title: The Prevalence of Sexual Violence among Female Refugees in Complex Humanitarian Emergencies: a Systematic Review and Meta-analysis.
abstract: OBJECTIVE
  Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain.
  
  
  OBJECTIVE
  Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies.
  
  
  METHODS
  We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources.
  
  
  METHODS
  Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected.
  
  
  METHODS
  Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2.
  
  
  RESULTS
  The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings.
  
  
  RESULTS
  The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias.
  
  
  CONCLUSIONS
  The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.
authors.affiliation: International Emergency Medicine and Public Health Fellowship Program, Department of Emergency Medicine, Johns Hopkins School of Medicine; Health Systems Program, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Vu
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Atif
authors.initials: A
authors.lastname: Adam
authors.affiliation: Department of Emergency Medicine, Johns Hopkins School of Medicine; Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Wirtz
authors.affiliation: International Emergency Medicine and Public Health Fellowship Program, Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
authors.forename: Kiemanh
authors.initials: K
authors.lastname: Pham
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Leonard
authors.initials: L
authors.lastname: Rubenstein
authors.affiliation: Johns Hopkins University School of Nursing, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Glass
authors.affiliation: Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Beyrer
authors.affiliation: Department of Medicine, Johns Hopkins School of Medicine; Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Sonal
authors.initials: S
authors.lastname: Singh