Violence against women and children in Yemen: A mixed-methods systematic review

Violence against women and children in Yemen: A mixed-methods systematic review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Violence against women and children in Yemen: A mixed-methods systematic review View ORCID Profile Samana Shreedhar , View ORCID Profile Sayali Arvind Chavan , View ORCID Profile Marwah Al-Zumair , View ORCID Profile Mirna Naccache , View ORCID Profile Priya Shreedhar , View ORCID Profile Lauren Maxwell doi: https://doi.org/10.1101/2024.08.01.24310001 Samana Shreedhar 1 Institute of Tropical Medicine and Public Health, Charité-Universitätsmedizin Berlin , Berlin, Germany Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Samana Shreedhar Sayali Arvind Chavan 1 Institute of Tropical Medicine and Public Health, Charité-Universitätsmedizin Berlin , Berlin, Germany 2 Heidelberg Institute of Global Health , Universitatklinikum Heidelberg, Germany Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sayali Arvind Chavan Marwah Al-Zumair 2 Heidelberg Institute of Global Health , Universitatklinikum Heidelberg, Germany Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Marwah Al-Zumair Mirna Naccache 2 Heidelberg Institute of Global Health , Universitatklinikum Heidelberg, Germany Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mirna Naccache Priya Shreedhar 2 Heidelberg Institute of Global Health , Universitatklinikum Heidelberg, Germany Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Priya Shreedhar Lauren Maxwell 2 Heidelberg Institute of Global Health , Universitatklinikum Heidelberg, Germany Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Lauren Maxwell For correspondence: lauren.maxwell{at}uni-heidelberg.de Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Violence against women and children (VAWC) is a significant health and human rights issue closely tied to multiple Sustainable Development Goals. While VAWC is prevalent in all countries, the severity and incidence of VAWC increase during wars, natural disasters, economic crises, and pandemics, all of which have affected Yemen in recent years. This systematic review synthesizes evidence from qualitative and quantitative studies on the types, prevalence, perpetrators of, and risk factors for VAWC in Yemen. Before initiating the search, the protocol and search strategy were registered to PROSPERO (CRD42021237855). We systematically searched four biomedical databases and grey literature sources and used reverse snowball sampling to identify eligible studies. The 31 studies included in the analysis depicted a range of forms of VAWC, encompassing honor violence, female genital mutilation and cutting, early and very early marriage, tourist marriage, family and intimate partner violence, and gender inequities in access to food, education, and medical care. Included studies reported a high prevalence of many forms of violence, including corporal punishment in schools and intimate partner violence. We reviewed study quality and how studies addressed ethical concerns in VAWC-related research. We found that several studies did not report ethics review or interviewer training and no studies discussed safety planning or addressing the mental health needs of participants in VAWC research. This systematic review provides a much-needed synthesis of existing research on VAWC in Yemen. Since the start of the 2014 war, Yemen has become the world’s largest humanitarian crisis, with the highest rate of maternal mortality and gender inequality in the world. We only identified one study initiated after the recent war in Yemen. This deficiency represents a missed opportunity to understand how the ongoing war has reversed prior gains in reducing the prevalence of child and very early child marriage and introduced new forms of gender-based violence, including tourist marriage. Introduction Violence against women and children (VAWC) is a global human rights issue that closely relates to the achievement of the Sustainable Development Goals (SDGs), particularly Goal 5, which aims to achieve gender equality and empower all women and girls and Goal 16, which seeks to promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build effective, accountable institutions. In this systematic review (SR), we summarize primary and secondary research related to the forms, perpetrators, consequences, and reporting of VAWC in Yemen to inform future research and the development of interventions that prevent VAWC in Yemen or address the consequences of VAWC. Humanitarian crisis In 2023, eighty percent of Yemen’s population of 29.8 million people required humanitarian assistance [ 1 ], and 4.5 million people were internally displaced [ 2 ], making Yemen the world’s largest humanitarian crisis. The recent war has decimated the country’s economy, healthcare, education, and infrastructure [ 3 ]. In addition to the ongoing humanitarian crisis, Yemen has deeply entrenched gender inequities where limited resources mean that women and girls do not have the same access to limited educational, health care, or food resources as their male counterparts [ 4 , 5 ]. As in any humanitarian crisis [ 6 ], the prolonged war disproportionately affected Yemeni women and children. Non-governmental organizations (NGOs) in Yemen report increased levels of forced, early marriage and trafficking of girls and young children in response to the ongoing war [ 7 ]. Girls are sexually exploited in bars and restaurants in the larger towns of Yemen and may be forced to traffic illegal drugs [ 8 ]. Both Saudi and Houthi forces have used child soldiers [ 9 ]. The economic crisis and targeted attacks on infrastructure, including education, health care, and government services, mean that child labor has become commonplace [ 8 ], affecting mental and physical health (19). Where school bombings have not occurred, parents are reluctant to send their children to school for fear of bombing, trafficking, recruitment of child soldiers, and other forms of community or war-related violence [ 10 ]. Violence against women Intimate partner violence (IPV), defined as “behavior by an intimate partner or ex-partner that leads to physical, sexual or psychological harm, including aggression, sexual coercion, psychological abuse, and controlling behaviors” [ 11 ], is the most prevalent form of gender-based violence (GBV) globally. Longstanding gender inequities codified into law mean that Yemeni women, their families, and their community may perceive their experience of IPV, including marital rape, as their fault [ 12 ]. Societal stigma associated with physical and sexual violence means that women and children have limited options for support or for reporting violence. Where support is available, the stigmatization of women or children who experience violence, especially sexual violence, prevents reporting or accessing available services [ 13 ]. Violence against children The World Health Organization (WHO) defines violence against children (VAC) as ‘’violence in all forms experienced by children who are under 18 years old, perpetrated by parents or other caregivers, peers, romantic partners, or strangers” [ 14 , 15 ]. Globally, 75% of children experience physical or emotional abuse from their parents, peers, or caretakers [ 14 , 15 ]. Female genital mutilation or cutting (FGM/C), defined as “all procedures involving partial or total removal of the external female genitalia or other intentional injuries to the female genital organs for non-medical reasons,” [ 16 ] is a prevalent cultural practice in Yemen and elsewhere in the Middle East and North Africa (MENA) and sub-Saharan Africa (SSA) [ 17 ]. The practice of FGM/C leads to an increase in urinary, vaginal, and pregnancy-related morbidities and mortalities, repeat surgeries, and death [ 12 ]. Gender inequitable access to food, education, employment, health care, and legal protections In 2021, Yemen ranked last out of 170 countries on the Gender Inequality Index (GII) [ 18 ]. Educational attainment and literacy in Yemen are low (8, 10), especially for women and only 6% of women work outside of their home [ 5 ]. Yemen has two legal systems, Shari’a and Kabeelee, or tribal law. Under Shari’a law, Yemeni women lack child custody protections and have limited to no right to divorce, property rights, or the right to manage their finances [ 19 ]. In contrast, men are legally entitled to control their spouse’s money and property, are the default recipients of child custody, and can divorce their wives by saying “talaq’’ [ 19 ]. Marital rape remains non-criminalized [ 20 ] even though Yemen acceded to the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) in 1984, mandating states to ensure that marriage is founded on free and full consent [ 21 ]. Yemen does not have a minimum age of marriage, even though Yemen ratified the Convention on the Rights of the Child in 1989, setting 18 as the minimum age for marriage. Intersectionality and violence against women and children Minority ethnic groups in Yemen, including the indigenous Akhdam or Muhamasheen community and refugees from Somalia, Sudan, or Ethiopia, face high levels of discrimination and violence in Yemen, including sexual assault and rape [ 22 ]. Homosexuality in Yemen is a criminal offence under Shari’a law that is punishable by death, which means that violence against lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) likely goes unreported [ 22 ]. Materials and Methods We used a mixed-methods SR design with a narrative synthesis approach to provide a broad overview of VAWC that could be used to inform policymakers and develop research priorities [ 23 ]. The SR protocol was developed using the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines [ 24 ] and registered on the PROSPERO Register of Systematic Reviews before initiating the search (CRD42021237855). We followed the 2020 PRISMA guidelines for conducting and reporting systematic reviews [ 25 ] and reported the PRISMA elements in Supplementary Table S1. Search strategy We conducted a systematic search of four electronic databases, Ovid (MEDLINE) and (Embase), Cumulated Index to Nursing and Allied Health Literature (CINAHL), and Web of Science (WoS), using a combination of MeSH and text terms (S2 Table). We ran the searches on 18 February 2021 and did not include language or date restrictions. We updated the search for Ovid (Medline), WoS, and CINAHL on 8 April 2024 but no longer had access to Ovid (Embase) and did not rerun that search. We also searched for additional citations using backward snowball sampling [ 26 ], reviewing the citations in included studies. Additional studies were identified through grey literature searches, using the Google search engine and reviewing NGO websites, including the United Nations High Commissioner for Refugees (UNHCR), Save the Children, United Nations Children’s Fund (UNICEF), and United Nations Family Planning Association (UNFPA) websites. We also reviewed Yemen country reports from the Demographic and Health Surveys (DHS) and the Multi-Cluster Indicator Surveys (MICS), population-representative survey research initiatives that focus on maternal and child health (MCH)-related outcomes. Inclusion criteria Included studies were primary research studies that used any design and that reported on any form of sexual, physical, emotional, or economic violence against Yemeni women and children, including IPV and family violence (early or very early marriage or forced marriage, femicide, prenatal sex selection, female infanticide, FGM/C, gendered access to food, education, vaccines, healthcare, employment; dowry-related violence; honor killings; child labor; child neglect and maltreatment) workplace violence; war-related violence (child soldiers, captivity, trafficking of women and children, war-related sexual violence, physical attacks on women and children (e.g., rape, bombing), indirect attacks (bombing of water treatment facilities, hospitals, schools); pandemic-related violence (child labor, increased family, or IPV), violence related to displacement, gendered access to masks or COVID-19 treatments or vaccines. Studies that did not report on VAWC in Yemen and publications that did not represent primary research or secondary analyses of participant-level data (e.g., commentaries, systematic reviews, editorials) were excluded. Data extraction and management Citations were exported to EndNote (version 9.3.3) for deduplication using the Braner approach [ 27 ]. Citations were then exported to Covidence version 2.0 [ 28 ] for title-abstract and full-text screening and data extraction using a pre-piloted data extraction form (Supplementary Text 5). Three reviewers (SC, MAL, SS) independently conducted the screening and data extraction. A fourth reviewer (LM) resolved disagreements. A meta-analysis was not possible due to the heterogeneity of study designs, types of violence, and age groups. We used thematic synthesis [ 29 ] to summarize findings across studies. We treated different types of violence as themes and identified additional themes, including risk factors, perpetrators, resources, and barriers to accessing resources, from the included studies and our review of related literature. Quality assessment We assessed the quality of included primary research studies using the Mixed Method Analysis Tool (MMAT), version 2018 [ 30 ], which reviews the study’s design, sampling strategy, generalizability, data collection methods, integrity of intervention (where applicable), and analytic approach. We did not review the quality of population-level surveys (e.g., MICS, DHS, Arab Family Survey), which are generally regarded as high quality. Quality assessment criteria were applied by two independent reviewers (SS, MN); disagreements were resolved through a third reviewer (LM). Results The screening process is summarized in the PRISMA Flow diagram [ 25 ] shown in Figure 1. From the initial search of the database conducted in February 2021, we identified 459 abstracts, while in the updated search done in April 2024, 106 abstracts were identified. After removing duplicates, 356 titles and abstracts (291 from the initial search and 65 from the updated search) were reviewed in Covidence. Subsequently, 63 studies were assessed for full-text eligibility, with 32 studies excluded for being systematic reviews, commentaries, editorials, or other non-primary research (19 studies) or for not measuring violence or stigma against Yemeni women and children (13 studies). Data was extracted from the 31 studies (6 reports and 25 articles(2 of which are grey literature sources)) that met the inclusion criteria. For details on the reasons for exclusion at the full-text review stage, refer to Supplementary Table S3. Overview of included studies Table 1 provides an overview of the types of violence, risk factors, and consequences examined in the included studies, excluding data from the Yemen DHS and MICS reports (n=4) as they were included in other studies in the table. We identified 17 primary research studies, six reports, and eight secondary analyses that met the study inclusion criteria. Studies and reports included a diversity of age groups and types of violence and covered all of Yemen’s 22 governorates. Primary research included four qualitative studies and two qualitative components of mixed-method studies [ 7 , 21 , 31 – 34 ]. Most qualitative studies conducted in-depth interviews (IDIs; N=3), one study used a focus group discussion (FGD) approach [ 21 ], and two studies analyzed answers to open-ended questions in a cross-sectional questionnaire [ 32 , 34 ]. Supplementary Table S4 provides a detailed overview of quantitative studies and the quantitative estimates in mixed studies, including types of violence, measurement approach, point estimates (e.g., prevalence), measures of uncertainty (if any), associated risk factors, and regional differences. All 20 quantitative studies employed a cross-sectional design. Four quantitative studies [ 16 , 35 – 37 ] used DHS data [ 12 , 38 , 39 ]. Two studies [ 36 , 40 ] used data from MICSs [ 41 ], and five studies used data from various national and sub-national household surveys conducted in Yemen [ 42 – 46 ]. View this table: View inline View popup Table 1. Overview of included studies Studies included different types of VAWC, offenders or perpetrators of violence, location of violence, risk factors, consequences of violence, and information on ethical concerns, access to services, or safety planning. We identified two studies related to early child marriage [ 7 , 21 ], seven studies on child abuse or maltreatment [ 21 , 40 , 47 – 51 ], five studies on FGM/C [ 16 , 36 , 43 , 44 , 46 ], seven studies on gender differences in education or health care services [ 35 , 37 , 42 , 45 , 52 – 54 ], and one study on community violence [ 31 ], IPV [ 32 ], attitudes towards honor violence [ 21 ], GBV [ 33 ], gender preference [ 37 ], dentist’s reports of suspected violence [ 55 ], and stigmatizing attitudes towards women with human immunodeficiency virus (HIV) [ 56 ]. No studies presented information on pandemic or war-related VAWC. All studies reported on risk factors and perpetrators, and most studies described barriers to reporting violence [ 7 , 16 , 31 – 34 , 36 , 40 , 42 – 44 , 47 – 53 , 55 , 57 ]. Other than the DHS and MICS, which are country-wide, studies that collected primary data were conducted in Aden, Sana’a, Al Hudaydah, Taiz, Al-Mukalla, Al-Mahrah, Lahij, and Hadramout governorates. Most studies included both urban and rural areas, although a few studies were limited to urban (N=2) [ 49 , 54 ] or rural (N=1) [ 44 ] populations. In most studies, verbal consent, as opposed to written consent, was obtained. This practice could be attributed to concerns about participant safety in research related to VAWC or to Yemen’s generally low literacy level. Over half of the studies (25 of 31) were conducted before the 2014 war. While most VAWC occurs within the home, three articles found that women were also likely to experience GBV outside the home [ 32 – 34 ]. Types of VAWC Family and intimate partner violence against women Neither the DHS from 1991/92, 1997, or 2013 nor the 2005/6 MICS included questions on women’s experience of partner or family violence. In addition to the DHS and MICS, two quantitative studies examined IPV [ 21 , 32 ]. One 2002 study of a stratified random sample of 111 ever-partnered women aged 15-55 in two areas of Sana’a found that 55% of women had experienced physical IPV (beatings, confinement to home, torture), 51% experienced threats, and 17% experienced sexual IPV [ 32 ]. Participants also reported experiencing violence perpetrated by their sons, brothers, fathers, mothers, and uncles [ 32 ]. Many participants reported that the violence they experienced was ‘’normal’’ and expected given societal norms [ 32 ]. Honor violence often occurs as a punitive response to perceived sexual immodesty in young girls, including after cases of sexual violence where the attribution of blame lies with the victim [ 21 ]. A 2009 qualitative study found that teenage girls in Yemen internalized honor violence. Participants reported acceptance of harsh punishments for girls who experienced sexual violence because they had ‘allowed’ or invited the violence [ 21 ]. Early and very early child marriage The 1991/92 DHS revealed that 31% of girls were married by the age of 15 [ 38 ], a figure that decreased to 29% in the 1997 DHS [ 39 ] and further dropped to 14% in the 2006 MICS [ 41 ], and significantly decreased to 3% in the 2013 DHS [ 12 ]. A 2009 focus group study involving 138 Yemeni girls aged 12 to 18 discovered that financially insecure families felt compelled to marry off their young daughters [ 21 ]. “First, I got married at 11, and second, my maternal uncle married me off. He found the groom through his connections, and he was 50 years old. It was a marriage of avarice. My uncle got a bribe of 200,000 rials, and my father got 160,000 in money and 300,000 in gold (dowry).…On the day of my marriage, I still had not reached puberty, and I reached puberty only in his house. He had intercourse with me on the first night, and of course, I did not know what a man does to a woman or how to act…my feelings on that night were horrible. I thought he was going to kill me, and he took me by force. I tried to defend myself that night, and I could not and then I fainted and lost consciousness and recovered only in the morning, and he left me alone to get rest.” (p. 462-463, [ 21 ]). Tourist marriage Tourist marriage, a recent manifestation of child marriage, involves a temporary union between a Yemeni girl and a man from a wealthy Gulf country. This phenomenon has arisen in response to the ongoing humanitarian crisis in Yemen stemming from the 2014 war. Tourist marriages can last from one day to several months and represent a temporary agreement rather than a legal marriage [ 7 , 21 ]. In a qualitative study involving stakeholders at NGOs focused on working and helping Yemeni women and children in crisis, a participant highlighted poverty as the primary factor contributing to the increasing incidence of this emerging form of child marriage [ 7 ]. “Poverty, economic hardship, unemployment and increasing cost of living were all raised as reasons for families to resort to child marriage as a coping mechanism to permit them to alleviate poverty or the burdens of a large family with many daughters. Girls from low-income families are more likely to marry before 18” (p. 9, [ 7 ]). Female genital mutilation and cutting Five cross-sectional studies measured FGM/C, defined as ‘’all procedures involving partial or total removal of the external female genitalia or other intentional injuries to the female genital organs for non-medical reasons’’ [ 16 , 36 , 43 , 44 , 46 ]. Three studies assessed both women’s and their husbands’ attitudes toward FGM/C [ 16 , 44 , 46 ]. Estimates of the prevalence of FGM/C ranged from 16% in a 2008 subnational survey [ 44 ] and the 2013 DHS [ 12 ] to around 20% in the 1997 DHS [ 39 ] and the 2003 Arab Family Health Survey [ 43 ] and 89% in a population-representative FGM/C-specific survey in three southern Yemeni governorates [ 46 ]. Traditional birth attendants called daya, gedah , kharshofa, or qabila conducted FGM/C at home or in the community [ 16 , 44 , 46 ]. While some studies found maternal education and knowledge of the harms of FGM/C was predictive of their daughter’s likelihood of experiencing FGM/C [ 16 , 44 ], other studies did not [ 46 ]. Gender preference The 1991/92 and 1997 DHS found that 20% and 33% of ever-married women preferred having a male over a female child [ 38 , 39 ]. In one qualitative study where 220 women aged 35 in Aden, Lahij, Hadramaut, Taiz, and Al Hudaydah governorates were asked about their gender preferences, respondents reported that they “pray to God” for a boy and not a girl child to make their husband happy [ 34 ]. “I had nine daughters; my husband wants a son. I was so frightened, it’s a girl that I started a fever and was shivering from fright.” (pregnant woman, aged 33, urban residence) (p. 7, [ 34 ]) “My husband is only waiting to hear the good news that the baby is a boy; he never thinks of me, only the gender of the baby, and I feel very badly.” (woman with three living children, aged 22, rural residence) (p. 7, [ 34 ]) Gender inequitable access to food, medical care, and education Six studies described gender inequities in access to food, medical services, or education using data from qualitative studies [ 42 , 52 – 54 ], the DHS [ 35 ], the Pan Arab Project for Family Health (PAPFAM) [ 42 ], and the 2016 Household Income, Expenditure and Consumption Surveys (HIECS) [ 45 ]. A cross-sectional quantitative study on gendered access to education with 8–15-year-olds in 20 Yemeni districts found that over 30% of girls were not able or allowed to attend school, compared to 10% of boys [ 42 ]. A cross-sectional, multi-country survey on gendered access to medical care, found that Yemeni boys exhibited a higher likelihood of seeking or receiving hospital care compared to girls (prevalence sex ratio 0.85; p<0.05) [ 35 ]. A statistically significant proportion of women (3.66 on a scale of 1 to 5; p<0.001) reported feeling guilty for accessing medical services and were less likely than their male counterparts to spend money on medical care [ 53 ]. A 2005 cross-sectional study on gender and literacy as determinants of care-seeking behavior found that 63% of low-literacy women delayed diagnosis of tuberculosis (TB) (longer than eight weeks) compared to 44% of fully literate women [ 52 ]. In a 2007 study, most women (69%) reported having been harmed by family members when seeking medical care within the formal health system [ 53 ]. The two cross-sectional surveys mentioned above also found that women must seek permission from their husbands or male family members before visiting a doctor or clinic [ 52 , 53 ]. Child abuse or maltreatment Seven studies measured violence against children (VAC) at home or in school, including emotional, physical, and sexual abuse [ 33 , 40 , 47 – 51 ]. The majority of the studies were cross-sectional. Four studies conducted interviews with children to gather information about their own experiences of abuse [ 21 , 47 , 48 , 51 ]. Two studies analyzed caregiver (mothers, aunts, grandmothers, guardians, teachers) reports of child abuse, either abuse that they had witnessed or been told about [ 40 , 50 ]. One study examined MICS data to determine the different forms of child abuse and related risk factors [ 40 ]. A high level (around 80%) of adults reported experiencing emotional abuse in their childhood across studies [ 40 , 47 , 49 – 51 ]. The 2013 DHS reported that 42% of children aged 2-14 (n=5,731) were exposed to severe physical punishment (being hit on the head or face with hands or by an implement) in the month before the survey. Nearly 80% (n=10,774) faced some form of physical discipline in the same timeframe [ 12 ]. The 2006 MICS reported that 94% of children aged 2-14 (n=2,702) were ever exposed to at least one form of physical or psychological abuse, and over 20% of children aged 5-14 (n=1,733) were engaged in child labor [ 41 ]. Three studies found a high prevalence of emotional and physical abuse among school children in Sana’a and four randomly selected districts of Aden [ 47 , 48 , 51 ]. A 2011 study of the different forms of child abuse prevalent in Yemen found that more than 90% of children aged 2-14 ever experienced emotional abuse [ 40 ], and a 2019 cross-sectional study found that 35% of students aged 18-24 reported experience of sexual abuse during their childhood [ 49 ]. A 2008 study of a random sample of students aged 7-10 (n=1,196) and another 2019 study with a random sample of students from five colleges at Hadramaut University (n=395) found shouting, yelling, hitting by hands, severe physical punishments, and sexual abuse to be commonly experienced by children [ 49 , 50 ]. Close to 60% of the interviewed mothers (n=119) of school-aged children living in rural areas reported hitting their children with their hands to discipline them [ 50 ]. Thirty-five per cent of students in one quantitative study (n=139) experienced sexual violence during childhood, defined as being “spoken to in a sexual way, unwanted sexual touching, forced to watch movies, take naked photos” [ 49 ]. Eighty per cent of students experienced verbal sexual harassment (n=111), and 19% (n=26) were coerced into watching pornographic movies [ 49 ]. Perpetrators of violence Most studies reported child abuse perpetrators as parents or other family members, teachers, and school principals in schools or universities [ 40 , 47 – 51 ]. FGM/C practices were mainly carried out by family, traditional healers, and community members at home or in health facilities [ 16 , 36 , 43 , 44 ]. Both partners and parents perpetrated honor violence [ 32 ]. Legal context Legal protections for women and children facing violence are limited. In cases of sexual violence against women or girls, families might force their daughters to marry the perpetrator as a means of restoring the family’s honor [ 7 , 21 ]. Divorced women are often blamed for their divorce [ 32 ]. One 2002 qualitative study found that Yemeni women felt that: ’Women have no rights…We are second-class citizens. Nobody listens, nobody cares, people think this is normal, but it is not normal" (p.343, [ 32 ]). In the same study, a participant reported, “’I do not believe what I hear from the media about equality between man and woman in our society. Our society is a men’s society. Men decide what is right and what is wrong, not only in the family but in the whole society. They interpret the holy Qur’an in harmony with their interest. We know that our religion (Islam) guarantees many rights for women, but men accept only what is good for them and do not accept what is not good for them. For example, in some parts of Yemen, the community does not accept women’s inheritance: this is against Islamic law! This is because they don’t accept women as people” (p.343, [ 32 ]). While Yemen is considering a bill that specifies girls should be at least 18 to marry, the bill has not been passed into law. In addition to country-level legal prohibitions against child marriage, alternative approaches that leverage Islamic prohibitions against child marriage are needed [ 21 ]. According to a workshop conducted by the Arab Resource Collective (ARC), early marriages are practiced due to weak laws and the inability to feed children [ 21 ]. The lack of birth or marriage registries makes it challenging to track the girls’ age at marriage [ 7 , 21 ], and the ongoing conflict has set back previous progress toward reducing child marriage in Yemen. “A boy and a girl can be considered adults, making it difficult for them to understand that they are marrying children. We managed to include it in the national dialogue, and we succeeded. But unfortunately, [child marriage] is now on hold due to conflict” (p. 10, [ 7 ]). In a study aiming to gather participant suggestions for mitigating child marriage, recommendations included providing financial support to families for girls’ education, funding NGOs dedicated to addressing child marriage, raising awareness within communities about girls’ rights, and implementing local interventions as potential strategies [ 7 ]. Quality assessment The quality of primary research studies, excluding population-representative studies like DHS and MICS, is summarized in Table S5. The quantitative studies on corporal punishment in schools and experience of child maltreatment and abuse followed similar well-described study designs and sampling frames [ 40 , 47 – 50 ], but were small in scale and not representative. Most of the included qualitative studies had clearly stated research questions, methods, and findings. However, one article did not specify how the analysis was coded [ 33 ], and neither the research question nor methods were clear in one article [ 31 ]. Ethical conduct of VAWC research We adapted the rubric developed by Peterman, et. al., [ 58 ] to assess studies’ compliance with established norms for the ethical conduct of VAWC research, described in Table 2 . Ethical concerns for VAWC research from the DHS and MICS studies is described elsewhere [ 59 – 62 ]. Studies that asked children or young adults about their experience of violence at home (N=3; 12,46,48) or in the classroom (N=3; 44–46) reported ethical clearance, verbal assent from participants, and used paper-based forms that did not collect identifying information. In two studies, where the participants were minors, consent was obtained from the parents [ 47 , 48 ]. The two qualitative studies that interviewed women and girls about their own experience of violence, including sexual violence, did not mention ethical approval or informed consent [ 21 , 32 ]. One of the studies mentioned that interviewers were trained psychology students and that they were accompanied by other women for safety purposes [ 32 ]. One quantitative study that interviewed male and female heads of household about their attitudes towards FGM/C, and in the case of women, their own experience of FGM/C, mentioned interviewer training, but did not specify what the training consisted of [ 46 ]. One quantitative survey of childhood experience of violence reported that the study team was trained to recognize any signs of distress exhibited as students completed the questionnaire [ 51 ]. No study mentioned making safety planning, resource lists, or support services available to participants. In one 2015 study, where female participants were sometimes accompanied by their husbands or older relatives, a second round of interviews was conducted when privacy could be ensured [ 34 ]. In resource-limited settings discussing the policy relevance of the findings is especially important to ensure ethical conduct and impact of future research, but most studies did not address the policy implications of their work. View this table: View inline View popup Table 2. Ethical conduct of primary VAWC studies Barriers, tools, strategies, and resources for addressing and reporting violence, including safety planning One 2002 study found that only 3% of women who experienced violence went to the police, preferring to reach out to parents or relatives or not seek any external support rather than the police or legal support [ 32 ]. Two studies reported that women could only go to the police when accompanied by a male household member, leading to underreporting of GBV [ 32 , 51 ]. Most studies did not ask women or children about reporting or whether they accessed any resources to address the violence. Religious and cultural norms were identified as the most critical barriers to reporting most types of VAWC [ 16 , 36 , 43 , 44 ]. A cross-sectional study that asked dentists about their intention to report suspected VAWC found that only 60% of dentists would report VAWC to the police, followed by other agencies in Yemen [ 55 ]. A 2017 AMRO regional study by UNICEF reported that a shortage of skilled NGO personnel and a lack of awareness of available services were key barriers to accessing resources, as NGOs addressing gender-related issues do not have the staff to effectively manage reported GBV cases and do not well understand how to connect women to services or what services are available [ 7 ]. The same study found that girls facing GBV and child marriage experience limitations to their mobility due to gender norms and restricted access to money needed to pay for resources that are generally located outside of their community [ 7 ]. Sexual abuse is highly stigmatized in Yemen, which limits reporting. One study found that women or girls who were sexually abused face “severe punishment” from their parents, who might “kill them” or “force them to marry rapists” [ 21 ]. The same study found that adolescent girls in Yemen felt that women and girls could be considered responsible for the sexual violence they experienced [ 21 ]. Two studies highlighted that a lack of education for girls and women increases their exposure to violence from husbands compared to more educated women [ 32 , 33 ]. Women reported the widespread cultural beliefs that they are second-class citizens and belong to men, which likely complicates their ability to report violence [ 32 ]. Poor implementation of the FGM/C law in Yemen, lack of educational infrastructure, lack of employment opportunities, and the ongoing conflict were also cited as barriers to reporting [ 44 ]. Lack of awareness of FGM/C status, which is at a very young age, was also cited as a barrier to reporting [ 16 ] Discussion This systematic review synthesizes evidence from qualitative and quantitative studies on the types, prevalence, perpetrators of, and risk factors for VAWC in Yemen. The 30 studies included in the analysis collected data on a range of forms of VAWC, including honor violence, female genital mutilation and cutting, early and very early marriage, tourist marriage, family and intimate partner violence, school-based violence, and gender inequities in access to food, education, and medical care. Included studies reported a high prevalence of many forms of violence, including corporal punishment in schools and intimate partner violence. We identified seven primary research studies that asked women or children about their experience of violence [ 21 , 32 , 46 – 49 , 51 ] and nine studies that reused data from the Yemen DHS, MICS, PAPFAM, and other national and sub-national household surveys [ 16 , 35 – 37 , 40 , 42 – 45 ]. Six additional studies asked Yemeni dentists about reporting violence [ 55 ], students about their attitudes towards women living with HIV [ 56 ], gender differences in the prevalence of depression [ 54 ], women’s perceptions of self-worth in relation to health-seeking behavior [ 53 ], tuberculosis patients on how gender and literacy affect healthcare access [ 52 ], and mothers on the factors that cause their fear of childbirth [ 34 ]. Studies measured IPV and non-partner family violence (both physical and psychological), sexual violence, early marriage, tourist marriage, child maltreatment, FGM/C, honor violence, child labor, school-based violence, including corporal punishment, and gender inequities in access to health care, education, and food. Studies had very different designs and sampling frameworks, preventing direct comparisons. Similar to global trends [ 63 ], we found that IPV and other forms of family violence were the most prevalent forms of violence reported in quantitative studies of different types of VAWC. Studies on structural violence in Yemeni society [ 31 , 33 ] linked political instability and social exclusion to GBV, including higher rates of violence and social stigma directed towards marginalized ethnic groups, like the Muhamasheen. Risk Factors Risk factors for VAWC included gender inequitable norms and laws, economic instability, lower SES, rural residence, low levels of parental education, and low levels of education in women and girls. IPV and FGM/C were linked to a lack of maternal education, cultural norms and traditions in Yemeni society and, in the case of IPV, restrictive divorce laws. FGM/C was linked to mothers’ experience of FGM/C and early marriage. Child maltreatment and early child marriage were related to low levels of parental education and markers of low SES, including larger household size and reduced household income. These findings align with the determinants of VAWC in humanitarian crises in other countries, where cultural, economic, and educational factors are related to the incidence of GBV [ 64 , 65 ]. For example, studies in Sudan and Egypt found that lack of parental education, older age (where older women are more likely to have undergone FGM/C), and patriarchal norms were associated with FGM/C [ 66 , 67 ]. One study included in the review compared attitudes towards honor violence between Yemen, the occupied Palestinian Territories, and Lebanon and found that adolescent girls from Yemen and the Palestinian Territories were more likely than Lebanese girls to believe that women and girls were themselves responsible for their exposure to sexual violence [ 21 ]. Barriers to reporting VAWC Barriers to reporting violence included the lack of gender equitable laws, services or support for women or children who experience violence, and gender-inequitable child custody laws. Studies found that violence, when reported, was reported to family members or the local Sheikh, which is consistent with another study that found stigma and lack of support for women who experienced violence led to underreporting [ 68 ]. Yemen could consider female police officers to address that barrier to reporting violence [ 32 ]. The study also found that educational programs and providing mental health services were effective in reducing violence [ 68 ]. Violence against3 children Preschool & school-aged children and adolescents reported a higher prevalence of emotional rather than physical abuse, which is consistent with research conducted in South Africa [ 69 , 70 ]. Studies in this review reported low levels of sexual violence against children, which is mirrored in global research and likely related to underreporting [ 71 – 73 ]. Included studies reported that male children experienced higher levels of maltreatment than female children, which was similar to findings from another study conducted in Iran [ 74 ] but differed from findings in other Arab countries, including Tunisia and UAE [ 75 ]. Although child labor is a significant concern in Yemen, only the 2005 MICS measured this form of violence against children. Rates of corporal violence at school and child experience of maltreatment or physical abuse seemed much higher in Yemen than in related contexts, such as Sudan and Syria [ 76 ]. One study indicated that children in rural areas encountered elevated levels of corporal punishment in schools [ 50 ], which was supported in another study in Mali and Libya [ 77 ]. Risk factors associated with child abuse and maltreatment, including gender, older age, rural residence, family socioeconomic status, family size, parent’s education, and parent’s alcohol use, were similar to those reported in a study in Saudi Arabia [ 78 ] and to findings from conflict-affected countries, including Pakistan [ 79 ] and Myanmar [ 80 ]. Sexual violence Sexual violence is a common yet highly stigmatized form of VAWC and is subject to high levels of underreporting [ 21 ]. Tourist marriage is a new form of GBV that is a last resort for families with limited resources to feed their families. Tourist marriage was also identified as an emerging concern in a study in Giza, Egypt [ 81 ]. Policymakers suggest that poverty reduction and community education [ 82 ] can help reduce early marriage in Yemen and other contexts in the Eastern Mediterranean, South and Southeast Asia and Africa [ 83 ]. Female genital mutilation and cutting Yemen has made strides to prevent FGM/C; however, the government’s statement against FCM/C falls short of a nationwide law [ 44 ]. In contrast, Egypt has passed a law that prohibits FGM/C and punishes perpetrators [ 44 , 67 ]. Women’s empowerment, the involvement of religious leaders, and the education of parents and communities have been cited as pathways towards reducing FGM/C [ 16 , 36 , 43 , 44 ]. Gender inequities in access to medical care, education Several included studies found gender inequities in healthcare access [ 35 , 52 , 53 ], education [ 45 ], and nutrition [ 37 ]. These studies are similar to those in other gender inequitable settings where women and girl children have lower levels of access to food [ 84 ], health care [ 85 ], and education [ 86 ] than males. Strengths & limitations This is the first mixed methods systematic review to summarize findings on different forms of VAWC in Yemen. We searched four biomedical databases and NGO websites and used snowball sampling to identify primary and secondary research on VAWC. Limitations stem from the predominantly cross-sectional design of most studies, constraining the ability to infer causality. Future research should focus on longitudinal studies to better understand the dynamics of VAWC over time and explore the efficacy of various intervention strategies. The high levels of stigma surrounding VAWC, especially sexual violence, may have led to underreporting. Most primary research studies, other than the large population-representative surveys like DHS and MICS, did not report on interviewer training to ensure women and children could report on their experience of violence in a safe environment, free of stigma from the interviewer. Adequately funding studies and ensuring that well-funded studies have a coherent plan to address ethical issues in VAWC research could ensure studies on VAWC in Yemen uphold best practices in ethical research on VAWC in resource-limited contexts. Recommendations for future work Most studies on VAWC were conducted before the 2014 war in Yemen. The war and pandemic have increased the frequency and forms of VAWC through multiple avenues. The humanitarian research and intervention communities should explore and address the causes and consequences of VAWC, and the international development community should consider investing in research to develop community-based efforts to support Yemeni women and children who experience or have experienced violence, including war-related violence and the associated trauma. This review found significant ethical concerns related to existing research, including the absence of informed consent or ethical review. Only two studies, outside of the DHS and MICS, mentioned interviewer training, and none of the studies that interviewed women or children about their experience of violence discussed safety planning or connecting women and children to available resources. Given the lack of resources in Yemen, using positive deviance [ 87 ] approaches to identify strategies that would be possible and safe for women and children who experience violence to mitigate or prevent violence. Yemen is a complex context, and Yemeni women and children need to inform the design and execution of research and interventions. Policy implications In keeping with policy-related research in Yemen [ 88 ], included studies identified severe poverty and displacement, cultural norms, societal stigma, and a lack of sufficient legal protections and support services as barriers to addressing VAWC in Yemen. Humanitarian support for Yemeni families in need is a crucial starting point to curb child and forced marriages [ 89 ]. Gender-inequitable child custody laws, cultural beliefs that normalize VAWC, and stigmatizing attitudes towards survivors of violence, including coercive marriages to preserve family honor in the context of sexual violence and blaming divorced women, [ 90 ] make addressing VAWC extremely complex. Addressing weak enforcement of protections for women and children [ 7 ] and gender inequitable laws or gaps in legislation, including no minimum age of marriage, should be part of a national strategy to address VAWC in Yemen [ 91 ]. A locally developed and supported policy action plan is essential for fostering lasting changes in gender-inequitable attitudes towards women and children [ 92 ]. This summary of the current landscape of VAWC-related research could support the design of a policy agenda that addresses barriers to measuring, reporting, and responding to VAWC. While not well described in the included studies, the large-scale conflict and related internal displacement have intensified GBV in Yemen [ 93 ]. Significant investment is needed in research and services, including basic needs, education, psychological services, and VAWC-related prevention and mitigation to support Yemeni women and children better. Similarly, child labour, an important form of violence that was not well explored in the included studies, should be considered in the research and development agenda [ 94 ]. By combining efforts to address gender inequitable laws and harmful cultural practices and providing holistic support to Yemeni families, Yemen can make strides towards reducing VAWC and creating a safer environment for women and children [ 95 ]. Conclusions VAWC is a global public health and human rights issue that affects the global community’s ability to achieve most of the 17 SDGs. Violence increases in unstable environments. Understanding and addressing VAWC is context-dependent, requiring meaningful community engagement, cross-sectoral support, and policy action. This SR highlights the high levels of VAWC in Yemen, driven by poverty, displacement, and gender inequitable norms and policies. While we know that VAWC increases during conflicts and when people are displaced, we did not identify any studies on VAWC that collected data after the onset of the ongoing conflict in Yemen, which represents a missed opportunity to understand how the ongoing war has reversed prior gains in reducing the prevalence of child and very early child marriage and introduced new forms of gender-based violence, including tourist marriage. The lack of funding for primary research on VAWC may be one reason why included studies did not report on interviewer training, mental health support for research participants, or safety planning, all of which should be included in VAWC-related research in humanitarian settings or fragile states. Addressing VAWC in Yemen will require a commitment on the part of the international community to fund locally-led efforts to determine immediate and long-term steps to alleviate the factors that drive VAWC (e.g., war, poverty), prevent and mitigate VAWC, and address the effects of VAWC on maternal and child health and related SDGs. Data Availability All data generated in this systematic review are available in the article or its appendices. Supporting Information S1 Table. PRISMA checklist S2 Table. Database-specific search strategies S3 Table. List of articles excluded at full-text review stage with reason for exclusion S1 Text. Data extraction form S4 Table. Overview of quantitative studies and quantitative section of mixed methods studies S5 Table. Quality assessment of included studies Acknowledgements We want to thank the participants in the primary research studies included in this review for their courage and honesty in confronting the global challenge of VAWC and the NGOs and researchers working to ensure that their stories are heard and their needs addressed. References 1. ↵ Yemen – Emergencies . In: World Food Programme [Internet] . 2023 . Available: https://www.wfp.org/emergencies/yemen-emergency 2. ↵ OCHA - Yemen Situation Report 2023 . United Nations Office for the Coordination of Humanitarian Affairs ; 2023 . Available: https://reports.unocha.org/en/country/yemen/ 3. ↵ National Plan to Implement Security Council Resolution 1325 Women, Security, and Peace 2020 – 2022 [Internet]. 2019 . 4. ↵ Sustainable Development Goals: Yemen . In: United National Development Programme [Internet] . 2021 . Available: https://www.ye.undp.org/content/yemen/en/home/sustainable-development-goals.html 5. ↵ Global Gender Gap Report 2021. World Economic Forum ; 2021 Mar. Available: https://www.weforum.org/publications/global-gender-gap-report-2021/ 6. ↵ Gender considerations in humanitarian response in Yemen . United Nations Office for the Coordination of Humanitarian Affairs . In: ReliefWeb Response (RW Response) . 2023 . 7. ↵ UNICEF & ICRW . Yemen Country Brief - UNICEF Regional Study on Child Marriage In the Middle East and North Africa . United Nations Children’s Fund (UNICEF) ; 2017 . Available: https://www.unicef.org/mena/media/1821/file/#20MENA-CMReport-YemenBrief.pdf.pdf . 2017. 8. ↵ Findings on the Worst Forms of Child Labor - Yemen. Bureau of International Labor Affairs, U.S. Department of Labor ; 2019 . Available: https://www.dol.gov/agencies/ilab/resources/reports/child-labor/yemen 9. ↵ UN Security Council: Children and armed conflict in Yemen - Report of the Secretary-General (S/2019/453) [EN/AR] . ReliefWeb; 2019 . Available: https://reliefweb.int/report/yemen/children-and-armed-conflict-yemen-report-secretary-general-s2019453-enar 10. ↵ Children of Yemen . In: Humanium [Internet] . 2021 . Available: https://www.humanium.org/en/yemen/ 11. ↵ Fact Sheet: Violence Against Women. In: World Health Organization [Internet] . Jun 2020 [cited 8 Jun 2020]. Available: https://www.who.int/news-room/fact-sheets/detail/violence-against-women 12. ↵ Ministry of Public Health and Population - MOPHP/Yemen, Central Statistical Organization - CSO/Yemen, Pan Arab Program for Family Health - PAPFAM, ICF International . Yemen National Health and Demographic Survey 2013 . Rockville, Maryland, USA : MOPHP, CSO, PAPFAM, and ICF International ; 2015 . Available: http://dhsprogram.com/pubs/pdf/FR296/FR296.pdf 13. ↵ Country Assessment on Violence against Women, Yemen ( 2010 ). United Nations; 2010. Available: https://www.un.org/womenwatch/ianwge/taskforces/vaw/Country_Assessment_on_Viol ence_against_Women_August_2_2010.pdf 14. ↵ Factsheet: Child Maltreatment . In: World Health Organization [Internet]. World Health Organization ; Jun 2020 [cited 8 Jun 2020]. Available: https://www.who.int/news-room/fact-sheets/detail/child-maltreatment/ 15. ↵ Fact Sheet: Violence Against Children . In: World Health Organization [Internet] . Jun 2020 [cited 8 Jun 2020]. Available: https://www.who.int/news-room/fact-sheets/detail/violence-against-children 16. ↵ Al-Khulaidi GA , Nakamura K , Seino K , Kizuki M . Decline of Supportive Attitudes among Husbands toward Female Genital Mutilation and Its Association to Those Practices in Yemen. Behrens T, editor . PLoS ONE . 2013 ; 8 : e83140 . doi: 10.1371/journal.pone.0083140 OpenUrl CrossRef PubMed 17. ↵ Fact Sheet: Female Genital Mutilation . In: World Health Organization [Internet] . 2020 [cited 3 Feb 2020]. Available: https://www.who.int/en/news-room/fact-sheets/detail/female-genital-mutilation . 18. ↵ UNDP Human Development Report - Gender Inequality Index . United Nations Development Programme ; Available: https://hdr.undp.org/data-center/thematic-composite-indices/gender-inequality-index#/indicies/GII 19. ↵ SIGI 2019 Global Report. OECD ; 2019 . Available: https://www.oecd-ilibrary.org/content/publication/bc56d212-en https://www.genderindex.org/country-profiles/ 20. ↵ Alaimo K . Increased Efforts by Modern States to Improve Their Reputations for Enforcing Women’s Human Rights . Int J Commun . 2016 ; 10 : 2481 – 2500 . OpenUrl 21. ↵ Ouis P . Honourable Traditions? Honour Violence , Early Marriage and Sexual Abuse of Teenage Girls in Lebanon, the Occupied Palestinian Territories and Yemen. Int J Child Rights . 2009 ; 17 : 445 – 474 . doi: 10.1163/157181808X389911 OpenUrl CrossRef 22. ↵ Country Reports on Human Rights Practices: Yemen for 2016 . Bureau of Democracy, Human Rights and Labor, United States Department of State ; 2016 . Available: https://www.state.gov/reports/2016-country-reports-on-human-rights-practices/yemen/ . 23. ↵ Pearson A , White H , Bath-Hextall F , Salmond S , Apostolo J , Kirkpatrick P . A mixed-methods approach to systematic reviews . Int J Evid Based Healthc . 2015 ; 13 : 121 – 131 . doi: 10.1097/XEB.0000000000000052 OpenUrl CrossRef PubMed 24. ↵ PRISMA-P Group , Moher D , Shamseer L , Clarke M , Ghersi D , Liberati A , et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement . Syst Rev . 2015 ; 4 : 1 . doi: 10.1186/2046-4053-4-1 OpenUrl CrossRef PubMed 25. ↵ Page MJ , McKenzie JE , Bossuyt PM , Boutron I , Hoffmann TC , Mulrow CD , et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . BMJ . 2021 ; n71 . doi: 10.1136/bmj.n71 OpenUrl CrossRef PubMed 26. ↵ Kohli A. Snowballing in Systematic Literature Review . In: LinkedIn [Internet] . 4 Jul 2020 . Available: https://www.linkedin.com/pulse/snowballing-systematic-literature-review-amanpreet-kohli/ . 27. ↵ Deduplicating in EndNote - An earlier version of the “Bramer method” for deduplicating . In: McGill Library [Internet]. 2021. Available: https://libraryguides.mcgill.ca/knowledge-syntheses/deduplicating#s-lg-box-16286927 28. ↵ Covidence Systematic Review Software, Veritas Health Innovation, Melbourne, Australia . In: Covidence [Internet] . 2023 . Available: www.covidence.org 29. ↵ Thomas J , Harden A . Methods for the thematic synthesis of qualitative research in systematic reviews . BMC Med Res Methodol . 2008 ; 8 : 45 . doi: 10.1186/1471-2288-8-45 OpenUrl CrossRef PubMed 30. ↵ Hong QN , Fàbregues S , Bartlett G , Boardman F , Cargo M , Dagenais P , et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers . Educ Inf . 2018 ; 34 : 285 – 291 . doi: 10.3233/EFI-180221 OpenUrl CrossRef 31. ↵ Christiansen C , Al-Thawr S . Muhamesheen activism: enacting citizenship during Yemen’s transition . Citizsh Stud . 2019 ; 23 : 115 – 138 . doi: 10.1080/13621025.2019.1583725 OpenUrl CrossRef 32. ↵ Ba-Obaid M , Bijleveld CCJH . Violence Against Women in Yemen: Official Statistics and an Exploratory Survey . Int Rev Vict . 2002 ; 9 : 331 – 347 . doi: 10.1177/026975800200900306 OpenUrl CrossRef 33. ↵ Lewis A. Violent crime and fragility[]: a study on violent offending among children and young people in Yemen . 2013 . Available: https://api.semanticscholar.org/CorpusID:152969638 34. ↵ Kempe A , Theorell T , Alwazer FN-A , Taher SA , Christensson K . Exploring women’s fear of childbirth in a high maternal mortality setting on the Arabian Peninsula . Glob Ment Health . 2015 ; 2 : e10 . doi: 10.1017/gmh.2015.6 OpenUrl CrossRef 35. ↵ Calu Costa J , Wehrmeister FC , Barros AJ , Victora CG . Gender bias in careseeking practices in 57 low– and middle–income countries . J Glob Health . 2017 ; 7 : 010418 . doi: 10.7189/jogh.07.010418 OpenUrl CrossRef 36. ↵ Liang M , Loaiza E , Diop NJ , Legesse B . Demographic perspectives of female genital mutilation . Reisel D , editor. Int J Hum Rights Healthc . 2016 ; 9 : 3 – 28 . doi: 10.1108/IJHRH-05-2015-0017 OpenUrl CrossRef 37. ↵ Mesbah Fathy Sharaf , Rashad AS , Elhussien Ibrahim Mansour . Son Preference and Child Under Nutrition in the Arab Countries: Is There a Gender Bias Against Girls ? 2019 [cited 8 Feb 2024]. doi: 10.13140/RG.2.2.24901.09443 OpenUrl CrossRef 38. ↵ Central Statistical Organization/Yemen, Pan Arab Project for Child Development, Macro International . Yemen Demographic and Maternal and Child Health Survey 1991/1992 . Calverton, Maryland, USA : Central Statistical Organization/Yemen and Macro International ; 1994 . Available: http://dhsprogram.com/pubs/pdf/FR52/FR52.pdf 39. ↵ Central Statistical Organization/Yemen, Macro International . Yemen Demographic and Maternal and Child Health Survey 1997 . Calverton, Maryland, USA : Central Statistical Organization/Yemen and Macro International ; 1998 . Available: http://dhsprogram.com/pubs/pdf/FR94/FR94.pdf 40. ↵ Akmatov MK . Child abuse in 28 developing and transitional countries--results from the Multiple Indicator Cluster Surveys . Int J Epidemiol . 2011 ; 40 : 219 – 227 . doi: 10.1093/ije/dyq168 OpenUrl CrossRef PubMed Web of Science 41. ↵ Ministry of Health and Population (Yemen), United Nations Children’s Fund (UNICEF), Pan Arab, Program for Family Health (PAPFAM) . Yemen Multiple Indicator Cluster Survey 2006, Final Report . Rockville, Maryland, USA : MOPHP, CSO, PAPFAM, and ICF International ; 2015 . Available: https://mics.unicef.org/survey_archives/yemen/survey0/index.html 42. ↵ Smits J , Huisman J . Determinants of educational participation and gender differences in education in six Arab countries . Acta Sociol . 2013 ; 56 : 325 – 346 . doi: 10.1177/0001699313496259 OpenUrl CrossRef 43. ↵ Yoder PS , Wang S , Johansen E . Estimates of Female Genital Mutilation/Cutting in 27 African Countries and Yemen . Stud Fam Plann . 2013 ; 44 : 189 – 204 . doi: 10.1111/j.1728-4465.2013.00352.x OpenUrl CrossRef PubMed 44. ↵ Alosaimi AN , Essén B , Riitta L , Nwaru BI , Mouniri H . Factors associated with female genital cutting in Yemen and its policy implications . Midwifery . 2019 ; 74 : 99 – 106 . doi: 10.1016/j.midw.2019.03.010 OpenUrl CrossRef PubMed 45. ↵ Assaad R , Hendy R , Salehi-Isfahani D . Inequality of opportunity in educational attainment in the Middle East and North Africa: Evidence from household surveys . Int J Educ Dev . 2019 ; 71 : 102070 . doi: 10.1016/j.ijedudev.2019.05.005 OpenUrl CrossRef 46. ↵ Al-Taj MA , Al-hadari MH . Prevalence and drivers of female genital mutilation/cutting in three coastal governorates in Yemen . BMC Public Health . 2023 ; 23 : 1363 . doi: 10.1186/s12889-023-16299-y OpenUrl CrossRef 47. ↵ Ba-Saddik ASS , Hattab AS . Emotional abuse towards children by schoolteachers in Aden Governorate, Yemen: A cross-sectional study . BMC Public Health . 2012 ; 12 : 647 . doi: 10.1186/1471-2458-12-647 OpenUrl CrossRef 48. ↵ Ba Saddik AS , Hattab AS . Physical abuse in basic-education schools in Aden governorate, Yemen: a cross-sectional study . East Mediterr Health J . 2013 ; 19 : 333 – 339 . doi: 10.26719/2013.19.4.333 OpenUrl CrossRef 49. ↵ Bamatraf FF . Prevalence and Risk Factors of Childhood Abuse among Hadhramout University Students in Yemen . World Fam Med . 2019 ; 17 : 42 – 54 . doi: 10.5742MEWFM.2019.93645 OpenUrl CrossRef 50. ↵ Alyahri A , Goodman R . Harsh corporal punishment of Yemeni children: Occurrence, type and associations . Child Abuse Negl . 2008 ; 32 : 766 – 773 . doi: 10.1016/j.chiabu.2008.01.001 OpenUrl CrossRef PubMed Web of Science 51. ↵ Alizzy A , Calvete E , Bushman BJ . Associations Between Experiencing and Witnessing Physical and Psychological Abuse and Internalizing and Externalizing Problems in Yemeni Children . J Fam Violence . 2017 ; 32 : 585 – 593 . doi: 10.1007/s10896-017-9916-5 OpenUrl CrossRef 52. ↵ Date J , Okita K . Gender and literacy: factors related to diagnostic delay and unsuccessful treatment of tuberculosis in the mountainous area of Yemen . Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis . 2005 ; 9 : 680 – 685 . OpenUrl 53. ↵ Chamberlain J , Watt S , Mohide P , Muggah H , Trim K , Bantebya Kyomuhendo G . Women’s perception of self-worth and access to health care . Int J Gynecol Obstet . 2007 ; 98 : 75 – 79 . doi: 10.1016/j.ijgo.2007.03.019 OpenUrl CrossRef PubMed 54. ↵ Alansari BM . GENDER DIFFERENCES IN DEPRESSION AMONG UNDERGRADUATES FROM SEVENTEEN ISLAMIC COUNTRIES . Soc Behav Personal Int J . 2006 ; 34 : 729 – 738 . doi: 10.2224/sbp.2006.34.6.729 OpenUrl CrossRef 55. ↵ El Tantawi M , Gaffar B , Arheiam A , AbdelAziz W , Al-Batayneh OB , Alhoti MF , et al. Dentists’ intention to report suspected violence: a cross-sectional study in eight Arab countries . BMJ Open . 2018 ; 8 : e019786 . doi: 10.1136/bmjopen-2017-019786 OpenUrl Abstract / FREE Full Text 56. ↵ Badahdah AM . Attitudes Toward Restricting the Sexual and Reproductive Rights of Women Living With HIV Infection in Yemen . J Assoc Nurses AIDS Care . 2016 ; 27 : 180 – 187 . doi: 10.1016/j.jana.2015.10.006 OpenUrl CrossRef 57. ↵ Kronfol NM . Access and barriers to health care delivery in Arab countries: a review . East Mediterr Health J . 2012 ; 18 : 1239 – 1246 . doi: 10.26719/2012.18.12.1239 OpenUrl CrossRef 58. ↵ Peterman A , Devries K , Guedes A , Chandan JS , Minhas S , Lim RQH , et al. Ethical reporting of research on violence against women and children: a review of current practice and recommendations for future guidelines . BMJ Glob Health . 2023 ; 8 : e011882 . OpenUrl Abstract / FREE Full Text 59. ↵ Bott S , Ruiz-Celis AP , Mendoza JA , Guedes A. Co-occurring violent discipline of children and intimate partner violence against women in Latin America and the Caribbean: a systematic search and secondary analysis of national datasets . BMJ Glob Health . 2021 ; 6 : e007063 . doi: 10.1136/bmjgh-2021-007063 OpenUrl Abstract / FREE Full Text 60. Guidelines for Producing Statistics on Violence against Women-Statistical Surveys . New York : United Nations Department of Economic and Social Affairs Statistics Division ; 2014 . Available: https://unstats.un.org/unsd/gender/docs/guidelines_statistics_vaw.pdf 61. Hancioglu A , Arnold F . Measuring Coverage in MNCH: Tracking Progress in Health for Women and Children Using DHS and MICS Household Surveys. Madise N, editor . PLoS Med . 2013 ; 10 : e1001391 . doi: 10.1371/journal.pmed.1001391 OpenUrl CrossRef PubMed 62. ↵ UNICEF Multiple Indicator Cluster Survey Manual 2005 . United Nations International Children’s Emergency Fund ; 2007 Apr. Available: https://mics.unicef.org/files?job=W1siZiIsIjIwMTUvMDQvMDIvMDYvMzcvMDYvMTE5L011bHRpcGxlX0luZGljYXRvcl9DbHVzdGVyX1N1cnZleV9NYW51YWxfMjAwNS5wZGYiXV0&sha=dd2e54d1ddd61cdb 63. ↵ Overview of Gender-Based Violence. Gender Data Portal . In: World Bank [Internet]. 1 Oct 2022 [cited 15 Jan 2024]. Available: https://genderdata.worldbank.org/data-stories/overview-of-gender-based-violence/ 64. ↵ Raftery P , Howard N , Palmer J , Hossain M . Gender-based violence (GBV) coordination in humanitarian and public health emergencies: a scoping review . Confl Health . 2022 ; 16 : 37 . doi: 10.1186/s13031-022-00471-z OpenUrl CrossRef PubMed 65. ↵ Murphy M , Ellsberg M , Balogun A , Garcia-Moreno C . Risk and protective factors for GBV among women and girls living in humanitarian setting: systematic review protocol . Syst Rev . 2021 ; 10 : 238 . doi: 10.1186/s13643-021-01795-2 OpenUrl CrossRef 66. ↵ Elduma AH . Female Genital Mutilation in Sudan . Open Access Maced J Med Sci . 2018 ; 6 : 430 – 434 . doi: 10.3889/oamjms.2018.099 OpenUrl CrossRef 67. ↵ Arafa A , Mostafa A , Eshak ES . Prevalence and risk factors of female genital mutilation in Egypt: a systematic review . Clin Epidemiol Glob Health . 2020 ; 8 : 850 – 857 . doi: 10.1016/j.cegh.2020.02.012 OpenUrl CrossRef 68. ↵ Douki S , Nacef F , Belhadj A , Bouasker A , Ghachem R . Violence against women in Arab and Islamic countries . Arch Womens Ment Health . 2003 ; 6 : 165 – 171 . doi: 10.1007/s00737-003-0170-x OpenUrl CrossRef PubMed 69. ↵ Meinck F , Cluver L , Loening-Voysey H , Bray R , Doubt J , Casale M , et al. Disclosure of physical, emotional and sexual child abuse, help-seeking and access to abuse response services in two South African Provinces . Psychol Health Med . 2017 ; 22 : 94 – 106 . doi: 10.1080/13548506.2016.1271950 OpenUrl CrossRef 70. ↵ Stoltenborgh M , Bakermans-Kranenburg MJ , Alink LRA , Van IJzendoorn MH . The Prevalence of Child Maltreatment across the Globe: Review of a Series of Meta-Analyses . Child Abuse Rev . 2015 ; 24 : 37 – 50 . doi: 10.1002/car.2353 OpenUrl CrossRef 71. ↵ Dworkin ER , Krahé B , Zinzow H . The global prevalence of sexual assault: A systematic review of international research since 2010 . Psychol Violence . 2021 ; 11 : 497 – 508 . doi: 10.1037/vio0000374 OpenUrl CrossRef 72. UNICEF. A Statistical Profile of Violence Against Children in Latin America and the Caribbean . New York : © United Nations Children’s Fund (UNICEF), Division of Data, Analytics, Planning and Monitoring ; 2022 . Available: https://www.unicef.org/lac/media/38241/file/A-statistical-profile-of-violence-against-children-in-latin-america-and-the-caribbean.pdf . 73. ↵ Agüero JM , Frisancho V . Measuring Violence against Women with Experimental Methods . Econ Dev Cult Change . 2022 ; 70 : 1565 – 1590 . doi: 10.1086/714008 OpenUrl CrossRef 74. ↵ Stephenson R , Sheikhattari P , Assasi N , Eftekhar H , Zamani Q , Maleki B , et al. Child maltreatment among school children in the Kurdistan Province, Iran . Child Abuse Negl . 2006 ; 30 : 231 – 245 . doi: 10.1016/j.chiabu.2005.10.009 OpenUrl CrossRef PubMed 75. ↵ Kelly S . Recent Gains and New Opportunities for Women’s Rights in the Gulf Arab States . Freedom House; 2009 . Available: https://freedomhouse.org/article/womens-activists-see-gains-gulf-arab-states$\#$.VcjK_JNVikq 76. ↵ UNICEF. A Profile of Violence against Children and Adolescents in the Middle East and North Africa . New York : UNICEF Division of Data, Research and Poli ; 2018 Jul. Available: https://www.unicef.org/mena/reports/profile-violence-against-children-and-adolescents-middle-east-and-north-africa 77. ↵ Violence is predominantly rural in North and West Africa . In: OECD [Internet] . 21 Mar 2023 [cited 15 Jan 2024]. Available: https://www.oecd.org/swac/news/violenceispredominantlyruralinnorthandwestafrica.htm 78. ↵ Al-Eissa MA , AlBuhairan FS , Qayad M , Saleheen H , Runyan D , Almuneef M . Determining child maltreatment incidence in Saudi Arabia using the ICAST-CH: a pilot study . Child Abuse Negl . 2015 ; 42 : 174 – 182 . doi: 10.1016/j.chiabu.2014.08.016 OpenUrl CrossRef 79. ↵ Lakhdir MPA , Farooq S , Khan UR , Parpio Y , Azam SI , Razzak J , et al. Factors Associated With Child Maltreatment Among Children Aged 11 to 17 Years in Community Settings of Karachi, Pakistan, Using Belsky Ecological Framework . J Interpers Violence . 2021 ; 36 : 297 – 313 . doi: 10.1177/0886260517726973 OpenUrl CrossRef 80. ↵ Aye WT , Lien L , Stigum H , Bjertness E . Childhood abuse and its association with adults’ mental health problems: a cross-sectional study among men and women in the Yangon Region of Myanmar . BMJ Open . 2021 ; 11 : e045870 . doi: 10.1136/bmjopen-2020-045870 OpenUrl CrossRef 81. ↵ Soliman HH , Alsharqawi NI , Younis MA . Is Tourism Marriage of Young Girls in Egypt a Form of Child Sexual Abuse? A Family Exploitation Perspective. J Child Sex Abuse . 2018 ; 27 : 122 – 140 . doi: 10.1080/10538712.2018.1425945 OpenUrl CrossRef 82. ↵ Ending Child Marriage: A Guide for Global Policy Action . UN Population Fund (UNFPA): International Planned Parenthood Federation; Forum on Marriage and the Rights of Women and Girls ; 2006 . Available: https://www.unfpa.org/sites/default/files/pub-pdf/endchildmarriage.pdf 83. ↵ Pourtaheri A , Sany SBT , Aghaee MA , Ahangari H , Peyman N . Prevalence and factors associated with child marriage, a systematic review . BMC Womens Health . 2023 ; 23 : 531 . doi: 10.1186/s12905-023-02634-3 OpenUrl CrossRef 84. ↵ Gender and Food Security and Nutrition . In: Food and Agriculture Organization (FAO) [Internet] . 2024 . Available: https://www.fao.org/gender/learning-center/thematic-areas/gender-and-food-security-and-nutrition/ 85. ↵ Kennedy E , Binder G , Humphries-Waa K , Tidhar T , Cini K , Comrie-Thomson L , et al. Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region . Lancet Glob Health . 2020 ; 8 : e1473 – e1488 . doi: 10.1016/S2214-109X(20)30354-5 OpenUrl CrossRef 86. ↵ Kattan RB , Khan MM . Closing the Gap: Tackling Remaining Disparities in Girls’ Education and Women’s Labor Market . In: World Bank Blogs [Internet] . 9 Mar 2023 . Available: https://blogs.worldbank.org/education/closing-gap-tackling-remaining-disparities-girls-education-and-womens-labor-market 87. ↵ Marsh DR , Schroeder DG , Dearden KA , Sternin J , Sternin M . The power of positive deviance . BMJ . 2004 ; 329 : 1177 – 1179 . doi: 10.1136/bmj.329.7475.1177 OpenUrl FREE Full Text 88. ↵ Al-Dhamari R . The Struggle of Yemeni Women between War and Harmful Social Norms . In: ReliefWeb [Internet]. 3 Feb 2021 [cited 15 Jan 2024]. Available: https://reliefweb.int/report/yemen/struggle-yemeni-women-between-war-and-harmful-social-norms 89. ↵ Yemen Country Profile of Phase I: UNFPA-UNICEF Global Programme to End Child Marriage . United Nations Children’s Fund (UNICEF) ; 2019 . Available: https://www.unicef.org/media/88851/file/Child-marriage-Yemen-profile-2019.pdf 90. ↵ Obligating Obedience. Violations of Women’s Rights in Yemen . Human Rights Watch; 2015 Jan. Available: https://www.hrw.org/reports/yemen0115_web.pdf 91. ↵ Yemen Gender Justice & The Law . United Nations Development Programme . New York : UNDP, UN Women, UNFPA, ESCWA ; 2018 . Available: https://www.undp.org/sites/g/files/zskgke326/files/migration/arabstates/Yemen-Country-Assessment---English.pdf 92. ↵ Shang B . Tackling Gender Inequality: Definitions, Trends, and Policy Designs . IMF Work Pap . 2022 ;2022: 1 . doi: 10.5089/9798400224843.001 OpenUrl CrossRef 93. ↵ Humanitarian Action for Children Yemen - June Update . United Nations Children’s Fund (UNICEF) ; 2021 . Available: https://www.unicef.org/media/102341/file/2021-HAC-Yemen-June-Update.pdf 94. ↵ Ahmed A , Almassajdi A . Child Labor’s Frightening Growth During the War in Yemen . In: University of Oregon-UNESCO Crossings Institute [Internet] . 5 Nov 2021 . Available : https://unesco.uoregon.edu/2022/01/22/child-labors-frightening-growth-during-the-war-in-yemen/ 95. ↵ Intensify efforts to prevent violence against women and girls . In: ReliefWeb [Internet] . 10 Dec 2023 . Available: https://reliefweb.int/report/yemen/intensify-efforts-prevent-violence-against-women-and-girls View the discussion thread. Back to top Previous Next Posted August 02, 2024. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Violence against women and children in Yemen: A mixed-methods systematic review Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Violence against women and children in Yemen: A mixed-methods systematic review Samana Shreedhar , Sayali Arvind Chavan , Marwah Al-Zumair , Mirna Naccache , Priya Shreedhar , Lauren Maxwell medRxiv 2024.08.01.24310001; doi: https://doi.org/10.1101/2024.08.01.24310001 Share This Article: Copy Citation Tools Violence against women and children in Yemen: A mixed-methods systematic review Samana Shreedhar , Sayali Arvind Chavan , Marwah Al-Zumair , Mirna Naccache , Priya Shreedhar , Lauren Maxwell medRxiv 2024.08.01.24310001; doi: https://doi.org/10.1101/2024.08.01.24310001 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Public and Global Health Subject Areas All Articles Addiction Medicine (573) Allergy and Immunology (865) Anesthesia (302) Cardiovascular Medicine (4453) Dentistry and Oral Medicine (444) Dermatology (383) Emergency Medicine (609) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1515) Epidemiology (15242) Forensic Medicine (30) Gastroenterology (1131) Genetic and Genomic Medicine (6615) Geriatric Medicine (669) Health Economics (1001) Health Informatics (4552) Health Policy (1372) Health Systems and Quality Improvement (1614) Hematology (543) HIV/AIDS (1270) Infectious Diseases (except HIV/AIDS) (15929) Intensive Care and Critical Care Medicine (1106) Medical Education (624) Medical Ethics (147) Nephrology (670) Neurology (6625) Nursing (346) Nutrition (999) Obstetrics and Gynecology (1148) Occupational and Environmental Health (957) Oncology (3344) Ophthalmology (979) Orthopedics (369) Otolaryngology (421) Pain Medicine (436) Palliative Medicine (130) Pathology (665) Pediatrics (1696) Pharmacology and Therapeutics (693) Primary Care Research (714) Psychiatry and Clinical Psychology (5461) Public and Global Health (9252) Radiology and Imaging (2207) Rehabilitation Medicine and Physical Therapy (1371) Respiratory Medicine (1197) Rheumatology (597) Sexual and Reproductive Health (715) Sports Medicine (530) Surgery (714) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a02ee171297c73a6',t:'MTc3OTk4ODMwOA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();