Background: Gender based violence (GBV) remains one of the most serious threats to the health and safety of women and girls worldwide. The problem is even more pronounced in refugee populations where women and girls are at increased risk of violence. In 2015, UNHCR reported the highest number of forcibly displaced people in recorded history. Despite growing need, there have been few rigorous evaluations of interventions aimed at primary GBV prevention and no systematic reviews of GBV prevention efforts specifically focused on refugee populations; reviews to date have primarily examined prevention of conflict related sexual violence, with very limited focus on other forms of GBV such as intimate partner violence

Methods: This study reviewed the scientific literature addressing strategies for primary prevention of GBV and their effectiveness among refugee populations over the past ten years (2006 to 2015). Narrative content analysis methods were used to extract findings related to prevention activities/programs recommended by the global humanitarian community, such as sociocultural norms change, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, and/or engaging men and boys in GBV prevention and response.

Results: Study findings indicate that a range of GBV prevention activities recommended by the global humanitarian community are currently being applied in a variety of settings. However, there remains a limited body of evidence on the effectiveness of GBV prevention programs, interventions, and strategies, especially among refugee populations.

Conclusion: Commonly agreed upon standards or guidelines for evaluation of GBV prevention programming, and publication of evaluations conducted using these guidelines, could assist humanitarian stakeholders to build and disseminate an evidence base of effective GBV prevention interventions, programs and strategies. Evaluation of GBV prevention efforts, especially among refugee populations, must be given higher priority to justify continuation or revision of recommended GBV activities/programs being implemented in diverse humanitarian settings.

Importance: Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain.

Objective: Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies.

Data Source: We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources.

Study Selection: Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected.

Data Extraction: Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2.

Main Outcomes: The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings.

Results: The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias.

Conclusions: The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.