once, and the cases start accumulating. And this harms children because if there is a case of maltreatment right now and I don’t have resources, I don’t go now. I go next week. So that puts children’s lives at greater risk. Yes, it has had an impact on us because, as there have been many complaints, our work, I would say, was not carried out immediately” (KII_11).suppliers were out of stock in every sense, biosecurity was the most complicated issue” (KII_7). When staff tested positive for COVID-19, the GBV response system faced human resource shortages, thereby resulting in slowed or halted service provision. A KI in the justice sector stated there was a reported “decline in the prosecution services” given that “staff started being ill and they had to [delay] all procedures” (KII_4). Physical distancing and lack of PPE also inhibited the capacity of the attorney general’s office to investigate GBV cases. For instance, one KI stated that they could not “carry out the same number of investigations” because:Lack of access to PPE was consistently referenced as a significant challenge, given that, ““We had to use [PPE], which wasn’t always available for the interventions… Access to victims was also limited for the same reasons. Like, ‘look, this might be a victim, but they’re in a restricted area of the hospital, so you can’t access to interview them.’ This also led us to reinvent ourselves. We said, ‘we’ll make a phone call; if you won’t let me in, take this phone to the person so I can talk to them.’ And this deals with access to technology, which institutionally is limited. So, the investigators had to use their own means and resources to investigate” (KII_4).In addition to acknowledging PPE inaccessibility, multiple service providers indicated that GBV service providers had not been prioritized for COVID-19 vaccinations, despite the essential nature of their work:“It has been stressful, very stressful to know that the fact that we also have to expose ourselves to work, to go out, to presential meetings, have us in a greater level of exposure, and that as a country we still do not have enough vaccines to ensure that we, from the justice system, have access to this option. But we have had enough colleagues who have died or who have fallen seriously ill” (KII_9).Despite the fact that the vaccine is already available, the vaccine rollout hasn’t been as quick as expected. Only a small percentage of the population has been vaccinated” (KII_2). Service providers also voiced concerns regarding health-system governance that may have negatively interfered with vaccine distribution:Service providers expressed general concern regarding slow vaccine distribution, saying, ““Another thing I think of is that the whole issue of corruption in the country … The health system is completely collapsed, but it’s collapsed because the money has been stolen! I mean, what do you do when there are no supplies? I mean, right now they [the government] … bought a lot of vaccines but it is uncertain when they will arrive, and the State is questioned and the State doesn’t know when the vaccines will be sent” (KII_12).take care of ourselves” and “coordinate better.” As a result, they said, “the institutional coordination improved a lot, fellowship improved a lot” (KI_11). Interviews also highlighted providers’ resourcefulness in linking women to services, despite a lack of resources. For example, in order to ensure service continuity for rural women in need of remote mental health and psychosocial support, providers would “top up [a client’s] phone so that she could receive therapy” (KII_2). Additionally, the KI described an innovative partnership wherein Uber provided promotional codes for survivors to attend court hearings when access to transportation was lacking (KII_2).Despite the myriad resource challenges faced by providers throughout the pandemic, several KIs noted that a few silver linings emerged. One service provider from the justice sector believed that the hardships helped her colleagues learn how to “Participants discussed challenges encountered by survivors and service providers when digitizing or attempting to digitize service provision or reporting. One of the most frequently discussed challenges was digital divides (DDs): inadequate access to information and communication technology. Participants mentioned that DDs intersected with existing gender inequities, poverty, and urban/rural disparities, and that the COVID-19 pandemic further marginalized certain women and girls from accessing technology and, therefore, GBV services.As noted by one key informant:There’s a lack of culture of accessing public information. Women lack access to mass media. And this is on top of the victims’ lack of knowledge about services provided through platforms and phone calls. So, all these situations add up (KII_16).Poverty was also described as exacerbating the DD. Among survivors living in poverty, the need to secure imminent survival needs outweighed the potential benefits associated with securing the technological prerequisites for GBV care. A KI working to provide free legal and psychological services to survivors described the trade-off between survival and technology needs:“When there are very high poverty levels, what humans do is try to find survival mechanisms, and what are our basic needs? Food and shelter. These are our main concerns because they allow us to survive. I can live without Internet reception or without a phone, but I cannot survive without any food or without a place to live” (KII_1).From the government, even right now, it’s being said for those who want to get vaccinated, they must register using a smartphone. Who has a smartphone, internet service, and the ability to drive, and to enroll?” (KII_6).Limited access to technology also directly impacted Guatemala’s pandemic response. DDs set the stage for inequitable vaccine access: “Service providers also highlighted that DDs widened urban–rural disparities concerning GBV service accessibility. Rural areas were described as having weaker internet and electrical infrastructure:“Victims in rural areas lack access to electricity, and obviously to the internet or a phone line... Even in super urban areas, there is an Internet problem. Even more so in rural communities. And that should not be forgotten in the case of Guatemala... So then what’s proposed to be done in virtually in some cases isn’t possible everywhere” (KII_16).On account of gender inequities, poverty, and urban/rural disparities, DDs were key barriers to receiving online/virtual services:“Even if there is the possibility to file reports and submit your documents online, most people still go to the bricks-and-mortar offices because they have no internet access. Sometimes, they own a smartphone but have no credit or anything. They sometimes only top up their phones with 5 quetzales that day to be able to send an email, but they can’t afford to spend more than that to take their classes or receive therapy. They were forced to prioritize their resources” (KII_2).The Women’s Prosecutor’s Office deals directly with victims a lot. And we certainly can’t communicate virtually with a victim because of their resources, and also because of the institution’s resources. Internet access is limited. It all goes back to the budget” (KII_16). Further, “prosecutors didn’t have computers with cameras for the virtual hearings,” thereby further contributing to justice system delays (KII_16).Another service provider working with the Indigenous Mayan community reflected on the limited technological resources available to GBV prevention and response organizations as well: “all the courts closed … due to containment” and “judicial processes of [cases] stopped” (KII_7). These suspensions generated a backlog in the justice system, wherein “some cases will even take 4 years to get to trial due to these delays and the number of reports filed last year [2020]” (KII_2).Service providers expressed that even when GBV was formally reported, survivors’ ability to navigate the health, legal, and social sectors involved was circumscribed by halted legal proceedings, diminished intersectoral collaboration, and the reduced capacity of emergency shelters. Regarding the justice sector, multiple service providers indicated that at the beginning of the COVID-19 pandemic, “were taken aback” and subsequently asked, “When are we going to get to trial? Will my case even get to trial? When will hearings resume?” (KII_2). In response to survivors’ concerns, a service provider aiding survivors seeking justice and protection stated, “We tried to calm the users down so that they didn’t panic and felt like they wouldn’t get the outcome they expected” (KII_2). The same service provider stated:In response to court closures, service providers indicated that women and girls with open cases awaiting trial ““We were not ready for such a crisis, no one was, so we didn’t know how we could coordinate rescue efforts with the government. We had to learn this on the go. We would call the Prosecutor’s Office and the user from our home. It was very complicated, and on some occasions, we could have handled things better, but even the government didn’t know what to do” (KII_2).Existing projects and initiatives planned by NGOs also had to be halted due to pandemic-related constraints. Thus, given fewer available community programs, survivors had fewer opportunities to connect with the GBV system:When we were finally able to provide our services on a normal basis, we had to focus on guaranteeing the safety of everyone, both our staff and the people we serve…The projects we were involved in the past were mostly field projects, and they had to stop, so later we had to see how we could resume them while performing other tasks at the same time. This has been an exhausting year for sure (KII_2).Pandemic-related movement restrictions also negatively affected admittance to emergency shelters. One service provider highlighted that survivors could not be admitted to shelters, thereby forcing survivors to return to the abuse, potentially leading to increased lethality:Most of the shelters were closed, so women had nowhere to go, so that meant they had to stay at home. In those cases, our suggestion was to get the perpetrator out of the house. Authorities started doing this because there were shelters that weren’t able to relocate the people they had taken in. Shelters had to figure out a way to provide food for all of them … These shelters are closed spaces, so you need to guarantee people’s safety (KII_2).Further, pandemic-related curfews dictated the specific times when survivors could be admitted to shelters:We didn’t have permission to go out after the curfew. Only doctors, prosecutors, and the police could. Also, most of the admissions needed to happen after the curfew, at 5:00 PM or 8:00 PM, so even if we had everything ready, if the person couldn’t get to the shelter before the curfew, then she wouldn’t be admitted (KII_2).Despite technological limitations, one service provider described the innovative strategy of partnering with law enforcement to bolster antiviolence campaign messages:We noticed that the police cars of the [Civil National Police] had loudspeakers and so we realized that our consultants who had been deployed to the departments could coordinate and move around the areas even during non-working hours, after the curfew, and deliver our messages. That was one of our strategies. The campaign we spread through social media and the radio... We implemented a strategy so that our team could approach the authorities, and we implemented ways of delivering information virtually (KII_14).victims don’t have to travel to the headquarters of their region or to the capital” to file a report or request security measures (KII_16).While the pandemic negatively affected coordination between different sectors involved in GBV prevention and response, this was not uniformly experienced by all service providers. One KI working for the justice system noted that the pandemic prompted the Public Ministry to establish prosecutor’s offices in every municipality in the country, meaning that “Drawing on the perspectives of 18 Guatemalan GBV service providers, this research qualitatively explored how the COVID-19 pandemic affected the Guatemalan GBV prevention and response system and related interactions between survivors and service providers. Our analysis highlights the interplay between sectors within GBV prevention and response  and between the GBV system and other sectors, such as transportation and information/communication. Ongoing state fragility and lack of COVID-19 vaccine availability in Guatemala further eroded GBV system strengthening and gender mainstreaming efforts.The COVID-19 pandemic and associated control measures fostered an environment in which poverty, food insecurity, unemployment, lack of electricity, precarious labor, and weak transportation infrastructure became increasingly prominent challenges for Guatemalans. The already high prevalence of food insecurity and malnutrition in Guatemala ,40 was hPrior to the arrival of COVID-19 in Guatemala, 80–90% of the urban poor and Indigenous women ,42 and mCOVID-19 precipitated significant gridlocks and delays in service access. The justice sector in particular experienced prominent delays above and beyond prepandemic access difficulties ,46. SimiFurther, mechanisms of GBV service delivery were forced to shift abruptly in Guatemala, particularly with the public transportation suspensions that went into effect from March to August 2020 . These lAccess obstacles, which were particularly magnified for survivors in rural and Indigenous communities, are rooted in the high concentration of services in Guatemala City and the economic and infrastructure issues that existed in Guatemala prior to the pandemic . PolicymOur findings should be considered alongside a few study limitations. First, the findings were drawn from interviews with service providers only. In-depth interviews with female survivors might have allowed for a greater understanding of the challenges they faced in interacting with the GBV system. Second, access to a stable internet connection was required to participate in the KIIs, potentially excluding service providers in rural areas with limited internet access. Future research should consider explicit targeting of providers in rural areas. Given the interviews were conducted in Spanish and the data were analyzed in English, it is possible that some of the nuances of participants’ responses were lost in translation. Finally, this study did not include service providers working for the Ministry of Health’s psychosocial services, who are responsible for providing follow-up care for victims.The COVID-19 pandemic and corresponding measures to prevent the spread of the virus have increased the risk of violence for women and girls across the globe and hindered their access to quality GBV-related services. Simultaneously, providers of GBV prevention and response services have been tasked with providing quality care in the face of significant resource challenges, slowed coordination, and minimal protections for their own physical and mental health. Similarly to other studies that have documented challenges in GBV service provision during the COVID-19 pandemic ,47,48,49


Children and young people risk being ‘disproportionately harmed’ by the COVID-19 pandemic. Whilst an evolving body of literature focuses on the impact of the pandemic on the mental health and wellbeing of children and young people, less attention has been paid to the collection of qualitative, exploratory data. The aim of this study was to examine young people in North East England’s experiences of COVID-19 and associated control measures. Flexible, qualitative diaries were collected with 31 young people aged 13–17 for six weeks between July and October 2020. Diary extracts were curated using Instagram Direct Messaging (DM), email and text messaging. At the end of this study, participants took part in a follow-up interview (conducted by telephone or Zoom), asking them to reflect on their diary entries. Thematic analysis of diaries and interviews yielded three central themes: (1) impacts upon mental health and emotional wellbeing; (2) disruptions and changes to education and school life; and (3) frustration, burden and responsibility. These findings highlight acute mental health impacts  as well as longer-term repercussions from disrupted education  on young people aged 13–17 as a result of the COVID-19 pandemic. Since March 2020, countries worldwide have implemented strict national and localised controls on movement in order to reduce the spread of COVID-19 and ease pressure on key services. UK measures have included the closure of schools, colleges and universities; bans on social gatherings; the closure of retail outlets; and strict limits on contact with specific settings or population groups , emphasiChildren and young people (CYP) are at particular risk from long-term repercussions of the COVID-19 pandemic . The GloAn evolving body of research focuses on the impact that the pandemic and subsequent lockdown restrictions have had on CYP’s mental health and wellbeing . In Irelhttps://covidrealities.org/, accessed on 12 February 2021), as well as ‘Coronavirus Diaries’, implemented by Britain Thinks, which asks 50 people across the UK to complete a weekly poll tracking their mood, views on the government and media consumption . Nevertheless, these studies have predominantly captured the experiences of adults or families. To our knowledge, just one of the studies outlined above has collected diaries directly with young people, as part of a youth-led, ethnographic action research project [Several oral history projects and qualitative studies have began (or are about to embark upon) projects using serial or longitudinal qualitative methods to explore CYP’s experiences of the pandemic ,18. Base project . FindingThus, our findings extend this developing area of work by focusing specifically upon mid-adolescents (aged 13–17) in one English region (the North East), thus providing temporal relevancy to the policy context and restrictions in place within the UK. Repercussions of the pandemic will be felt geographically. The North of England’s economy has been hit harder than the rest of the country during the COVID-19 pandemic, with inequalities between the ‘Northern Powerhouse’  and the rest of the country exacerbated . These bTherefore, the aim of this study was to use diary-based qualitative methods to explore young people in North East England’s experiences of the COVID-19 pandemic and associated control measures. We set out to examine: (1) the impact of COVID-19 on young people’s physical and mental health and wellbeing; (2) young people’s coping mechanisms during periods of restriction; (3) the impact of ‘fractured’ or ‘interrupted’ experiences of schooling; (4) young people’s worries and hopes about their future; and (5) young people’s expectations of a post-pandemic ‘normal’. To our knowledge, this is the only published study (to date) to use written and/or visual, arts-based diaries over a prolonged period of time to document UK young people’s journeys in and out of lockdown over the course of the pandemic.Data were derived from a broader longitudinal project focused on understanding young people’s experiences of pandemic restrictions and the impact of restrictions on their mental health, wellbeing and education. This paper reports findings from the first exploratory phase of data collection, in the immediate aftermath of the first national lockdown. All participants resided in North East England, which has been marked as an area of ‘high COVID-19 risk’ and subject to strict social distancing restrictions since the implementation of localised tier systems at the end of summer 2020. We focused efforts on the recruitment of young people in areas of deprivation. Participants were recruited from youth and community organisations, detached youth work schemes, and regional charitable and third sector organisations, as well as via social media. We also distributed information about this study through university and funder networks, as well as our personal and professional networks. Young people were purposively sampled according to age (at date of recruitment), gender and socio-economic status (SES). SES was classified using the Index of Multiple Deprivation (IMD) quintiles (where 5 is ‘most deprived’) and determined by participant postcodes. Sample size was ultimately guided by: the breadth and focus of the research aims and objectives; the demands placed on participants; the depth of data likely generated; pragmatic constraints; and the analytic goals and purpose of the overall project . All participants took part in a short ‘getting-to-know-you’ telephone conversation with the lead researcher (S.S.) at the beginning of this study. During this conversation, young people completed a digital consent form, a copy of which was sent to them for their records; verbal consent was also sought from a parent or guardian for those under 16. Participants provided demographic information  and completed the Warwick–Edinburgh Mental Wellbeing scale (WEMWBS), validated for use with young people ,23. At tDigital, qualitative diary extracts were solicited specifically for the purpose of research with 31 young people aged 13–17 for six weeks between July and October 2020; followed up by a semi-structured interview  and combined with interview transcripts for analysis. Primary data comprised written material (diary and interview extracts), with visual materials used to elicit detailed and located narratives from young people.Diary extracts, verbatim interview transcripts and field notes were analysed using applied thematic analysis techniques , followiOur approach to data collection, coding and analysis was guided by COnsolidated criteria for REporting Qualitative (COREQ) research . Our fulThirty-two young people were initially recruited; one young person changed their mind and withdrew from this study a few days after recruitment, resulting in the analysis of data from 31 young people. Participant characteristics  are presented in The restrictions that young people describe in the sections that follow include social distancing, both in a literal (maintaining 2 m distance) and figurative (ceasing or reduction in contact with friends and family members outside of the own household) sense, school closures and remote learning, and localised lockdowns of retail, community and hospitality spaces. Such restrictions interacted, amplified and overlayed in young people’s lives. Analysis of diaries and interviews yielded three central themes: (1) impacts on young people’s mental health and emotional wellbeing; (2) disruptions and changes to education and school life; (3) frustration, burden and responsibility. Each overarching theme consisted of several sub-themes, which are outlined in Sub-themes and further supporting extracts for this theme are illustrated in I’m gonna tell you how Mrs Rona has affected me. Before lockdown my life was busy and I liked it that way, always having something to do whether that’s sports, going out or just having fun. Corona came along and you do try and stay positive but I believe in everyone’s case we didn’t think the virus would go on for this long and it would be a short term thing. Months went on, you just felt a bit claustrophobic and like life’s not really real in a way”—Female, Aged 16, Diary Extract, 24 August 2020.“Young people frequently took a step back to reflect and described this period of their life as ‘surreal’ or ‘the new normal’, with some detailing how they might feel if and when things ‘return to normal’ or what a post-pandemic future will look like:you are gonna have to keep a mask on you, wear your mask, keep your hands sanitised. I think even after this is all over, It’s still going to be even weird, being in a social space, being in town, like with so many people…One thing me and somebody else was talking about, was concerts, who is going to trust going to a concert again, like a proper one”—Female, Aged 16, Zoom Interview, 2 October 2020.“All of the young people in our study experienced emotional repercussions linked to the pandemic. Most young people described feeling lonely, anxious and all of them missed their friends, extended family, social contact and interaction. Several had pre-existing mental health conditions or lived experience of difficulties which were exacerbated during national restrictions. This meant that opportunities for face-to-face contact during Summer 2020, when restrictions were eased, were of huge benefit to young people’s mental health and wellbeing see . As we mToday has not been a very good day as I found out that we are being put in a local lockdown. This actually made me really upset as it means I can’t see my family anymore. I found out as soon as I got in from school and my full mood dropped. I went to my grandma and grandads house so I could see them before we went into local lockdown at midnight. It was really sad knowing that this was going to be the last time I saw them for the foreseeable future. I really hope it doesn’t last long and we can go back to how things were really soon”—Female, Aged 15, Diary Extract, 18 September 2020.“Nevertheless, not all young people experienced lockdown in the same ways. Some described being excited about lockdown, at least initially, with others identifying positive impacts. It provided a change in pace or a break for those where school was a source of anxiety; for others, it strengthened family bonds.I actually enjoyed lockdown because you only had to speak to people that you wanted to. You can’t exactly walk out of a lesson to go walk your dog”—Male, Aged 14, Telephone interview, 9 October 2020.“Finally, for some young people, keeping busy by maintaining routines and a sense of normality, or even a sense of excitement over relatively small things, in order to break the mundane nature of lockdown, were helpful. For example, young people described trying new hobbies, interests or activities during this time see .When I found out we were going into lockdown I was actually quite excited about the idea—came at a time when school was getting quite stressful (mocks approaching and lots of work). I saw lockdown as an opportunity to sort of reset and take a month or two just to relax. I also get quite down in the winter months, not depressed but less happy i guess, so felt like time with not school would be good. Once we got to about 2 weeks into lockdown I started getting really on edge and found myself getting annoyed and frustrated easily especially with my little brother”—Male, Aged 17, Diary Extract, 31 August 2020“Sub-themes and further supporting extracts for this theme are illustrated in I start school again on Tuesday which is annoying and its definitely going to be very different which worries me a bit, particularly because we have to wear face masks not to mention the fact that it is year 11 that I am starting. But I will get to see all of my friends again so that’s good.”—Female, Aged 15, Diary Extract, 6 September 2020“As life became busier, young people felt the emotional strain of higher workloads and anxiety about school, and the impact that lockdown restrictions could have on their future, were central to young people’s narratives. This was particularly pertinent to those facing educational transitions, for whom GCSE or A-Level exams were subsequently cancelled, and those who recognised that the pandemic may impact those sitting exams in 2021. For those young people, lockdown and the months leading up to exam results day were fraught with uncertainty as, for a long period of time, they were left unsure as to how their results would be calculated.“my college experience is being put in jeopardy”—Female, Aged 16, Diary Extract, 14 September 2020.Some young people expressed disappointment with being unable to sit exams, and the lack of closure this, and other milestones associated with leaving school such as prom, represents. Some young people felt that they had somehow cheated by getting good GCSE or A-Level grades, even though their eventual grades were a reflection of mock results and the effort they had put in up until lockdown. They felt that, without physically sitting the exam, that their grades were somehow not real or ‘not deserved’. For those starting college, this knocked their confidence and introduced an element of ‘imposter syndrome’:The gov is saying that real exams will go forward no matter what but I reckon coming out of winter the pandemic will be at its worst and I reckon it won’t be good enough to have exams. Personally I want to do the actual exams…I feel like exams give a sort of closure to the school period of my life which i thinks kinda important. I know going from year 12 to 13 felt like there was no real change  or for implementing/easing restrictions at the wrong times :Quite recently new restrictions have been introduced for Coronavirus: including a curfew at 10:00 and meetings above 6 outside of school banned which has obviously caused a stir in the community. Personally I feel the government are contradicting themselves, going from discounts on meals to get people back in restaurants to reintroducing policies about group size, not to mention the fact that young people aren’t allowed to meet up outside of school despite spending 6 h jammed in crowded corridors together. Although I think some precautions need to be taken, me not being able to see my school friends is pointless and stupid.”—Male, Aged 14, Diary Extract, 23 September 2020“Second, they levelled disbelief and frustration at rules imposed ‘on the ground’, largely at school, which they felt did not make sense such as not being able to socially distance fully when travelling to and from school (such as on the bus) and not being able to mix with classmates outside of school. Finally, they expressed disappointment and at times anger with those not following rules and restrictions and not taking risks seriously, with some young people describing this as ‘selfish’, suggesting, at times, that this led to young people being unfairly blamed or labelled for spreading the virus.It got to the point where people just wouldn’t ask me out. Which, obviously, fair enough, but it was still quite disheartening. I don’t know if that’s the word, but it was big FOMO, like I definitely felt a lot of FOMO during lockdown, when people would still go out, and then I had made this decision to not go out”—Female, Aged 16, Zoom Interview, 2 October 2020.“Thus, with the exception of one or two young people who felt restrictions were too heavy handed, young people in our study described high levels of compliance with pandemic restrictions. This reflects findings from other studies focusing on adherence to rules and rule breaking. Whilst frustrated and tired, they suggested that restrictions, such as lockdowns, were necessary in order to keep people safe and worried that attempts to return to ‘normal’ life too quickly would ultimately be harmful:The government is also opening lots of things up then blaming people for socialising—if it’s not safe to socialise, then they shouldn’t be encouraging people to use them. It’s just all annoying.”—Male, Aged 16, Diary Extract, 15 September 2020.“Our findings highlight acute mental health impacts  as well as longer-term repercussions from disrupted education  on young people aged 13–17 as a result of the COVID-19 pandemic. In the sections that follow, we have mapped our findings against the original aims of our study, to illustrate how we met these a priori aims, and how our data advances understanding in each of these areas, reinforced by supporting literature.Like participants in Demkowicz et al. (2020), young people in our study experienced the removal of ‘normal life’ and lack of social contact on an unprecedented scale, culminating in feelings of uncertainty, loss and grief , feelingThis idea is supported by wider literature. Whilst some evidence suggests young people’s mental health has worsened during the pandemic ,16, otheDay to day, young people articulated a range of coping mechanisms such as keeping busy, maintaining routines, using technology to keep in contact with friends and family and taking advantage of better weather and easing of restrictions across summer months. At a much broader, macro level, young people coped through reinforcing that sacrifices were needed in order to keep people safe. Whilst we did not set out to specifically examine this, young people organically reflected on adherence to restrictions and their frustrations with both the Government and those not following the rules, and their views on this became a dominant part of their narratives. Young people in our study articulated high levels of adherence to social distancing rules, and a sense of responsibility and burden for other people’s health. Similarly, Demkowicz et al. (2020) found that young people aged 16–19 felt they had made important sacrifices over the past year, giving up normal teenage experiences ; howeverThis mirrors population-level data on adherence to rules and guidelines  and ONS https://www.gov.uk/coronavirus/education-and-childcare, accessed on 10 March 2021). Such closures have become the source of much political and academic debate, and there have been conflicting findings as to whether school closures reduce community transmission of COVID-19 [Young people’s narratives were dominated by their thoughts and experiences of school closures and changes to their experience of education. At the time of writing, schools in England have re-opened on 8 March 2021 having been closed to all but children of vulnerable and key workers in England since 5 January 2021, with all school and college exams and assessments cancelled for a second year . There were some gender and age patterning in young people’s accounts. Notably, those experiencing educational transition, particularly those in exam years or moving into exam years, appeared more likely to feel stress or anxiety. We have since begun collecting the next phase of diary data—whilst outside the scope of this paper, some younger participants have subsequently moved into their GCSE year. In the earlier stages of the pandemic, these young people were at home with very little school work to do. A greater workload combined with the sustained nature of social distancing requirements means that these young people are now feeling greater levels of anxiety and isolation, a finding again complimented by WEMWBS scores. Differences according to age have also been shown in wider literature. Further findings from the Co-Space study demonstrate higher levels of behavioural and restless/attentional difficulties for primary (4–10 years old) than secondary (11–17 years old) school aged children. However, they reported higher levels of emotional difficulties for secondary than primary school aged children. Between January and February 2021, parents from both age groups reported increases in behavioural, emotional, and attentional difficulties .Young people’s worries and hopes about their future were fundamentally linked to their experiences of education over the past 12 months, and they articulated high levels of uncertainty and fear about the long-term impacts this would have on their life. This is supported by existing surveys of young people; the British Science Association found that young people’s (aged 14–18) biggest fear was the impact Covid-19 was going to have on education, examination, and qualifications . What weYoung people identified how strange the past 12 months have been for them. Despite difficulties associated with social distancing, they expressed wariness about returning to busy and crowded spaces, and felt some parts of life has resumed too quickly. They worried that this would result in further lockdowns; in hindsight, they were right to be concerned about this possibility, As we now approach the COVID-19 ‘roadmap’ for easing of restrictions in England, our intention is to explore these ideas further in subsequent phases of this project.There are several strengths of this study. First, the findings presented here are based on phase 1 of a longitudinal qualitative study. The remaining phases of this multi-method research project comprise: (1) a second wave of diary data collection; (2) serial interviews; (3) in-depth interviews with school staff; and (4) co-production of arts-based materials in partnership with young people and creative practitioners. As a strength of the broader study, this piece of longitudinal work will ultimately span summer 2020 as well as one full year of academic schooling. This study is the first to use longitudinal diary-based methods to document young people’s thoughts and experiences of the pandemic. Drawing on Hadi and Cross, we assert that such prolonged rapport and engagement with participants enhances rigour and trustworthiness in qualitative data . Use of this is the closest thing I’ve ever done to keeping a diary and to be honest its quite therapeutic!”—Male, Aged 17, Diary Extract, 6 October 2020.“Second, our findings advance the field methodologically through use of digital technologies  to collect diary accounts and conduct interviews. A growing literature indicates that collecting data in this way provides rich, multi-media insights into the world of young people, not readily accessed through other methods; as well as affording young people the ability to express themselves via text and creative mediums, greater freedom to talk about sensitive issues, and to exercise control over the interviewer/interviewee dynamic . We usedOne limitation of our study is that curation of diaries depended very much on young people’s motivation to take part, a limitation which has been acknowledged previously . Some paAnother limitation is that, whilst our sample was mixed in terms of deprivation levels and we captured experiences from a diverse set of young people, with the exception of one young carer, our study lacks the voice of vulnerable or specifically marginalised young people such as the LGBTQ+ community, young people who were shielding, those at risk of homelessness, involved in the criminal justice system, BAME communities or young people living in households with substance abuse or domestic violence. Such voices have been under-represented throughout the pandemic response, and there has been a lack of data collection on protected characteristics across the board which prevents an intersectional approach.Thus, whilst our findings suggest that many young people are disadvantaged or struggling at the moment, even those from relatively affluent families, we are cognisant that our work may only scratch the surface of the potential impact that COVID-19 will have on CYP from different backgrounds. Here, it is important to acknowledge the issue of digital exclusion or digital poverty, which is significantly influenced by income, language, literacy, culture, and ethnicity . FurtherTo our knowledge, this is the first study to curate longitudinal qualitative diaries with young people over the course of the pandemic. Whilst CYP are largely physically unaffected by COVID-19, they are likely to experience the most long-term damage, particularly in relation to education, mental health and employment. Our findings have several implications. Our study demonstrates that young people are not ‘all in the pandemic together’ and adds to a body of evidence focusing on how COVID-19 has widened existing inequalities for this generation. Most schools have been forced to embrace virtual learning platforms leading to inevitable debates about the extent to which digital learning will be part of the ‘new normal’, leading to some young people, particularly those from disadvantaged communities, being left behind, and jeopardising the long posited ‘levelling up’ agenda from current government. Whilst some young people developed coping strategies to mitigate harm, young people in our study reported largely negative impacts upon their mental health and wellbeing, such as isolation, stress, anxiety, grief and loss, and the long-term consequences of such sustained levels of isolation remain to be seen. Despite this, some young people were indeed very happy with social distancing restrictions—particularly school closure—and it may be that schools are not the panacea to social ills, or that the pandemic represents a turning point or ‘teachable moment’ for education. Future work should explore this with different groups of young people, particularly those with lived experience of mental health difficulties, trauma or those excluded from traditional school settings. Going forward, there is a need for clear cross-government strategy on health and social inequalities, which places CYP at the heart of this plan. There is also a need for tailored, mental health support for young people, co-produced and adapted to post-pandemic life. Further, we found that even those who struggled with social distancing measures found the leap back into busy, mainstream settings difficult when restrictions eased. Thus, echoing Dewa et al. (2020), we argue that there is also a need for practical support to help young people transition out of lockdown and into the ‘new normal’.


In recent years, global attention to disability inclusion in humanitarian and development contexts, notably comprising disability inclusion within the Sustainable Development Goals, has significantly increased. As a result, UN agencies and programmes are increasingly seeking to understand and increase the extent to which persons with disabilities are accounted for and included in their efforts to provide life-saving assistance. To explore the effects and effectiveness of such measurement, this paper applies a complexity-informed, realist evaluation methodology to a case study of a single measurement intervention. This intervention, ‘A9’, was the first indicator designed to measure the number of persons with disabilities assisted annually by the United Nations World Food Programme (WFP). Realist logic of analysis combined with complexity theory was employed to generate context-mechanism-outcome configurations (CMOC’s) against which primary interviews and secondary data were analysed. We show that within the complexity of the WFP system, the roll-out of the A9 measurement intervention generated delayed, counter-intuitive and unanticipated effects. In turn, path dependency and emergent behaviours meant that the intervention mechanisms of yesterday were destined to become the implementation context of tomorrow. These findings challenge the current reliance on quantitative data within humanitarian-development disability inclusion efforts and contribute to our understanding of how data can best be leveraged to support inclusion in such contexts.  Disability inclusion (DI) is an increasingly prominent concern across humanitarian and development work. The collection, analysis and use of disability-relevant data, particularly disaggregated data, has been championed as a way to operationalise the DI agenda and advance the sustainable development goals (SDG) stated aim of ‘leaving no one behind’ ,2. MeasuWFP is the world’s largest humanitarian organisation, created in 1961 to provide multilateral food assistance. Known colloquially as the ‘logistics engine’ of the UN system, WFP has developed an organisational preference for using quantitative data to support operating at scale; measuring billions of funding dollars received, thousands of metric tonnes of food delivered, and tens of millions of persons assisted annually. In the recent context of growing sectoral attention to DI, WFP made several organisational commitments, including disaggregation of its beneficiary data by disability, alongside sex and age. In 2018, this became the trigger for the launch of a new performance indicator—‘A9’—measuring the number of persons with disabilities reached by WFP assistance. A9 was thus designed as an output indicator , meaningBy 2020, WFP recognized that A9 was not functioning as intended and, as part of a partnership with Trinity College Dublin, set out to understand why and what could be done differently as they advanced the disability inclusion agenda. Here, we used a complexity informed, realist methodology to build an empirically testable account of ‘how’ and ‘why’ the A9 indicator resulted in myriad outcomes across WFP’s various operating contexts. What seemed like a small change—disaggregating one indicator among many, had system wide, unanticipated effects. Over the 3-year history of the intervention, the bi-directional dynamics of organisational change meant that the WFP system responded to A9, while the A9 indicator was itself manipulated and revised through its use and interpretation. This layered nature of organisational change meant that as disability measurement expanded, the intervention mechanisms of yesterday were destined to become the implementation context of tomorrow. Our goal is to assess how a disability measurement intervention operated in practice, to help improve understanding of how best data can be leveraged to support inclusion in humanitarian and development activities.This paper presents a case study, using realist evaluation, of the development and implementation of WFP’s A9 indicator. This case study of A9 forms one component of an ongoing, realist evaluation of the use of evidence as a pathway to mainstreaming disability-inclusive programming in WFP. Realist evaluation is a theory driven, explanatory focused research methodology that seeks to answer the question ‘what works, for whom, in which contexts, and why?’. It does this by identifying underlying, generative mechanisms (M) which, in certain contexts (C), operate to produce observable outcomes (O), framed as CMO-configurations (CMOC) . MechaniThe aim of a realist evaluation is to identify generative mechanisms that can inform transferable guidance—the end result is knowledge which is partial but cumulative, and which can inform further theorizing . To achiThe case study unfolded across 3 phases: theory gleaning; generation of initial programme theories (formatted as CMOC’s); and refinement of CMOC’s through analysis of secondary data and primary interview data. To begin, we sought to make explicit the underlying theory of A9, to understand by which mechanisms and to what outcome its designers expected the intervention to function. Manzano  describeThis initial phase was key as it revealed many underlying motivations and considerations that might not be recalled in later interviews, thus focusing the direction of data collection toward specific theory refinement. As we proceeded, we understood that at the time of its conceptualisation and launch, key WFP staff viewed A9 as an initial move toward meeting its public commitments on collecting disability-related data. The theory gleaning phase also served a practical purpose, as it fostered relationships with WFP staff that facilitated access to A9 data. It was our experience that building this trust contributed to greater openness in subsequent interviews, giving us deeper insight to stakeholders reasoning regarding A9. This phase confirmed our expectation that A9 could serve as a ‘ready-made’, natural case study as WFP embarked upon standardising the use of disability-related data.The theory gleaning phase underpinned the development of initial theories about how and why A9 functioned, and these theories, along with a document analysis informed by complexity theory, contributed to CMOC’s. Realist evaluation has been criticised for a lack of clear detail about how CMOC’s are constructed . In our In realist evaluation, middle range theory (MRT) is employed to “explicate the underlying logic of programs”  through We note that our MRT, complexity theory, is a framework rather than a unified theory, and some components, such as systems theory, may have ambitions to grander monikers than mere ‘middle’ range theory. However, complexity comprises and delineates multiple useful concepts, including “open” systems, path dependence, feedback loops, emergence and self-organisation, which informed the development of CMOC’s, to which the interviews were coded. The initial CMOC’s were refined, augmented or refuted through analysis of secondary A9 data and qualitative interviews with WFP staff. We analysed the sources of the data reported for A9, such as surveys, estimates, etc., as these sources indicated how WFP was using and responding to A9 in practice. Drawing on the realist concept of depth ontology, we focused not on the numbers produced by A9, but at a deeper level, analysed the underlying sources for these numbers, and what this indicated about how A9 was being used . DrawingA total of 19 participant interviews were conducted as part of the larger realist evaluation of implementation of disability-related data collection efforts in WFP. A subset of these interviews (n = 9) either made unprompted mention of A9 or were iteratively adapted to include questions related to A9. All interviews were conducted remotely and were consistent with the ‘teacher-learner’ cycle of realist interviews, whereby theories are explicitly shared with the interviewee for comment . The parIn this section we present the CMOCs in a ‘stackable’ order , wherebyCMO-configuration: In the post-2015, SDG agenda, DI was a new priority among humanitarian and development actors and the donor governments who fund WFP’s work, but it was not yet a systematised element of WFP practice (context). As a standard setting, voluntarily funded organisation, WFP perceived pressure to respond (mechanism) to the growing DI imperative with demonstrable action. This led WFP staff to design and launch the novel A9 indicator, making it mandatory for all country offices to measure and report the numbers of persons with disabilities receiving WFP assistance (outcome).These influences were evident in minutes from WFP’s Executive Board meetings, made up of donor government representatives, where enhanced reporting on the inclusion of persons with disabilities in WFP activities was repeatedly requested. Contemporaneously, relevant donors and other UN agencies and humanitarian and development actors were publishing materials highlighting an increased focus on disability inclusion. Within this context, A9 likely served dual political and practical purposes; demonstrating to donors that WFP was taking DI seriously, and directing field staff on how, where, and when to start collecting data disaggregated by disability.The following quotations, taken from the primary interviews with WFP staff, illustrate their response to disability-related data as it was emerging within the WFP landscape, with a sense of permeability between actors in the broader humanitarian-development context:Monitoring & Evaluation (M&E) Staff: “I mean, we can see it everywhere, not in WFP, but we can see it in the world news in everything—that people with disabilities now is on the agenda. I don’t know how they got there, but they are in the agenda, right?”Protection Staff: “I think it had been raised a lot within the executive board, with the member states. I don’t know exactly why, but for sure, there was, it had been raised by a few members.”Across the humanitarian-development sphere, WFP is embedded in multiple systems where boundaries and, in-keeping with complex systems, “the notions of ‘inside’ and ‘outside’ are never simple or uncontested” . For exaComplex, open systems are characterized by ‘fuzzy boundaries’, where boundaries constitute both the activity of the system, and the way in which those boundaries are described. WFP considers itself a food security organisation, which responds and prioritises assistance based on need. Disability, therefore, could be perceived as shifting its modus operandi to privilege a person’s ‘status’, i.e., whether or not they are identified by WFP as having a disability. However, given the malleability inherent in complex adaptive systems, and at least partly in response to interpenetration with surrounding systems, the creation of A9 moulded the boundaries of WFPs mandate to consider more explicitly, the relationship between disability and food security needs. CMO-configuration: WFP designed and launched the novel A9 indicator, making reporting mandatory for all country offices (CO’s) globally, but competing workstreams and priorities across WFP’s high-need, limited-resource operational environment (context), meant that learning was impeded (mechanism), with the result that although WFP staff identified issues implementing A9, these could not be adequately addressed (outcome).From our earlier theory gleaning, including review of contemporaneous internal email threads referring to A9 development and implementation, we surmised that A9 was designed as an adaptation of the Washington Group Short Set of Questions. This is an internationally validated tool for disaggregating data by disability and is increasingly favoured by sectoral actors and donors ,25. The M&E Staff: “The intention was in any case to start gathering some data, make COs aware of the need to think about disabilities, and to gather lessons learnt and improve. So, it was a first step…We wanted to profit [from the opportunity] to include and to start, you know? And then after that, I did go back to the technical unit a couple of times to say, “Guys, I mean this is the information we have gotten—it’s not very good. These are the lessons learned. So it’s time to revise these methodologies.”…they told me, “OK, wait a little bit. We’ll call you back when we are able to touch on this topic.”Although WFP staff viewed A9 as an initial move toward meeting its organisational commitments on collecting disability-related data, feedback loops; the mechanism by which experiential learning could have refined A9 through its life cycle, were initially frustrated due to the realities of WFP’s competing priorities and constrained resources. A negative  feedback loop is a learning loop which enables corrective action when departures from intended actions or errors occur. Although A9 underwent at least one revision in the three years of its operation, as evidenced in WFP’s indicator compendium, there was insufficient feedback and corrective action to address the underlying implementation challenges. This inadvertently created a ‘cul-de-sac’ whereby implementing A9 could stand as a self-contained outcome, i.e., data for data’s sake, rather than as an informative step toward inclusive action. Thus, A9 was functioning as an end rather than a means toward more inclusive programming. This resulted in confusion and frustration among staff who expected that disability disaggregated data should contribute to planning programmes or understanding the inclusion gap, but found A9 struggling to do either.CMO-configuration: In the face of WFP staff experiencing issues implementing A9 and with initially limited internal expertise to draw on support implementation, A9 continued to be mandatory, with donors and senior management requesting the data (context). WFP staff at various levels began to judge (mechanism), on a case-by-case basis, whether and how to report on A9. Consequently, different country office’s variously applied or ignored A9, with the result that at an organisational-level, A9 did not reliably produce useful and comparable data (outcome).A9 was a ‘thin’ resource, in that it was WFP’s first corporate measurement approach for DI and so for a period stood alone, tied to neither training or wider guidance. The resultant response, as A9 was adopted in advance of dedicated work to embed and reinforce DI across the system, was correspondingly scanty in terms of reliable data. The following quotes illustrate the concerns related to the validity of the data and the need for support:Regional Support Staff: “But then as I as I just mentioned, in most cases, that numbers just seem so ridiculously low that I would rather remove it, although it’s mandatory to report on. But I would rather remove it or just use the 15 percent overall number sort of as a blanket thing...the numbers that the country officers were reporting was so much lower [than the global average] that it almost seemed really ridiculous to report it.”Programme Manager Staff: “if you’re going to be introducing anything that’s new, and this [A9] is going to be really out of the box for pretty much everybody, it cannot come without guidance methodology. How do we really collect this? What is the relevance of it? How do we analyze and interpret it and apply it? So that, I think, has to be there.”Agents within a system are themselves complex, giving rise to the system’s capacity to innovate on the ground and overcome structural gaps . DespiteCMO-configuration: WFP staff were increasingly wary of the data being produced by A9, and they struggled to use the data to inform the design or application of assistance programmes to ensure the inclusion of persons with disabilities (context). Over time, buy-in and support for A9 decreased as doubts increased (mechanism), reducing A9′s credibility and sustainability, triggering a re-design of the indicator (outcome).The authors of A9 envisioned it as a necessary first step on the path toward DI, and may have hoped to harness the complex adaptiveness of WFP by planting a first seed which could then grow awareness through the organisation. However, causal processes are not linear, and unpredictability as to where a first step may lead is compounded by self-organisation within the system. Given agent’s ability to organize and respond to change, a new intervention can be “defeated by the systems response to the policy itself” , as illuProtection Staff Member: “We didn’t at that stage understand why we were collecting the data. So we collect data because we were required to collect the data. But the data wasn’t being used to inform programming. And that’s very obvious in the fact that, you know, disability was considered an output indicator and not an outcome indicator. And I need it to be an outcome indicator to be able to directly correlate it with how we adjust programming. As an output indicator it provides me with very little information beyond: this is how many people with disabilities we provided assistance to. But that doesn’t give me any information on whether they are facing challenges, whether we needed to establish new measures for them...”Agents in this  system had flexibility and agency in how they interpreted and responded to the resource of A9. Their response to the resource—in realist terms, the generative mechanism—was influenced by their context, which in turn was influenced by the outcomes of previous context-mechanism interactions. As we have seen, these included inadequate pathways to refine A9 through use, and A9′s inability to produce reliable data at a point in WFP’s programme cycle that could influence change. This resulted in decreasing buy-in for A9, ultimately culminating in a review and redesign of the indicator, of which this analysis was part.The case study of WFP’s A9 indicator allowed us to map “the contours of complexity” at the outset of this multi-year evaluation , and to While the production of organisation-wide, comparable data may have been a reasonable aim of A9, uniformity of application could not be achieved, in part due to the impact of the intervention taking place in multiple social realities, across varied contexts. This was recognised by the indicator document itself, which laid out alternative reporting methods, but even within this ‘sanctioned’ variation, unanticipated outcomes arose. The most interesting element here is not the numbers of persons with disabilities reported by A9. Indeed, our first engagement with A9 was in relation to the methodological improvements WFP wished to implement to increase the reliability of the data. Rather, this paper sought to understand how the intervention—regardless of its inherent quality—was operationalised across the system, as “process data provides a useful explanation of the observed outcome” .The answer to ‘what works’ is always ‘it depends’, with the answer dependent upon for whom the intervention is intended to work, and in which context(s) . To asceWhen A9 was launched, disability inclusion was seen as a problem to be solved, rather than a system state to be achieved. A9 was introduced at a time when the humanitarian-development context was in flux in terms of DI, and the characteristically short timelines of both funding and implementation across the sector compelled staff to react quickly. This enabled a reductionist approach whereby a linear solution—to count the number of persons with disabilities reached annually, using a simplified, untested adaptation of the Washington Group Questions, was insufficient to achieve the system-state change of inclusivity toward which sector-wide DI efforts ultimately strive. Given that “a critical feature of all programmes is that, as they are delivered, they are embedded in social systems” , the sucThrough its communication and interpenetration with other complex, open systems, including the wider multi-lateral system of donor infrastructure and the humanitarian-development sector, WFP developed and launched its goal of becoming a disability-inclusive organisation writ large. Since 2018, when A9 was conceptualised and launched, WFP has expanded its engagement with DI and by 2020, WFP had introduced a new implementation roadmap, alongside dedicated human resources and an increasing number of supportive—and demanding—donors. As the context became more favorable to DI overall, the outcomes produced by A9 were increasingly unsatisfactory. A9 did produce data for the majority of WFP’s country contexts over multiple years, but over time, counting the number of programme beneficiaries with disabilities was perceived as an insufficient measurement. As this context around A9 shifted, staff responded to and utilisied A9 in multiple ways, but ultimately agents in the system could not overcome the lack of a pathway for A9 data to inform WFP activities through beneficiary targeting or programming design.To avoid humanitarian data collection earning the dreaded label of being a ‘tick-box’ exercise, thought must be given to the type and purpose of data collected, with careful planning to ensure the information generated has a pathway to inform action. We acknowledge that while complex adaptive systems are difficult if not impossible to predict, it may still be possible to guide sub-components of the system toward common outcomes, provided a unified vision of the ultimate goal is clearly articulated and disseminated. This evaluation of A9 showed that until the resource of A9 is sufficiently ‘thickened’ or augmented by additional measurement and support, it is likely that CO’s will continue to manipulate the indicator and struggle to action the data in their activities.The history of an intervention cannot be overlooked, as it shapes the context, which is key to success or failure . As WFP This case study has limitations. As is common for a humanitarian organisation, and is exacerbated during a global pandemic, staff turnover was high as people were redeployed to new emergencies or assumed new roles. This meant that it was not possible to identify or reach all persons involved in the conceptualisation of A9; while resource constraints and practicality made interviewing all staff who interacted with A9 unfeasible. This may have created bias in the interview sample and excluded important perspectives from informing and refining our theorising. Due to travel restrictions imposed by COVID-19, interviews were conducted by phone or via online audio/video platforms, however we propose that this did not significantly impact data quality, as given the nature of their work, WFP staff were already habituated to working remotely.Social change has a bi-directional nature, as people’s actions and agency are shaped by community and institutions, and these structures change over time as a result of who comprises them . SuccessUltimately, the head-counting of disaggregation alone presents too reductive a solution to the complexity inherent in large humanitarian-development organisations, their operational contexts, and the problem of disability exclusion itself. To achieve the system state of ‘disability inclusivity’, data-disaggregation alone will be insufficient. The CMOC’s presented here have explanatory power as to how and why disaggregation can produce outcomes other than those intended, pointing to the need for the sector to look beyond only quantitative disaggregation as the evidence base for inclusive action, and to anticipate complexity wherever such measurement is implemented.