Co-occurrence of Witnessing Intimate Partner Violence against Women and Experiencing Violence in Childhood in Refugee Settlements in Uganda

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However, little is known about the co-occurrence of witnessing IPVAW and experiencing VAC in humanitarian settings. We examined the prevalence of witnessing IPVAW, and its association with a) experiencing physical and emotional VAC perpetrated by a caregiver; b) experiencing sexual violence by any perpetrator; and c) the endorsement of norms justifying IPVAW among children and young people aged 13-24 years in Uganda refugee settlements. Methods: We analyzed data from the first-ever Ugandan Humanitarian Violence against Children and Youth Survey (HVACS) conducted from March to April 2022, involving 1,338 females and 927 males aged 13-24 years. Analyses used cross-tabulation with a chi-square test and estimation of a multivariate logistic regression model. Results: The prevalence of witnessing IPVAW was higher among males (30.5%) than females (19.0%). For both females and males, witnessing IPVAW was associated with an increased likelihood of reporting experiencing physical (Females: adjusted odds ratio (AOR) 4.1; 95% confidence interval (CI): 2.6-6.2 vs Males: AOR 4.1, 95% CI: 1.9-8.2), and emotional VAC perpetrated by a caregiver (Females: AOR 2.8, 95% CI: 1.8-4.4 vs Males: AOR 2.6, 95% CI: 1.3-5.2) compared to those who did not witness IPVAW. Unlike females, witnessing IPVAW among males significantly increased the odds of experiencing sexual violence by any perpetrator for males (AOR= 3.1; 95% CI=2.1-4.7), and endorsing norms justify IPVAW (AOR= 2.9; 95% CI=1.4-5.9) compared to those who never witnessed IPVAW. Conclusion: Coupled with the endorsement of IPVAW, the co-occurrence of IPVAW and caregiver-perpetrated VAC is common among children and young people in refugee settlements in Uganda. These findings underscore the need to synergize gender-based violence and child protection sectors and develop prevention and response programming around intersecting IPVAW and VAC risk factors within homes in refugee settlements and similar settings. Intimate Partner Violence Violence against children Co-occurrence Caregivers Humanitarian settings Figures Figure 1 Figure 2 Introduction The World Health Organization (WHO) estimates that about 1 in 3 women globally have experienced some physical and/or sexual violence by an intimate partner in their lifetime (1). It is also estimated that about half of children aged 2-17 years experience physical, sexual, or emotional violence or neglect each year (2). Intimate partner violence against women (IPVAW) and violence against children (VAC) are pervasive in humanitarian settings, including in Uganda, which is the third largest refugee-hosting country globally with an estimated refugee population of 1.6 million as of April 2024(3). A cross-sectional community-based study in the Rwamwanja refugee settlement in Uganda showed that approximately 63% and 69% of female household heads had experienced sexual and physical intimate partner violence (IPV) perpetrated by their male partners, respectively(4). The first-ever Humanitarian Violence Against Children Survey (HVACS) in Uganda showed about half of males and 43 % of females aged 18–24 years experienced any violence (sexual, physical, or emotional) before age 18 (5). IPVAW and VAC frequently co-occur within the same households (6, 7), and intersect in several ways, including overlapping risk factors, shared root causes, and consequences for women’s and children’s physical and mental health (8, 9). The co-occurrence of IPVAW and VAC may be heightened in refugee households due to weakened social, institutional, and economic structures and complex humanitarian emergencies (10). However, little is known about the prevalence of IPVAW-VAC co-occurrence in humanitarian contexts. This gap may hinder efforts to address violence in these settings adequately and the achievement of Sustainable Development Goal 5, which targets gender equality and empowerment for all women and girls. Estimating the prevalence of co-occurrence of IPVAW and VAC in humanitarian settings is complicated due in part to lack of standardized measurement (11) and a scarcity of rigorous large-scale population-based surveys from these settings (12). As a result, policymakers and programs rely on estimates from the general population. However, generalization based on studies in non-humanitarian settings is problematic, as children and women, who constitute the largest population in refugee settings, may have unique experiences (13, 14). Literature drawn from non-humanitarian contexts shows that children exposed to parental violence are likely to be exposed to adverse childhood experiences (ACEs). In particular, witnessing IPVAW in childhood is a risk factor for VAC, including sexual, physical, or emotional violence (15). A systematic review of the co-occurrence of IPV and VAC in low- and middle-income countries (LMICs) found that IPVAW is generally associated with female caregiver perpetration of VAC (7). In some cases, male-perpetrated IPVAW, especially if sexual or emotional, may reduce perpetration of VAC by a female caregiver; however, such cases are exceptions. A secondary analysis of a school-based cluster randomized trial in Uganda revealed that one-third of caregiver-adolescent dyads reported both IPV and VAC, with dyads reporting IPV more likely to report VAC (16). Another study from Uganda revealed that 26% of children who reported witnessing IPV, also experienced violence during their childhood years (17). Similar findings have also been documented in studies based in high-income countries, including the United States of America (18, 19). Qualitative studies have also explored IPVAW-VAC co-occurrence in households and suggest that IPVAW and VAC not only co-occur but also influence each other, creating cycles of abuse (20, 21). Exposure to violence, including witnessing IPVAW can lead to the intergenerational transmission of violence, thus perpetuating cycles of violence (22). Furthermore, in line with the social learning theory, children and adolescents exposed to violence may normalize violence (23). Studies drawn from the first rounds of violence against children surveys (VACS) in LMICs highlight the association between witnessing IPV in childhood and experiencing or perpetrating IPV in adulthood. For instance, in Malawi, VanderEnde and colleagues found that men who witnessed IPVAW in childhood were more likely to perpetrate it as young adults (24). Studies in Nigeria and Bangladesh also found that witnessing inter-parental violence increased the likelihood of experiencing IPV for both women and men and endorsement of norms justifying IPVAW (25, 26). In Peru, women who witnessed domestic violence against their mothers during childhood were more likely to have experienced IPV in the past year compared to those who did not report such violence (27). While extensive evidence exists on the co-occurrence of IPVAW and VAC, most of these studies are based on data from non-humanitarian settings or cover fewer camps/settlements, which cannot be generalized to represent refugee populations (7, 8, 17, 18). We examined the prevalence of witnessing IPVAW, and its association with experiencing (i) VAC (physical, sexual, and emotional) perpetrated by a caregiver and (ii) sexual violence perpetrated by any person) among children and young people aged 13-24 years in refugee settlements in Uganda. We also examined the association between witnessing IPVAW and the justification of IPVAW. Methods Study design and setting We analyzed data from the 2022 Uganda Humanitarian Violence Against Children and Youth Survey (HVACS). Details about the study design have been published elsewhere (5). In summary, the 2022 Uganda HVACS is a representative, cross-sectional, household-based survey of children and youth aged 13-24 years in 13 refugee settlements in Uganda. Similar to the standard VACS methodology (designed for non-humanitarian contexts)(28), the Uganda HVACS was designed to measure the prevalence and circumstances surrounding emotional, physical, and sexual violence, including witnessing IPV (5). In addition, the survey sought to identify risk and protective factors and the consequences of physical, sexual, and emotional violence. Sampling The Uganda HVACS used a three-stage, split sampling design to select and interview participants. The first stage involved a random selection of 56 zones (28 for female and 28 for male interviews) from a list of 109 provided by the United Nations High Commissioner for Refugees (UNHCR) and the Department of Refugees in the Office of the Prime Minister (OPM), which are the two organizations responsible for refugees’ affairs in Uganda. In the second stage, 193 and 134 households were randomly selected with equal probability from each of the sampled female and male zones, respectively. In the third stage, one eligible individual in each household was randomly selected for interview. A split sampling approach involving separate zones (clusters) for female and male participants was used to ensure the protection of participants' confidentiality and to minimize the chance that opposite-sex perpetrators and survivors could be interviewed in the same community (28). Data Collection The Uganda HVACS data were collected electronically between March and April 2022 using a standardized questionnaire programmed in Open Data Kit (ODK) and administered through Android-enabled tablets. The data collection team included research assistants and team leaders, who received comprehensive training on survey content and protocol, ethical aspects of research, and the electronic data collection system. Measures To explore IPVAW-VAC co-occurrence within the same households, we used questions administered to children aged 13–17 years about their lifetime experiences of violence, while for youth aged 18–24, we used questions about their experiences before the age of 18 years. Witnessing IPVAW in childhood hereafter referred to as “ witnessing IPVAW ,” was assessed based on a question asking participants the number of times (never, once, a few times, or many times) they saw or heard their mother or step-mother being punched, kicked, or beaten up by their father or step-father in their lifetime (for 13-17-year-olds) and before the age of 18 (for 18-24year-olds). Witnessing IPVAW was dichotomized into 1, representing those who reported witnessing IPVAW at least once in childhood (0-17 years), and 0 otherwise. Physical VAC perpetrated by a caregiver was assessed based on a question asking participants if they had ever experienced any physical acts of violence in their lifetime (e.g., slapping, pushing, punching, kicking, whipping, beating with an object, choking, smothering, trying to drown, burning, and using or threatening to use a gun, knife, or other weapon) perpetrated by a parent, adult caregiver, or other adult relatives. Physical VAC perpetrated by a caregiver was defined as having experienced one or more of these forms of physical acts of violence perpetrated by a parent, adult caregiver, or other adult relative in a lifetime for 13-17-year-olds and before age 18 years for 18-24-year-olds. Emotional VAC perpetrated by a caregiver was assessed based on a question asking participants if they had ever experienced incidents such as being told they were not loved or did not deserve to be loved, that they should never have been born or should have died, or being ridiculed or put down (e.g., being told they were stupid or useless). Emotional VAC perpetrated by a caregiver was defined as having experienced one or more of these forms of emotional violence perpetrated by a parent, adult caregiver, or other adult relative in a lifetime for 13-17-year-olds and before age 18 years for 18-24-year-olds. Sexual VAC included having experienced one or more incidents of unwanted sexual incidents, including unwanted sexual touching, unwanted attempted sex, physically forced sex, and pressured (threats, harassment, luring, or tricking) sex in childhood perpetrated by any perpetrator. Compared to physical or emotional VAC, there was no direct question asked about the type of sexual VAC perpetrators. Sexual VAC was defined as having experienced one or more of these forms of sexual violence perpetrated by any perpetrator in a lifetime for 13-17-year-olds and before age 18 years for 18-24-year-olds. Justification of IPVAW wasdeterminedbased on five questions that assessed if it was acceptable for a husband to beat his wife if she: goes out without telling him; neglects the children; argues with him; refuses to have sex with him or burns the food. Endorsement of each statement about wife-beating was coded 1, or 0 otherwise. We created a composite score that ranged from 0 (i.e., said ‘no’ to all the five indicators) to 5 (i.e., said ‘yes’ to all the five indicators). The scores were then dichotomized: 0 for zero scores, and 1 for scores of 1 or more. Socio-demographic variables : We controlled for a) age, categorized into two groups (1 = 13-17 years and 2 = 18-24 years); b) level of education (coded as 0 =never attended , 1 = some/completed primary, and 2 = some/completed secondary or higher); c) worked for payment in the past 12 months (yes/no) and d) country of origin (coded as 1 = South Sudan, 2 = Democratic Republic of Congo (DRC), and 3 = others). Analysis Analysis is based on 1,338 females and 927 males aged 13-24 years who completed the survey. We used cross-tabulation with the χ² test to examine the association between witnessing IPVAW and socio-demographic characteristics; experiencing VAC (physical and emotional violence by a caregiver, and sexual violence by any perpetrator); and endorsement of norms justifying IPVAW among 13-24-year-olds. To further examine the association between witnessing IPVAW and the experience of VAC and justification of IPVAW, we estimated a logistic regression model adjusting for socio-demographic factors: age, level of education, work status, and country of origin. We considered a p-value <0.05 statistically significant, with 95% confidence intervals. All analyses were performed using Stata® version 18, accounting for the complex survey design by applying weights to the estimates. Ethical considerations Ethical approval was obtained from the Population Council IRB (Protocol 986), as well as from the local review board, Mildmay Uganda Research and Ethics Committee (MUREC) – REC REF 0310-2021. The Uganda National Council for Science and Technology (UNCST) granted the research clearance (SS1130ES). All participants provided verbal informed consent to participate in the survey in line with the WHO’s Ethical and Safety Recommendations for Researching, Documenting, and Monitoring Sexual Violence in Emergencies (29). In addition, gender-based violence (GBV) counselors or caseworkers, seconded to the survey by UNHCR implementing partners, accompanied the data collection team to offer immediate psychosocial support to study participants in need of it, as well as to provide referrals for additional care (including health facility, counseling services, child protection, and shelters), where appropriate. Results Background characteristics Approximately half of female and male participants were aged 13-17 years (Table 1). Significantly more males than females had some, or completed secondary, or higher educational level (23.9% vs. 10.6%) and had worked for money or other payments in the past 12 months (47.2% vs. 30.7%). Most participants were from South Sudan, followed by the DRC, and other countries (including Rwanda, Burundi, Somalia, Ethiopia, Eritrea, and Sudan). Table 1 Prevalence of witnessing IPVAW, experiencing VAC, and endorsing IPVAW The prevalence of witnessing IPVAW in childhood among 13–24-year-olds was significantly higher among males than females (30.5% vs 19.0%; Figure 1 ). The prevalence of physical VAC perpetrated by a caregiver was also significantly higher among males than females aged 13-24 years (38.5% vs 21.0%). The prevalence of emotional VAC perpetrated by a caregiver among 13-24-year-olds was 19.9% for females and 23.6% for males. The prevalence of sexual VAC by any perpetrator among 13-24-year-olds was 13.9% and 9.9% for females and males, respectively. About 57.7% and 47.0% of females and males, respectively, endorsed norms justifying IPVAW. Figure 1: Prevalence of witnessing IPVAW, experiencing VAC, and endorsement of norms justifying IPVAW among females and males aged 13–24, Uganda HVACS 2022 Associations between witnessing IPVAW and socio-demographic factors For both females and males, there was no statistically significant difference in the proportion reporting witnessing IPVAW by socio-demographic factors: age, educational attainment, and country of origin ( Table 2 ). Among all categories of participants—females and males aged 13-24 years who reported witnessing and not witnessing IPVAW—a majority had some or completed primary education (between 67.8% and 83.8%). Among males, a greater proportion of those who had ever witnessed IPVAW had ever worked for pay (65.7%) compared to those who had not witnessed IPVAW (39.0%). Table 2 Association between witnessing IPVAW and experience of VAC For both females and males, the proportion reporting physical or emotional VAC perpetrated by a caregiver was significantly higher among those who reported witnessing IPVAW than among those who did not ( Table 3 ). The proportion of males reporting experience of sexual VAC by any perpetrator was significantly higher among those who witnessed IPVAW compared to those who did not. Compared to females, the proportion of males endorsing norms justifying IPVAW was significantly higher among those who witnessed IPVAW than those who never witnessed IPVAW (65.8% vs 38.7%). Table 3 We further examined the likelihood of experiencing VAC and endorsing norms justifying IPVAW among children and young people aged 13-24 years who witnessed IPVAW, controlling for socio-demographic factors: age, educational attainment, work status, and country of origin. The odds of experiencing physical VAC at the hand of a caregiver were 4 times higher for females (AOR= 4.1; 95% CI=2.7-6.3 [orange markers]) and males (AOR= 4.0; 95% CI=2.0-8.2 [blue markers]) who witnessed IPVAW compared to those who never witnessed IPVAW ( Figure 2 ). Similarly, witnessing IPVAW increased the odds of experiencing emotional VAC at the hands of a caregiver by over 2.6 times for females (AOR= 2.8; CI=1.7-4.7) and for males (AOR= 2.6; 95% CI=1.4-5.0) compared to those who did not witness IPVAW. Unlike females, witnessing IPVAW significantly increased the odds of experiencing sexual VAC by any perpetrator for males (AOR= 3.1; 95% CI=2.1-4.7). Unlike females, males who witnessed IPVAW were more likely to justify IPV against women (AOR= 2.9; 95% CI=1.5.9) compared to those who never witnessed IPVAW. Figure 2: Odds of experiencing VAC, and justifying IPWAW in females and males aged 13–24 who witnessed IPVAW, Uganda HVACS 2022 Discussion The co-occurrence of IPVAW and VAC within the same households has received limited attention in humanitarian settings where violence is heightened due, in part, to fragility and weakened social and protective networks ( 30 ). In this paper, we examined the association between witnessing IPVAW and experiencing VAC perpetrated by parents or caregivers (for physical and emotional violence) and any person (for sexual violence) among children and young people aged 13–24 years in Uganda’s refugee settlements. Witnessing IPVAW among young people aged 13–24 years was common in the study settings, and more prevalent in males than females (30% vs 19%). Our study found no statistically significant difference in exposure to IPVAW with respect to socio-demographic factors: age, education level, and country of origin. This finding suggests that IPVAW is a global public health problem transcending all social layers and cultural backgrounds. This may be particularly true in humanitarian contexts, which exacerbate the risk of gender-based violence (GBV) due to marginalization, weakened economic power, and broken social and protective networks ( 31 ). We found that the prevalence of physical and emotional VAC perpetrated by a caregiver was higher among males than females. This may be explained by gender differences. For instance, boys tend to exhibit more externalizing behaviors such as aggression or defiance, which can provoke more punitive responses from caregivers ( 32 ). Conversely, the prevalence of sexual violence (by any perpetrator) was higher in females than males (though not statistically significant), which underscores the increased vulnerability of females to sexual violence due to entrenched power imbalances between the two genders. Our findings show that children who witnessed IPVAW were more likely to report experiencing physical and emotional violence at the hands of a caregiver than those who never witnessed IPVAW. The finding aligns with conclusions from other studies based on non-humanitarian VACS in LMIC and other settings, including in Uganda, highlighting intersections between witnessing IPVAW and experiencing VAC ( 17 , 18 , 24 , 33 ). IPVAW-VAC co-occurrence within the same households may happen through several mechanisms. IPV may create a hostile home environment, increasing stress and conflict, lowering parental patience, and reducing parents' emotional availability and capacity to provide a safe environment, leading to frustration, harsher parenting practices, neglect, and a higher likelihood of children experiencing physical, emotional, or sexual violence ( 34 , 35 ). However, the overlap between witnessing IPVAW and experiencing VAC may be compounded by other risk factors such as poverty, lower parental education level, poor relationship with parents, and alcohol or drug abuse, which our study did not account for ( 36 ). Similar to studies from non-humanitarian settings ( 25 – 27 ), witnessing IPVAW was associated with the endorsement of norms justifying IPV against women. This relationship was strong among male participants. Published literature shows that repeated exposure to IPV between parents or caregivers is a risk factor for normalization of violence, which in turn may lead to perpetration of IPV in adulthood ( 37 ). When witnessing IPVAW becomes a routine part of an individual's experience, it can desensitize them to violence and lead them to accept it as a normal aspect of relationships. Such normalization can lead to the endorsement of norms that justify violence, including IPVAW, as the behavior becomes ingrained as a standard or expected part of relationships. This is common in patriarchal societies where men tend to have great dominance over women in terms of power, social value, entitlement, and roles ( 38 ). Strength and limitations we used a robust, representative dataset from children and youth aged 13–24 years across all 13 refugee settlements in Uganda, providing unique insights on the co-occurrence of witnessing IPVAW and experiencing VAC in the hands of a parent or caregiver. Our study has some limitations. The cross-sectional design allowed us to explore associations between witnessing IPVAW and experiencing VAC, and endorsement of IPVAW, but not to establish causality between these variables. Additionally, the study relied on retrospective reports on witnessing IPVAW and experiencing VAC, which may be affected by recall bias, social desirability bias, and stigma around disclosing violence experienced and witnessed in childhood. Although our results indicate a significant association between witnessing IPVAW and experiencing VAC in Uganda refugee settlement settings, further research is needed to explore health consequences and risk factors for co-occurrence of IPVAW and VAC within the same households. In a related study, we established that experiencing sexual, physical, or emotional VAC was associated with poor mental health (severe mental distress, suicidal ideation and/or attempted suicide and self-harm) in Uganda refugee settlements ( 39 ). Thus, children exposed to both IPVAW and VAC may experience higher risk of poor mental health outcomes. Conclusion and implications Coupled with the endorsement of IPVAW, the co-occurrence of IPVAW and caregiver-perpetrated VAC is common among children and young people in refugee settlements in Uganda. These experiences may lead to both short- and long-term health consequences, including mental health issues ( 39 ), and affect the well-being of children in the study settings. The findings have implications for practice, policy, and research. Notably, programming to address IPVAW and VAC in humanitarian settings is coordinated by different sub-sectors, GBV, and child protection, respectively. Our findings underscore the need for these sectors to create synergies and leverage programming around intersecting IPVAW-VAC risk factors in households within refugee settlements. The high prevalence of the co-occurrence of IPVAW and VAC perpetrated by caregivers in the study setting underscores the need for effective screening for both exposure to IPVAW and VAC among children and adolescents. Routine screening for violence have been shown to promote the detection of child survivors and their uptake of relevant services ( 40 ). Current screening tools need to be expanded to ensure that they are responsive to the reality of IPVAW-VAC co-occurrence. Additionally, the screening should go beyond focusing on children alone. Effective prevention and response programs are also needed for women who are experiencing IPVAW. There is also need for more emphasis on promoting positive parenting norms, transforming harmful social norms around child-rearing, and providing parent and caregiver support through information and skill-building sessions to foster nurturing non-violent parenting. Abbreviations VAC Violence Against Children HVACS Humanitarians Violence Against Children Survey LMIC Lower-and Middle-Income Countries IPV Intimate Partner Violence IPVAW Intimate Partner Violence Against Women GBV Gender-Based Violence WHO World Health Organization UNHCR United Nations High Commissioner for Refugees OPM Office of the Prime Minister Declarations Declarations Ethics approval and consent to participate Ethical approval was obtained from the Population Council IRB (Protocol 986), as well as from the local review board, Mildmay Uganda Research and Ethics Committee (MUREC) – REC REF 0310-2021. All participants provided verbal informed consent to participate in the survey. Consent for publication Not applicable. Data availability The datasets generated and/or analyzed during the current study are available in the Population Council repository. https://dataverse.harvard.edu/dataverse/popcouncil. Competing interests The authors declare that they have no competing interests Funding This study was funded by the Foreign, Commonwealth and Development Office (FCDO) through the Baobab Research Program Consortium (RPC) (PO8912). Author contributions GO, FO, SM, and CU conceptualized the study. GO analyzed the data and wrote the first draft. FO, SM, GS, PK, YW, CK, DY, YB, BW and CU reviewed the manuscript for substantial intellectual content. All authors contributed to substantive revisions of the manuscript and read and approved the final manuscript. Acknowledgments: We are deeply grateful to all the research participants who shared their time, and experiences with the research team. We also would like to thank the diligent and dedicated team of data collectors who made this work possible. We are grateful for the technical support provided by the US Centers for Disease Control and Prevention, Together for Girls Partnership, Office of the Prime Minister- Uganda, UNHCR-Uganda, UNHCR Regional Bureau for East and Horn of Africa and the Great Lakes Region, and UNHCR implementing partners and Baobab RPC’s Council Advisory Group (CAG) members during the design and implementation of the study. The opinions expressed in the paper are, however, solely those of the authors and do not necessarily reflect the views of the funding agency or partners that provided technical support to the research. References WH0. Global status report on violence prevention 2014. Geneve, Switzerland World Health Organization (WHO); 2014. Report No.: 9241564792. Hillis S, Mercy J, Amobi A, Kress H. Global prevalence of past-year violence against children: a systematic review and minimum estimates. Pediatrics. 2016;137(3). OPM. Uganda Comprehensive Refugees Response Portal. 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Association between witnessing domestic violence against the mother in childhood and intimate partner violence in adulthood: A population-based analysis of Peru. European Journal of Obstetrics & Gynecology and Reproductive Biology: X. 2024;21:100275. Chiang LF, Kress H, Sumner SA, Gleckel J, Kawemama P, Gordon RN. Violence Against Children Surveys (VACS): towards a global surveillance system. Injury prevention. 2016;22(Suppl 1):i17-i22. WHO. WHO Ethical and Safety Recommendations for Researching, Documenting and Monitoring Sexual Violence in Emergencies. https://www.who.int/publications/i/item/9789241595681. Geneva: World Health Organization (WHO); 2007. Zeid S, Gilmore K, Khosla R, Papowitz H, Engel D, Dakkak H, et al. Women’s, children’s, and adolescents’ health in humanitarian and other crises. Bmj. 2015;351. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma, Violence, & Abuse. 2011;12(3):127-34. Chaplin TM, Aldao A. Gender differences in emotion expression in children: a meta-analytic review. Psychological bulletin. 2013;139(4):735. Falb KL, Blackwell A, Hategekimana JdD, Sifat M, Roth D, O’Connor M. Co-occurring intimate partner violence and child abuse in eastern democratic republic of congo: the influence of early life experiences of abuse. Violence against women. 2024;30(3-4):873-89. Holt S, Buckley H, Whelan S. The impact of exposure to domestic violence on children and young people: A review of the literature. Child abuse & neglect. 2008;32(8):797-810. Chiesa AE, Kallechey L, Harlaar N, Ford CR, Garrido EF, Betts WR, et al. Intimate partner violence victimization and parenting: A systematic review. Child abuse & neglect. 2018;80:285-300. Foran HM, O'Leary KD. Alcohol and intimate partner violence: A meta-analytic review. Clinical psychology review. 2008;28(7):1222-34. Mbilinyi LF, Logan-Greene PB, Neighbors C, Walker DD, Roffman RA, Zegree J. exposure to domestic violence and childhood emotional abuse: Childhood Domestic Violence Exposure among a Community Sample of Adult Perpetrators: What Mediates the Connection? Journal of aggression, maltreatment & trauma. 2012;21(2):171. Sikweyiya Y, Addo-Lartey AA, Alangea DO, Dako-Gyeke P, Chirwa ED, Coker-Appiah D, et al. Patriarchy and gender-inequitable attitudes as drivers of intimate partner violence against women in the central region of Ghana. BMC public health. 2020;20:1-11. Kisaakye P, Seruwagi G, Odwe G, Obare F, Muthuri S, Kabiru CW, et al. Associations between childhood violence and mental health in refugee settings in Uganda. Child Protection and Practice. 2024;2:100038. Undie CC, Mak'anyengo M. If we ask, will they tell?(and then, what?): screening for sexual violence against children in Kenya. Child abuse review. 2022;31(1):11-26. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Cite Share Download PDF Status: Published Journal Publication published 17 Apr, 2025 Read the published version in Conflict and Health → Version 1 posted Editorial decision: Revision requested 04 Nov, 2024 Reviews received at journal 02 Nov, 2024 Reviews received at journal 30 Oct, 2024 Reviewers agreed at journal 12 Oct, 2024 Reviewers agreed at journal 09 Oct, 2024 Reviewers invited by journal 06 Oct, 2024 Editor assigned by journal 19 Sep, 2024 Submission checks completed at journal 19 Sep, 2024 First submitted to journal 19 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5117966","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":373992349,"identity":"82a5e2ef-fa21-4fa5-aad5-f2779be52ce5","order_by":0,"name":"George Odwe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYHACAwaGCjhHQoZILWcQWniI08LYhuAR1iLv3rxN4uO8O3Lm7IePSRfUWPAwsPc+foFPi+GZY2WSM7c9M7bsSUuTnnEM6DCe42YWeLXMyDG7zbvtcOKGGzxm0rwNQC0SaWwGBLX8nUOKFnkJoBbGBlQtzA/waTHgOVb+s+cY2C/J1jxAv7DxHGPDp4NBvr15s8GPGnCIHbzNU1Mnx8/exvwBry0HwNQBBrjzgVawSeC1pQFdCxDgt2UUjIJRMApGHAAAsSNDeDw7fg8AAAAASUVORK5CYII=","orcid":"","institution":"Population Council","correspondingAuthor":true,"prefix":"","firstName":"George","middleName":"","lastName":"Odwe","suffix":""},{"id":373992350,"identity":"7f3691c1-0b1c-4214-ae2c-9f86c9628324","order_by":1,"name":"Francis Onyango","email":"","orcid":"","institution":"Population Council","correspondingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Onyango","suffix":""},{"id":373992351,"identity":"afd478cd-df56-4ddb-803f-b7b104a731a5","order_by":2,"name":"Stella Muthuri","email":"","orcid":"","institution":"Population Council","correspondingAuthor":false,"prefix":"","firstName":"Stella","middleName":"","lastName":"Muthuri","suffix":""},{"id":373992352,"identity":"9f623e5f-5a8a-4d6f-96fa-4b81020b80cc","order_by":3,"name":"Peter Kisaakye","email":"","orcid":"","institution":"Population Council","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Kisaakye","suffix":""},{"id":373992353,"identity":"c0cf4ebd-55db-4fed-95af-497fabaae8d5","order_by":4,"name":"Dagim Habteyesus","email":"","orcid":"","institution":"Population Council","correspondingAuthor":false,"prefix":"","firstName":"Dagim","middleName":"","lastName":"Habteyesus","suffix":""},{"id":373992354,"identity":"747cc255-5114-4ecf-bee7-3708eaf119cd","order_by":5,"name":"Gloria Seruwagi","email":"","orcid":"","institution":"Population Council","correspondingAuthor":false,"prefix":"","firstName":"Gloria","middleName":"","lastName":"Seruwagi","suffix":""},{"id":373992355,"identity":"41f457ba-4d0c-42e7-9df1-3cf33f5ac3b4","order_by":6,"name":"Yohannes Dibaba Wado","email":"","orcid":"","institution":"African Population and Health Research Center (APHRC), APHRC Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Yohannes","middleName":"Dibaba","lastName":"Wado","suffix":""},{"id":373992357,"identity":"9a10a690-5a3f-43e8-812c-2c0636650f13","order_by":7,"name":"Yadeta Bacha","email":"","orcid":"","institution":"African Population and Health Research Center (APHRC), APHRC Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Yadeta","middleName":"","lastName":"Bacha","suffix":""},{"id":373992359,"identity":"27909cd2-74ee-4fd1-b0c9-16023c75017a","order_by":8,"name":"Bonnie Wandera","email":"","orcid":"","institution":"African Population and Health Research Center (APHRC), APHRC Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Bonnie","middleName":"","lastName":"Wandera","suffix":""},{"id":373992361,"identity":"604c7816-5a9d-417b-8b5d-e3ba28c94a85","order_by":9,"name":"Caroline W. Kabiru","email":"","orcid":"","institution":"African Population and Health Research Center (APHRC), APHRC Headquarters","correspondingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"W.","lastName":"Kabiru","suffix":""},{"id":373992364,"identity":"5c8b976d-a6ee-4b4e-9fdd-1daf63742222","order_by":10,"name":"Chi-Chi Undie","email":"","orcid":"","institution":"Population Council","correspondingAuthor":false,"prefix":"","firstName":"Chi-Chi","middleName":"","lastName":"Undie","suffix":""}],"badges":[],"createdAt":"2024-09-19 15:04:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5117966/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5117966/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13031-025-00661-5","type":"published","date":"2025-04-17T15:58:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72206380,"identity":"43397ea3-e477-4d63-96aa-2f8f1081b535","added_by":"auto","created_at":"2024-12-23 16:42:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":217778,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence of witnessing IPVAW, experiencing VAC, and endorsement of norms justifying IPVAW among females and males aged 13–24, Uganda HVACS 2022\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5117966/v1/02b0bcbf8714a1eb131544bb.png"},{"id":72207065,"identity":"68da986b-42a5-48e4-89c5-745a8d2d690e","added_by":"auto","created_at":"2024-12-23 16:50:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":263737,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOdds of experiencing VAC, and justifying IPWAW in females and males aged 13–24 who witnessed IPVAW, Uganda HVACS 2022\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5117966/v1/6dc207ce6f543d2c8383acf9.png"},{"id":81050943,"identity":"59ef6859-9a47-4392-adb1-4175db968945","added_by":"auto","created_at":"2025-04-21 16:08:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1521245,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5117966/v1/e2c45b86-ce5c-4147-9f21-3f8c97b13487.pdf"},{"id":72206379,"identity":"6345f0e6-573d-4aba-9b97-020b72d6aff0","added_by":"auto","created_at":"2024-12-23 16:42:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17672,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5117966/v1/a480c8899abced8842d7ce80.docx"},{"id":72206381,"identity":"df3d220c-c336-48ec-ba43-6bf6e052c1d3","added_by":"auto","created_at":"2024-12-23 16:42:31","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":18703,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5117966/v1/19734ccea23e1a98388c2576.docx"},{"id":72206383,"identity":"9afdf4dd-dae4-4f93-b9ba-7614751d84ba","added_by":"auto","created_at":"2024-12-23 16:42:31","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18164,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-5117966/v1/88af463871dafdccdaab0eea.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-occurrence of Witnessing Intimate Partner Violence against Women and Experiencing Violence in Childhood in Refugee Settlements in Uganda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe World Health Organization (WHO) estimates that about 1 in 3 women globally have experienced some physical and/or sexual violence by an intimate partner in their lifetime (1). It is also estimated that about half of children aged 2-17 years experience physical, sexual, or emotional violence or neglect each year (2). Intimate partner violence against women (IPVAW) and violence against children (VAC) are pervasive in humanitarian settings, including in Uganda, which is the third largest refugee-hosting country globally with an estimated refugee population of 1.6 million as of April 2024(3).\u0026nbsp;A cross-sectional community-based study in the Rwamwanja refugee settlement in Uganda showed that approximately 63% and 69% of female household heads had experienced sexual and physical intimate partner violence (IPV) perpetrated by their male partners, respectively(4). The first-ever Humanitarian Violence Against Children Survey (HVACS) in Uganda showed about half of males and 43 % of females aged 18–24 years experienced any violence (sexual, physical, or emotional) before age 18 (5).\u003c/p\u003e\n\u003cp\u003eIPVAW and VAC frequently co-occur within the same households (6, 7), and intersect in several ways, including overlapping risk factors, shared root causes, and consequences for women’s and children’s physical and mental health (8, 9).\u0026nbsp;The co-occurrence of IPVAW and VAC may be heightened in refugee households due to weakened social, institutional, and economic structures and complex humanitarian emergencies (10). However, little is known about the prevalence of IPVAW-VAC co-occurrence in humanitarian contexts. This gap may hinder efforts to address violence in these settings adequately and the achievement of Sustainable Development Goal 5, which targets gender equality and empowerment for all women and girls.\u003c/p\u003e\n\u003cp\u003eEstimating the prevalence of co-occurrence of IPVAW and VAC in humanitarian settings is complicated due in part to lack of standardized measurement (11) and a scarcity of rigorous large-scale population-based surveys from these settings (12). As a result, policymakers and programs rely on estimates from the general population. However, generalization based on studies in non-humanitarian settings is problematic, as children and women, who constitute the largest population in refugee settings, may have unique experiences (13, 14).\u003c/p\u003e\n\u003cp\u003eLiterature drawn from non-humanitarian contexts shows that children exposed to parental violence are likely to be exposed to adverse childhood experiences (ACEs). In particular, \u0026nbsp; witnessing IPVAW in childhood is a risk factor for VAC, including sexual, physical, or emotional violence (15). A systematic review of the co-occurrence of IPV and VAC in low- and middle-income countries (LMICs) found that IPVAW is generally associated with female caregiver perpetration of VAC (7). In some cases, male-perpetrated IPVAW, especially if sexual or emotional, may reduce perpetration of VAC by a female caregiver; however, such cases are exceptions. A secondary analysis of a school-based cluster randomized trial in Uganda revealed that one-third of caregiver-adolescent dyads reported both IPV and VAC, with dyads reporting IPV more likely to report VAC (16). Another study from Uganda revealed that 26% of children who reported witnessing IPV, also experienced violence during their childhood years (17). Similar findings have also been documented in studies based in high-income countries, including the United States of America (18, 19). Qualitative studies have also explored IPVAW-VAC co-occurrence in households and suggest that IPVAW and VAC not only co-occur but also influence each other, creating cycles of abuse (20, 21).\u003c/p\u003e\n\u003cp\u003eExposure to violence, including witnessing IPVAW can lead to the intergenerational transmission of violence, thus perpetuating cycles of violence (22). Furthermore, in line with the social learning theory, children and adolescents exposed to violence may normalize violence (23). Studies drawn from the first rounds of violence against children surveys (VACS) in LMICs highlight the association between witnessing IPV in childhood and experiencing or perpetrating IPV in adulthood. For instance, in Malawi,\u0026nbsp;VanderEnde\u0026nbsp;and colleagues found that men who witnessed IPVAW\u0026nbsp;in childhood were more likely to perpetrate it as young adults (24).\u0026nbsp;Studies in Nigeria and Bangladesh also found that witnessing inter-parental violence increased the likelihood of experiencing IPV for both women and men and endorsement of norms justifying IPVAW (25, 26). In Peru, women who witnessed domestic violence against their mothers during childhood were more likely to have experienced IPV in the past year compared to those who did not report such violence (27).\u003c/p\u003e\n\u003cp\u003eWhile extensive evidence exists on the co-occurrence of IPVAW and VAC, most of these studies are based on data from non-humanitarian settings or cover fewer camps/settlements, which cannot be generalized to represent refugee populations (7, 8, 17, 18). We examined the prevalence of witnessing IPVAW, and its association with experiencing (i) VAC (physical, sexual, and emotional) perpetrated by a caregiver and (ii) sexual violence perpetrated by any person) among children and young people aged 13-24 years in refugee settlements in Uganda. We also examined the association between witnessing IPVAW and the justification of IPVAW.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design and setting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe analyzed data from the 2022 Uganda\u0026nbsp;Humanitarian Violence Against Children and Youth Survey (HVACS). Details about the study design have been published elsewhere (5). In summary, the 2022 Uganda HVACS is a representative, cross-sectional, household-based survey\u0026nbsp;of children and youth aged 13-24 years in 13 refugee settlements in Uganda. Similar to the standard VACS methodology (designed for non-humanitarian contexts)(28), the Uganda HVACS was designed to measure the prevalence and circumstances surrounding emotional, physical, and sexual violence, including witnessing IPV (5). In addition, the survey sought to identify risk and protective factors and the consequences of physical, sexual, and emotional violence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSampling\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Uganda HVACS used a three-stage, split sampling design to select and interview participants. The first stage involved a random selection of 56 zones (28 for female and 28 for male interviews) from a list of 109 provided by the United Nations High Commissioner for Refugees (UNHCR) and the Department of Refugees in the Office of the Prime Minister (OPM), which are the two organizations responsible for refugees\u0026rsquo; affairs in Uganda. In the second stage, 193 and 134 households were randomly selected with equal probability from each of the sampled female and male zones, respectively. In the third stage, one eligible individual in each household was randomly selected for interview. A split sampling approach involving separate zones (clusters) for female and male participants was used to ensure the protection of participants\u0026apos; confidentiality and to minimize the chance that opposite-sex perpetrators and survivors could be interviewed in the same community (28).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Uganda HVACS data were collected electronically between March and April 2022 using a standardized questionnaire programmed in Open Data Kit (ODK) and administered through Android-enabled tablets. The data collection team included research assistants and team leaders, who received comprehensive training on survey content and protocol, ethical aspects of research, and the electronic data collection system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo explore IPVAW-VAC co-occurrence within the same households, we used questions administered to children aged 13\u0026ndash;17 years about their lifetime experiences of violence, while for youth aged 18\u0026ndash;24, we used questions about their experiences before the age of 18 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWitnessing IPVAW\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003cstrong\u003ein childhood\u003c/strong\u003e\u003c/em\u003ehereafter referred to as \u0026ldquo;\u003cstrong\u003e\u003cem\u003ewitnessing IPVAW\u003c/em\u003e\u003c/strong\u003e,\u0026rdquo; was assessed based on a question asking participants the number of times (never, once, a few times, or many times) they saw or heard their mother or step-mother being punched, kicked, or beaten up by their father or step-father in their lifetime (for 13-17-year-olds) and before the age of 18 (for 18-24year-olds). Witnessing IPVAW was dichotomized into 1, representing those who reported witnessing IPVAW at least once in childhood (0-17 years), and 0 otherwise.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhysical VAC perpetrated by a caregiver\u003c/em\u003e\u003c/strong\u003e was assessed based on a question asking participants if they had ever experienced any physical acts of violence in their lifetime (e.g.,\u0026nbsp;slapping, pushing, punching, kicking, whipping, beating with an object, choking, smothering, trying to drown, burning, and using or threatening to use a gun, knife, or other weapon) perpetrated by a parent,\u0026nbsp;adult caregiver, or other adult relatives. Physical\u0026nbsp;VAC perpetrated by a caregiver was defined as having experienced one or more of these forms of physical acts of violence\u0026nbsp;perpetrated by a parent, adult caregiver, or other adult relative in a lifetime for 13-17-year-olds and before age 18 years for 18-24-year-olds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEmotional VAC perpetrated by a caregiver\u003c/em\u003e\u003c/strong\u003e was assessed based on a question asking participants if they had ever experienced incidents such as being told they were not loved or did not deserve to be loved, that they should never have been born or should have died, or being ridiculed or put down (e.g., being told they were stupid or useless). Emotional VAC perpetrated by a caregiver was defined as having experienced one or more of these forms of emotional violence perpetrated by a parent, adult caregiver, or other adult relative in a lifetime for 13-17-year-olds and before age 18 years for 18-24-year-olds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSexual VAC\u003c/em\u003e\u003c/strong\u003e included having experienced one or more incidents of unwanted sexual incidents, including unwanted sexual touching, unwanted attempted sex, physically forced sex, and pressured (threats, harassment, luring, or tricking) sex in childhood perpetrated by any perpetrator. Compared to physical or emotional VAC, there was no direct question asked about the type of sexual VAC perpetrators. Sexual VAC was defined as having experienced one or more of these forms of sexual violence perpetrated by any perpetrator in a lifetime for 13-17-year-olds and before age 18 years for 18-24-year-olds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eJustification of IPVAW\u003c/em\u003e\u0026nbsp;\u003c/strong\u003ewasdeterminedbased on five questions that assessed if it was acceptable for a husband to beat his wife if she: goes out without telling him; neglects the children; argues with him; refuses to have sex with him or burns the food. Endorsement of each statement about wife-beating was coded 1, or 0 otherwise. We created a composite score that ranged from 0 (i.e., said \u0026lsquo;no\u0026rsquo; to all the five indicators) to 5 (i.e., said \u0026lsquo;yes\u0026rsquo; to all the five indicators). \u0026nbsp;The scores were then dichotomized: \u0026nbsp;0 for zero scores, and 1 for scores of 1 or more.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocio-demographic variables\u003c/em\u003e:\u003c/strong\u003e We controlled for a) age, categorized into two groups (1 = 13-17 years and 2 = 18-24 years); b) level of education (coded as 0 =never attended , 1 = some/completed primary, and 2 = some/completed secondary or higher); c) worked for payment in the past 12 months (yes/no) and d) country of origin (coded as 1 = South Sudan, 2 = Democratic Republic of Congo (DRC), and 3 = others).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAnalysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis is based on 1,338 females and 927 males aged 13-24 years who completed the survey. We used cross-tabulation with the \u0026chi;\u0026sup2; test to examine the association between witnessing IPVAW and socio-demographic characteristics; experiencing VAC (physical and emotional violence by a caregiver, and sexual violence by any perpetrator); and endorsement of norms justifying IPVAW among 13-24-year-olds. To further examine the association between witnessing IPVAW and the experience of VAC and justification of IPVAW, we estimated a logistic regression model adjusting for socio-demographic factors: age, level of education, work status, and country of origin. We considered a p-value \u0026lt;0.05 statistically significant, with 95% confidence intervals. All analyses were performed using Stata\u0026reg; version 18, accounting for the complex survey design by applying weights to the estimates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical considerations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Population Council IRB (Protocol 986), as well as from the local review board, Mildmay Uganda Research and Ethics Committee (MUREC) \u0026ndash; REC REF 0310-2021. The Uganda National Council for Science and Technology (UNCST) granted the research clearance (SS1130ES). All participants provided verbal informed consent to participate in the survey in line with the WHO\u0026rsquo;s Ethical and Safety Recommendations for Researching, Documenting, and Monitoring Sexual Violence in Emergencies (29). In addition, gender-based violence (GBV) counselors or caseworkers, seconded to the survey by UNHCR implementing partners, accompanied the data collection team to offer immediate psychosocial support to study participants in need of it, as well as to provide referrals for additional care (including health facility, counseling services, child protection, and shelters), where appropriate.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBackground characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproximately half of female and male participants were aged 13-17 years\u003cstrong\u003e\u0026nbsp;(Table 1).\u003c/strong\u003e Significantly more males than females had some, or completed secondary, or higher educational level (23.9% vs. 10.6%) and had worked for money or other payments in the past 12 months (47.2% vs. 30.7%). Most participants were from South Sudan, followed by the DRC, and other countries (including Rwanda, Burundi, Somalia, Ethiopia, Eritrea, and Sudan).\u003c/p\u003e\n\u003cp\u003eTable 1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrevalence of witnessing IPVAW, experiencing VAC, and endorsing IPVAW\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence of witnessing IPVAW in childhood among 13\u0026ndash;24-year-olds was significantly higher among males than females (30.5% vs 19.0%; \u003cstrong\u003eFigure 1\u003c/strong\u003e). The prevalence of physical VAC perpetrated by a caregiver was also significantly higher among males than females aged 13-24 years (38.5% vs 21.0%). The prevalence of emotional VAC perpetrated by a caregiver among 13-24-year-olds was 19.9% for females and 23.6% for males. The prevalence of sexual VAC by any perpetrator among 13-24-year-olds was 13.9% and 9.9% for females and males, respectively. About 57.7% and 47.0% of females and males, respectively, endorsed norms justifying IPVAW.\u003c/p\u003e\n\u003cp\u003eFigure 1:\u003cstrong\u003e\u0026nbsp;Prevalence of witnessing IPVAW, experiencing VAC, and endorsement of norms justifying IPVAW among females and males aged 13\u0026ndash;24, Uganda HVACS 2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssociations between witnessing IPVAW and socio-demographic factors\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor both females and males, there was no statistically significant difference in the proportion reporting witnessing IPVAW by socio-demographic factors: age, educational attainment, and country of origin (\u003cstrong\u003eTable 2\u003c/strong\u003e). Among all categories of participants\u0026mdash;females and males aged 13-24 years who reported witnessing and not witnessing IPVAW\u0026mdash;a majority had some or completed primary education (between 67.8% and 83.8%). Among males, a greater proportion of those who had ever witnessed IPVAW had ever worked for pay (65.7%) compared to those who had not witnessed IPVAW (39.0%).\u003c/p\u003e\n\u003cp\u003eTable 2\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAssociation between witnessing IPVAW and experience of VAC\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor both females and males, the proportion reporting physical or emotional VAC perpetrated by a caregiver was significantly higher among those who reported witnessing IPVAW than among those who did not (\u003cstrong\u003eTable 3\u003c/strong\u003e). The proportion of males reporting experience of sexual VAC by any perpetrator was significantly higher among those who witnessed IPVAW compared to those who did not. Compared to females, the proportion of males endorsing norms justifying IPVAW was significantly higher among those who witnessed IPVAW than those who never witnessed IPVAW (65.8% vs 38.7%).\u003c/p\u003e\n\u003cp\u003eTable 3\u003c/p\u003e\n\u003cp\u003eWe further examined the likelihood of experiencing VAC and endorsing norms justifying IPVAW among children and young people aged 13-24 years who witnessed IPVAW, controlling for socio-demographic factors: age, educational attainment, work status, and country of origin. The odds of experiencing physical VAC at the hand of a caregiver were 4 times higher for females (AOR= 4.1; 95% CI=2.7-6.3 [orange markers]) and males (AOR= 4.0; 95% CI=2.0-8.2 [blue markers]) who witnessed IPVAW compared to those who never witnessed IPVAW (\u003cstrong\u003eFigure 2\u003c/strong\u003e). Similarly, witnessing IPVAW increased the odds of experiencing emotional VAC at the hands of a caregiver by over 2.6 times for females (AOR= 2.8; CI=1.7-4.7) and for males (AOR= 2.6; 95% CI=1.4-5.0) compared to those who did not witness IPVAW. Unlike females, witnessing IPVAW significantly increased the odds of experiencing sexual VAC by any perpetrator for males (AOR= 3.1; 95% CI=2.1-4.7). Unlike females, males who witnessed IPVAW were more likely to justify IPV against women (AOR= 2.9; 95% CI=1.5.9) compared to those who never witnessed IPVAW.\u003c/p\u003e\n\u003cp\u003eFigure 2: \u003cstrong\u003eOdds of experiencing VAC, and justifying IPWAW in females and males aged 13\u0026ndash;24 who witnessed IPVAW, Uganda HVACS 2022\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe co-occurrence of IPVAW and VAC within the same households has received limited attention in humanitarian settings where violence is heightened due, in part, to fragility and weakened social and protective networks (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In this paper, we examined the association between witnessing IPVAW and experiencing VAC perpetrated by parents or caregivers (for physical and emotional violence) and any person (for sexual violence) among children and young people aged 13\u0026ndash;24 years in Uganda\u0026rsquo;s refugee settlements.\u003c/p\u003e \u003cp\u003eWitnessing IPVAW among young people aged 13\u0026ndash;24 years was common in the study settings, and more prevalent in males than females (30% vs 19%). Our study found no statistically significant difference in exposure to IPVAW with respect to socio-demographic factors: age, education level, and country of origin. This finding suggests that IPVAW is a global public health problem transcending all social layers and cultural backgrounds. This may be particularly true in humanitarian contexts, which exacerbate the risk of gender-based violence (GBV) due to marginalization, weakened economic power, and broken social and protective networks (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe found that the prevalence of physical and emotional VAC perpetrated by a caregiver was higher among males than females. This may be explained by gender differences. For instance, boys tend to exhibit more externalizing behaviors such as aggression or defiance, which can provoke more punitive responses from caregivers (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Conversely, the prevalence of sexual violence (by any perpetrator) was higher in females than males (though not statistically significant), which underscores the increased vulnerability of females to sexual violence due to entrenched power imbalances between the two genders.\u003c/p\u003e \u003cp\u003eOur findings show that children who witnessed IPVAW were more likely to report experiencing physical and emotional violence at the hands of a caregiver than those who never witnessed IPVAW. The finding aligns with conclusions from other studies based on non-humanitarian VACS in LMIC and other settings, including in Uganda, highlighting intersections between witnessing IPVAW and experiencing VAC (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). IPVAW-VAC co-occurrence within the same households may happen through several mechanisms. IPV may create a hostile home environment, increasing stress and conflict, lowering parental patience, and reducing parents' emotional availability and capacity to provide a safe environment, leading to frustration, harsher parenting practices, neglect, and a higher likelihood of children experiencing physical, emotional, or sexual violence (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, the overlap between witnessing IPVAW and experiencing VAC may be compounded by other risk factors such as poverty, lower parental education level, poor relationship with parents, and alcohol or drug abuse, which our study did not account for (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSimilar to studies from non-humanitarian settings (\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), witnessing IPVAW was associated with the endorsement of norms justifying IPV against women. This relationship was strong among male participants. Published literature shows that repeated exposure to IPV between parents or caregivers is a risk factor for normalization of violence, which in turn may lead to perpetration of IPV in adulthood (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). When witnessing IPVAW becomes a routine part of an individual's experience, it can desensitize them to violence and lead them to accept it as a normal aspect of relationships. Such normalization can lead to the endorsement of norms that justify violence, including IPVAW, as the behavior becomes ingrained as a standard or expected part of relationships. This is common in patriarchal societies where men tend to have great dominance over women in terms of power, social value, entitlement, and roles (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eStrength and limitations\u003c/h3\u003e\n\u003cp\u003ewe used a robust, representative dataset from children and youth aged 13\u0026ndash;24 years across all 13 refugee settlements in Uganda, providing unique insights on the co-occurrence of witnessing IPVAW and experiencing VAC in the hands of a parent or caregiver. Our study has some limitations. The cross-sectional design allowed us to explore associations between witnessing IPVAW and experiencing VAC, and endorsement of IPVAW, but not to establish causality between these variables. Additionally, the study relied on retrospective reports on witnessing IPVAW and experiencing VAC, which may be affected by recall bias, social desirability bias, and stigma around disclosing violence experienced and witnessed in childhood. Although our results indicate a significant association between witnessing IPVAW and experiencing VAC in Uganda refugee settlement settings, further research is needed to explore health consequences and risk factors for co-occurrence of IPVAW and VAC within the same households. In a related study, we established that experiencing sexual, physical, or emotional VAC was associated with poor mental health (severe mental distress, suicidal ideation and/or attempted suicide and self-harm) in Uganda refugee settlements (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Thus, children exposed to both IPVAW and VAC may experience higher risk of poor mental health outcomes.\u003c/p\u003e"},{"header":"Conclusion and implications","content":"\u003cp\u003eCoupled with the endorsement of IPVAW, the co-occurrence of IPVAW and caregiver-perpetrated VAC is common among children and young people in refugee settlements in Uganda. These experiences may lead to both short- and long-term health consequences, including mental health issues (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), and affect the well-being of children in the study settings. The findings have implications for practice, policy, and research. Notably, programming to address IPVAW and VAC in humanitarian settings is coordinated by different sub-sectors, GBV, and child protection, respectively. Our findings underscore the need for these sectors to create synergies and leverage programming around intersecting IPVAW-VAC risk factors in households within refugee settlements.\u003c/p\u003e \u003cp\u003eThe high prevalence of the co-occurrence of IPVAW and VAC perpetrated by caregivers in the study setting underscores the need for effective screening for both exposure to IPVAW and VAC among children and adolescents. Routine screening for violence have been shown to promote the detection of child survivors and their uptake of relevant services (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Current screening tools need to be expanded to ensure that they are responsive to the reality of IPVAW-VAC co-occurrence. Additionally, the screening should go beyond focusing on children alone. Effective prevention and response programs are also needed for women who are experiencing IPVAW. There is also need for more emphasis on promoting positive parenting norms, transforming harmful social norms around child-rearing, and providing parent and caregiver support through information and skill-building sessions to foster nurturing non-violent parenting.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eViolence Against Children\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHVACS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHumanitarians Violence Against Children Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLower-and Middle-Income Countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntimate Partner Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPVAW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntimate Partner Violence Against Women\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGBV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGender-Based Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNHCR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations High Commissioner for Refugees\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOPM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOffice of the Prime Minister\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclarations Ethics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Population Council IRB (Protocol 986), as well as from the local review board, Mildmay Uganda Research and Ethics Committee (MUREC) \u0026ndash; REC REF 0310-2021. All participants provided verbal informed consent to participate in the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available in the Population Council repository. https://dataverse.harvard.edu/dataverse/popcouncil.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Foreign, Commonwealth and Development Office (FCDO) through the Baobab Research Program Consortium (RPC) (PO8912).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGO, FO, SM, and CU conceptualized the study. GO analyzed the data and wrote the first draft. FO, SM, GS, PK, YW, CK, DY, YB, BW and CU reviewed the manuscript for substantial intellectual content.\u0026nbsp;All authors contributed to substantive revisions of the manuscript and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are deeply grateful to all the research participants who shared their time, and experiences with the research team. We also would like to thank the diligent and dedicated team of data collectors who made this work possible. We are grateful for the technical support provided by the US Centers for Disease Control and Prevention, Together for Girls Partnership, Office of the Prime Minister- Uganda, UNHCR-Uganda, UNHCR Regional Bureau for East and Horn of Africa and the Great Lakes Region, and UNHCR implementing partners and Baobab RPC\u0026rsquo;s Council Advisory Group (CAG) members during the design and implementation of the study. The opinions expressed in the paper are, however, solely those of the authors and do not necessarily reflect the views of the funding agency or partners that provided technical support to the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWH0. Global status report on violence prevention 2014. Geneve, Switzerland World Health Organization (WHO); 2014. Report No.: 9241564792.\u003c/li\u003e\n\u003cli\u003eHillis S, Mercy J, Amobi A, Kress H. 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The impact of exposure to domestic violence on children and young people: A review of the literature. Child abuse \u0026amp; neglect. 2008;32(8):797-810.\u003c/li\u003e\n\u003cli\u003eChiesa AE, Kallechey L, Harlaar N, Ford CR, Garrido EF, Betts WR, et al. Intimate partner violence victimization and parenting: A systematic review. Child abuse \u0026amp; neglect. 2018;80:285-300.\u003c/li\u003e\n\u003cli\u003eForan HM, O\u0026apos;Leary KD. Alcohol and intimate partner violence: A meta-analytic review. Clinical psychology review. 2008;28(7):1222-34.\u003c/li\u003e\n\u003cli\u003eMbilinyi LF, Logan-Greene PB, Neighbors C, Walker DD, Roffman RA, Zegree J. exposure to domestic violence and childhood emotional abuse: Childhood Domestic Violence Exposure among a Community Sample of Adult Perpetrators: What Mediates the Connection? Journal of aggression, maltreatment \u0026amp; trauma. 2012;21(2):171.\u003c/li\u003e\n\u003cli\u003eSikweyiya Y, Addo-Lartey AA, Alangea DO, Dako-Gyeke P, Chirwa ED, Coker-Appiah D, et al. Patriarchy and gender-inequitable attitudes as drivers of intimate partner violence against women in the central region of Ghana. BMC public health. 2020;20:1-11.\u003c/li\u003e\n\u003cli\u003eKisaakye P, Seruwagi G, Odwe G, Obare F, Muthuri S, Kabiru CW, et al. Associations between childhood violence and mental health in refugee settings in Uganda. Child Protection and Practice. 2024;2:100038.\u003c/li\u003e\n\u003cli\u003eUndie CC, Mak\u0026apos;anyengo M. If we ask, will they tell?(and then, what?): screening for sexual violence against children in Kenya. Child abuse review. 2022;31(1):11-26.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intimate Partner Violence, Violence against children, Co-occurrence, Caregivers, Humanitarian settings","lastPublishedDoi":"10.21203/rs.3.rs-5117966/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5117966/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIntimate partner violence against women (IPVAW) and violence against children (VAC) frequently co-occur within the same households. However, little is known about the co-occurrence of witnessing IPVAW and experiencing VAC in humanitarian settings. We examined the prevalence of witnessing IPVAW, and its association with a) experiencing physical and emotional VAC perpetrated by a caregiver; b) experiencing sexual violence by any perpetrator; and c) the endorsement of norms justifying IPVAW among children and young people aged 13-24 years in Uganda refugee settlements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe analyzed data from the first-ever Ugandan Humanitarian Violence against Children and Youth Survey (HVACS) conducted from March to April 2022, involving 1,338 females and 927 males aged 13-24 years. Analyses used cross-tabulation with a chi-square test and estimation of a multivariate logistic regression model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe prevalence of witnessing IPVAW was higher among males (30.5%) than females (19.0%). For both females and males, witnessing IPVAW was associated with an increased likelihood of reporting experiencing physical (Females: adjusted odds ratio (AOR) 4.1; 95% confidence interval (CI): 2.6-6.2 vs Males: AOR 4.1, 95% CI: 1.9-8.2), and emotional VAC perpetrated by a caregiver (Females: AOR 2.8, 95% CI: 1.8-4.4 vs Males: AOR 2.6, 95% CI: 1.3-5.2) compared to those who did not witness IPVAW. Unlike females, witnessing IPVAW among males significantly increased the odds of experiencing sexual violence by any perpetrator for males (AOR= 3.1; 95% CI=2.1-4.7), and endorsing norms justify IPVAW (AOR= 2.9; 95% CI=1.4-5.9) compared to those who never witnessed IPVAW.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eCoupled with the endorsement of IPVAW, the co-occurrence of IPVAW and caregiver-perpetrated VAC is common among children and young people in refugee settlements in Uganda. These findings underscore the need to synergize gender-based violence and child protection sectors and develop prevention and response programming around intersecting IPVAW and VAC risk factors within homes in refugee settlements and similar settings.\u003c/p\u003e","manuscriptTitle":"Co-occurrence of Witnessing Intimate Partner Violence against Women and Experiencing Violence in Childhood in Refugee Settlements in Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-23 16:42:26","doi":"10.21203/rs.3.rs-5117966/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-04T17:05:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-02T22:49:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-30T19:25:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40585325852662276426056265849821912272","date":"2024-10-12T22:12:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143515721640462236906850888262547898062","date":"2024-10-09T05:19:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-07T02:54:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-20T03:56:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-20T03:54:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Conflict and Health","date":"2024-09-19T15:03:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"24ea98d0-57d1-43f0-85e6-089c76281c10","owner":[],"postedDate":"December 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-21T16:02:34+00:00","versionOfRecord":{"articleIdentity":"rs-5117966","link":"https://doi.org/10.1186/s13031-025-00661-5","journal":{"identity":"conflict-and-health","isVorOnly":false,"title":"Conflict and Health"},"publishedOn":"2025-04-17 15:58:02","publishedOnDateReadable":"April 17th, 2025"},"versionCreatedAt":"2024-12-23 16:42:26","video":"","vorDoi":"10.1186/s13031-025-00661-5","vorDoiUrl":"https://doi.org/10.1186/s13031-025-00661-5","workflowStages":[]},"version":"v1","identity":"rs-5117966","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5117966","identity":"rs-5117966","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}