Post-Resettlement Attitudes and Behaviors Toward Domestic Violence: A Scoping Review

1. Introduction

The basic foundations of domestic violence (DV) have emanated from a variety of fields, including psychology (e.g., frustration-aggression theory, cognitive-behavioral theory), biobehavioral sciences (e.g., individualist theories), criminology, sociology, public health, and others (Larsen 2016; Astbury et al. 2013). DV includes different forms, based on the United Nations definition "physical, sexual, emotional, economic or psychological actions or threats of actions that frighten, intimate, terrorize, manipulate, hurt, humiliate, blame, injure, or wound someone" (United Nations 2023), and impacts survivors' reproductive, sexual, and psychological health and well-being (World Health Organization 2015). DV can occur in any domestic relationship; however, Intimate Partner Violence (IVP) happens between two partners in an intimate relationship. For our study, we follow with many others and use DV and intimate partner violence (IPV) interchangeably, referring to the abuse between partners. DV can occur among all genders and across the lifespan; however, it disproportionately impacts women, especially pregnant women, mothers with young children, and ethnical minorities (Astbury et al. 2013). In the most recent report by the United Nations, about one in three women worldwide experienced types of intimate physical or sexual abuse during their life span (Organization 2021). Women from countries representing diverse cultural settings reported a high rate of partner-related violence and a low rate of using supportive services (World Health Organization 2005).

Although several studies reported higher rates of DV among minority communities, to our knowledge, there are not enough strong data indicating higher DV rates among refugees compared to the general population. Most existing articles emphasized the severity of DV due to the lower rate of help-seeking among refugees and several exacerbating factors for refugee and immigrant women (Gonçalves and Matos 2016; Menjivar and Salcido 2002). This study aims to examine Afghan and Arab refugee women's attitudes and help-seeking in the case of DV and explore the existing research, practice, and policy recommendations presented by the available literature.

1.1. Afghan and Aran Refugee Women

Middle East countries are among the largest countries of origin for newcomers in the US, including refugees from Afghanistan, Iraq, and Syria (Batalova 2023). Since the collapse of the Afghan democratic government in August 2021, more than 1.6 million Afghans have fled the country because of conflict, violence, and poverty ("Afghanistan Refugee Crisis Explained," 2023). More than 97,000 have come to the United States (Batalova 2023; "At a Memorandum of Understanding Signing Ceremony with the #AfghanEvac Coalition - United States Department of State" 2023). Along with this major refugee crisis from Afghanistan, over 6.8 million refugees have also been displaced from the Syrian Arab Republic alone ("UNHCR - Refugee Statistics" 2023), and 3.7 Arab Americans now call the US home ("Demographics — Arab American Institute" 2023), many of them refugees (Batalova 2023). This study gives special consideration to these communities because of this extraordinary magnitude of displacement. We used the term refugee for all individuals forced to leave their homes and resettle in Western countries due to war and conflicts, including refugees, Special Immigrant Visa holders (SIVs), and parolees. The Afghan and Arab communities, despite their distinct cultural backgrounds, share overarching similarities that warrant our focus in the context of domestic violence research and support. Both communities have been deeply affected by conflict, uncertainty, and the destruction of social and community support systems, creating an environment conducive to DV (Rubin 2002; "Refugee Crises in the Arab World - Carnegie Endowment for International Peace" 2023).

Afghanistan is a multi-ethnic and mostly tribal society comprising a wide range of ethnolinguistic groups (Lamer 2011). Over the last forty years, Afghanistan has seen the rise and fall of various governments and has been victim to a long history of domination by foreign conquerors such as the Soviet Union and the US-led invasion of Afghanistan starting in 2001 (Rubin 2002). Decades of war and foreign intervention have disrupted family structures and exacerbated the risk of intimate partner violence (IPV) in Afghanistan (World Health Organization 2005; Rubin 2002; "UNHCR - Refugee Statistics" 2023; Gracia 2004; Fernández-Fontelo et al. 2019). According to the World Health Organization (WHO), at least 17% of Afghan women have experienced sexual violence, and 52% reported experiencing physical violence (World Health Organization 2015). Though these rates are alarming, it is also known that instances of domestic violence are vastly underreported, meaning this number is likely even higher (Lins and Carvalho 2016).

Similarly, the Arab World is also a territorially characterized region including about 350 million people with diverse ethnical backgrounds who live in what are now recognized as 22 Arab countries or states ("UNDP Annual Report 2014 | United Nations Development Programme" 2023; Mojahed et al. 2022). The Arab Region has experienced tremendous war and political and social upheaval in recent years ("Refugee Crises in the Arab World - Carnegie Endowment for International Peace," 2023). Data indicated that at the end of 2022, the Middle East and North Africa (MENA) hosted 2.4 million refugees and 12.6 million internally displaced people ("Middle East and North Africa," 2023). MENA has experienced significant political and social upheaval, resulting in health and safety concerns for women ("Refugee Crises in the Arab World - Carnegie Endowment for International Peace" 2023; "Middle East and North Africa" 2023; "UNHCR - Refugee Statistics" 2023; "). A 2019 systematic review on the prevalence of intimate partner violence in Arab countries reported that the actual rate of DV and intimate partner violence (IPV) against women in the Arab world could be much higher than the UN general estimates of 37% and as high as 6-59% for physical violence, 3-40% for sexual violence, and 5-91% for emotional or psychological violence ("Facts and Figures: Ending Violence against Women and Girls" 2023; Elghossain et al. 2019; Moshtagh et al. 2023).

Beyond the pre-resettlement challenges, both communities also face post-resettlement barriers, including language barriers, cultural norms, and economic constraints, which impact their ability to seek help and escape DV situations ("Power and Control Tactics Used against Immigrant Women," 2023; Fariyal Ross-Sheriff 2013). Additionally, the societal importance of preserving family honor and reputation, as well as the expectation for women to modify their behavior to prevent abuse, are common threads in both communities (Moshtagh et al., 2023; Shannon, O'Dougherty, and Mehta 2012; Usta, Farver, and Pashayan 2007, Barakat 1993). Educational disparities also play a role, with higher levels of education often associated with reduced acceptance of DV ("Afghanistan Multiple Indicator Cluster Survey (MICS), 2022-2023 | UNICEF Afghanistan" 2023). Conflict and uncertainty, as seen in Afghanistan and the Arab Middle East region, the destruction of social and community supports, trauma, and poverty can also perpetuate existing and facilitate new instances of domestic violence (Gibbs et al. 2020).

These shared circumstances emphasize the need to better understand refugee women's responses and decision-making processes to DV in the new environment and provide more effective support within refugee communities (Gibbs et al. 2020). Recognizing these similarities is crucial for developing research, interventions, and policies that can empower Afghan and Arab refugee women in responding to various forms of DV and ultimately foster more supportive and safer environments (Astbury et al. 2013; Gonçalves and Matos 2016; Menjivar and Salcido 2002; Meguid and Bakry 2006).

1.2. Refugee Women’s Approach Toward Domestic Violence

In addition to coming from countries and communities with uncertainty and instability, the overwhelming day-to-day life and responsibilities after resettlement and a lack of financial security can increase the conflict in the family environment and impact refugee women's degree of experiencing abuse within the relationship (Fariyal Ross-Sheriff 2013).

Several factors can impact survivors of DV's action-taking and decision-making toward DV. Financial instability has been reported as a factor that impacts response to DV, especially for women who face challenges finding employment ("How Domestic Violence Impacts Women's Economic Participation & Family Well-Being in Refugee Resettlement, 2017" 2017). Individual level of education also has been reported to have an association with women's perspectives of DV and help-seeking approach (Coker et al. 2000). In Afghanistan, a study conducted in both urban and rural communities reported that 81% of women with no educational background justified DV in the case that women leaving home without informing their partner. However, amongst women with their secondary education completed, only 60% agreed on the same justification ("Afghanistan Multiple Indicator Cluster Survey (MICS), 2022-2023 | UNICEF Afghanistan" 2023). Although the acceptance of IPV among women in Afghanistan decreased with higher education and higher economic standing, a 60% acceptance of DV among the most educated Afghan society could indicate that other factors outside of education may contribute to women's acceptance of violence, which could include factors like tribalism and institutional influences that could shape the perception and attitudes toward DV among women in Afghanistan (Mannell et al. 2021).

1.3. Impact of Religion and Cultural Norms on Gender Roles, Domestic Violence and Divorce

Understanding how Muslim marriages fail and the response of religious and sociocultural norms to domestic violence and divorce is important for informing interventions for Arab and Afghan refugee families; unfortunately, perspectives relying mostly on hegemonic Western research framing and findings may be of limited use (Esmaeili and Schoebi 2017). While the Middle East is composed of various countries, most of these countries are labeled as Muslim-majority and practice Islamic laws. However, the challenges to addressing DV within communities originating from these countries are rooted in the diversity of ethnicity and religion. The religious compositions dominant in the Middle East include major Abrahamic religions (Islam, Christianity, and Judaism), several minorities, and individuals not affiliated with any religion (“Which Religions Are Practiced In The Middle East?” 2019). The multitude of religions makes it nearly impossible to generalize the impacts of religion and culture on DV; however, it is evident that faith directs family values (Dollahite, Marks, and Dalton 2018).

In Islam, the family forms the basic building block of society, and despite the many pressures of life in the Western environment on Muslims, the family institution remains strong (Dhami and Sheikh 2000). The Arab traditional family remains a vital cultural force through which individuals and communities are taught their cultural values (Barakat 1993; Haj-Yahia 2000). In Arab societies, the family is the central social security system for the young and the old; parents take care of their children well into their adult lives, and children responsibly must care for their aged parents. Consequently, and unlike in Western host societies, the marriage of Arab refugees is not an individual but a major family matter, a social and financial contract between two families. Since such two families may be composed of 40-50 or even more members, no disgruntled spouse, no matter how aggrieved, can make a divorce decision without the consent of all concerned parties (Al-Krenawi and Jackson 2014). Divorce is seen as a failure, an irresponsibility, and a deviation from religiously enshrined cultural norms (Al Kazi 2008). In the Islamic ruling, however, if the spouses seek divorce, the Quran encourages first on meditation rather than rushing to divorce; meanwhile, it permits divorce and encourages the men to act in a great manner (Surah Al-Baqarah, Qur'an 2:228-229; Quranic 2021; “Ayah Al-Baqarah (The Cow) 2:229” 2023). Whether leaving the marriage or remaining, Muslim women may have to contend with judgment about how they respond to DV without risking family destruction or community exclusion, as the community and the spouses often misuse the religon texts to convince women that gender-power norms, including abuse is an accepted part of their Muslim faith (Abugideiri 2010).

In the discussion on how the dissonance between Western and Arab perspectives on marriage, domestic violence, and divorce play out in Arab refugee families in the United States, here is where individualistic (Western, Global North, USA) and collectivistic (Global South, Arab) cultures seem to collide (Oyserman 2017) And yet, divorce rates have been increasing in the past two decade not only in the West but also in the Arab Region. For example, between 1996 and 2017 Egypt has seen an 83% increase in divorce rates (Reda 2019). This rise has been attributed to a 2000 law change that grants women a no-fault divorce if they renounce their right to entitled financial benefits (Samaha N 2016). Theoretically, many employed women may afford to do that. Globalization, higher education, and increased female employment in the Middle East and North Africa (MENA) might have reduced the primacy of gender role expectations (Cohen and Finzi-Dottan 2012). Research findings in MENA point out that the participation of Muslim women in local economies is modulated more by the need for female labor rather than by religious and cultural framing of gender roles (Karshenas and Moghadam, 2001; World Bank Report, 2004, World Bank Report 2014). However, religiously sanctioned gender roles remain powerful determinants of social life that tend to change extremely slowly (Perales and Bouma 2019). Despite the rising rates of female employment and divorce in the MENA, a marital breakup comes at a prohibitive cost for women. Divorce continues to be stigmatized (Frisby et al 2012) and women must suffer post-divorce disapproval and blame from their families and communities. Thus, many employed and self-reliant Arab women choose to endure DV and stay in the marriage in order to avoid social humiliation, discrimination, and exclusion.

Afghanistan, or more officially the Islamic Emirate of Afghanistan, is a non-Arab Muslim country which has been violently aggressed for over a century by the United Kingdom, Soviet Union, and the United States. Distrustful of purported Western liberal values seen as a disguise for global conquest and exploitation, the country is ruled by an Islamic government strictly adhering to the Sunni Hanafi school. This directly impacts women's ability to dress, attend school, and practice religion (“Taking a Terrible Toll: The Taliban’s Education Ban” 2023), affecting their family life as well. The impact of the government on education can be seen through women’s attitudes toward domestic violence. Educated Afghan women were 15% less likely to accept domestic violence from their partners when compared with those who received no formal education (“Most Women in Afghanistan Justify Domestic Violence” 2023). Despite the reported high percentage of acceptance of domestic abuse among Afghan women, it is important to consider that the highly traditional practices and legal approaches to domestic abuse are all factors that limit Afghan women in their ability to be vocal about their true beliefs and attitudes toward domestic violence (Afrouz et al 2021). This multi-ethnic country (Ministry of Justice of Afghanistan, 2003) allows for various religious interpretations and cultures. A highly patriarchal and problematic legal system can affect the likelihood of women seeking help for IPV, especially across the different ethnic groups living in Afghanistan (ethnic Tajiks had significantly greater odds of reporting help-seeking behavior for IPV than ethnic Pashtuns) (Metheny and Stephenson 2018).

Finally, the role of religion and culture in Afghan and Arab communities is intertwined with many traditional values, given that culture and religion are passed through family stories. Earlier generations would maintain these values in the grandparents' home, resulting in constant family gatherings and teachings. How these stories are passed on in refugee families ultimately depends on the religious level and the family structure. This scoping review intended to explore whether post-resettlement acculturation to Western values might reduce the sociocultural and religious opprobrium on divorce to permit a change in attitudes and behaviors towards domestic violence in Arab and Afghan refugees.

1.4. Impact of Family Structure

The overlapping similarity between these two communities, Arab and Afghan, lies in the societal importance of protecting the face and reputation of the men and families. According to Barakat (1993), in Arab society, families remain tightly knit- spouses do not have much privacy or independence. Families also strongly influence ideas like marriage and divorce (Barakat 1993); immediate and often trusted distant relatives are involved in marital disputes, and together, the families will consult and attempt to find a solution. Traditionally, this solution will focus on the holiness of family values, continuity, and the family's reputation. Even if both partners are dissatisfied in their marriage, or if one is suffering at the hands of the other, maintaining family integrity has tremendous cultural and societal importance (Kulwicki et al 2010; Balice et al 2019).

Furthermore, women are often expected to alter their actions to help prevent any conflict or family dispute. A cross-sectional exploratory study conducted with a sample of 260 participants from Jordan, including 110 male (42.5%) participants and 149 female (57.5%), revealed the tendency for Jordanian society to expect the abused wife to change behavior and assume responsibility in instances of abuse and a reliance on informal agents in instances of repeated abuse such as community or religious figures, their family and other means (Btoush and Haj-Yahia 2008). The fear of possible grave consequences from perceived disloyalty to the victims' families or spouses and the lack of personal resources to leave or change the situation could lead to entrapment and isolation for refugee women (Usta, Farver, and Pashayan 2007). This family and community condoning of domestic violence creates firm societal and community expectations to keep instances of domestic violence private and within the family, finding the solution withinside rather than airing family issues to the larger community. Traditionally, this solution will focus on the holiness of family values, continuity, and the family's reputation. Even if both partners are dissatisfied in their marriage, maintaining family integrity has tremendous cultural and societal importance; as Watson (1995) phrases it, "better an enduring marriage than a family divided and weakened by divorce" (p. 39). Regardless of changes in the contemporary family due to urbanization, the traditional family as a collective force remains a vital cultural force through which individuals and communities are taught their cultural values (Barakat 1993; Haj-Yahia 2000).

In the end, despite leaving their home countries, refugee women often face increased rates of domestic violence, furthered by post-resettlement environments, family structure, educational attainment disparities, and religious and cultural norms. After resettlement in a new country, women's education levels and ability to acclimate to the new environment. Both individually and as a community can also greatly influence their perception of marital violence and help-seeking behaviors. (Meguid and Bakry 2006). Understanding how these populations experience barriers to moving forward with community solutions, legislature, and healthcare interventions is important. This scoping review aims to understand better the impact of culture on Afghan and Arab refugee women's attitudes, help-seeking, and decision-making regarding domestic violence and to create a path for future research, strategies for interventions, and policies to support women from refugee communities in their response to DV.

2. Methods

This review aims to map the 1980-2022 literature on the attitudes and/or behaviors of Afghan and Arab Refugee women resettled in Western countries towards domestic violence (DV) and action-taking in the case of DV. Due to the probing nature of this review, a scoping review was designed to explore the breadth of literature available and to provide methodological flexibility to address the broad nature of our research question and study criteria. Our scoping review follows the enhanced Arksey and O'Malley approach and uses the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Extension for Scoping Review Guidelines, and the PRISMA-ScR Checklist and Guidelines (Moher et al. 2009).

2.1. Methodological Framework

Arksey and O'Malley (Arksey and O'Malley 2005) describe four reasons for performing a scoping review. Our review complies with the first, third, and fourth reasons: (1) to examine the extent, range, and nature of available research on a topic or question; (3) to summarize and disseminate research findings across a body of research evidence, and (4) to identify gaps in the literature to aid planning and commissioning of future research. We opted for an enhanced scoping review model that integrates qualitative and quantitative literature assessment and employs an interprofessional team-based approach through all stages of the scoping review (Westphaln et al. 2021).

2.1.1 Arksey and O'Malley Framework: Stage 1 - Identify the Review Question

We first conceptualized our research question based on a rapid but broad literature review in five successive "blast searches." Finding out that Afghan and Arab refugee DV studies are carried out across various disciplines and professions prompted us to choose a transdisciplinary, interprofessional, team-based approach. A wide range of roles, expertise, skills, and professional contexts are embodied within the eight members of our team, which included a public health doctoral student with experience in DV and sexual health (AG), a medical doctor, and public health professional with expertise in Afghan refugee women's health and DV (ZG), an Arab-American data scientist in healthcare and medicine (ZC), a psychiatric epidemiologist trained in cultural anthropology and with expertise in Arab refugee trauma and DV (PMK), a public health specialist (YPA), and three UC Davis students (2 Afghan-American and 1 Iranian-American) with substantial work experience at student-run refugee clinics (LA, RH, and SAMA). After training for two months in scoping and systematic reviews, PRISMA, and Covidence, our team had bi-weekly review meetings communicating across different disciplines for twelve months.

We identified our review question: Does the literature on Afghan and Arab refugees identify post-resettlement gendered acculturative changes in attitudes and behaviors towards domestic violence? We defined refugees as married Afghan and Arab females and males aged 18 years or more resettled in developed Western host countries (USA, Canada, EU, Australia, New Zealand).

2.1.2. Arksey and O'Malley Framework: Stage 2- Identify Relevant Literature

For this scoping review, we searched the following databases: SCOPUS, PubMed, PsychInfo, CINAHL, Web of Science, the Directory of Open Access Journals, and Embase. The Principal Investigator of the project led the construction of the search strategy. Five initial blast searches were performed to probe search terms and refine the research question and inclusion and exclusion criteria.

The following search terms were chosen: Afghan Refugees / Afghan Women / Refugees from Afghanistan / Afghanistan Refugees / Arab Refugees / Arab Women / Refugees from Arab countries / Iraq/ Syria/ Yemen/ Libya/ Sudan/ Somalia/ Refugees / Arab domestic violence / intimate partner violence / DV / IPV / domestic abuse / gender-based violence / domestic violence / gendered violence / spousal abuse/partner abuse / gendered acculturation / developed countries / America / USA / US / Europe / European Union / EU / Canada / New Zealand / Australia. The subsequent searches yielded 724 articles. Article titles and abstracts were imported into an Endnote library and uploaded into Covidence ("Covidence - Better Systematic Review Management" 2023), a review management software. Covidence removed 285 duplicates, leaving 439 studies to be screened based on inclusion and exclusion criteria.

2.1.3. Arksey and O'Malley Framework: Stage 3- Selecting Studies

Inclusion and Exclusion Criteria:

Articles were assessed for eligibility based on the inclusion and exclusion criteria (Table 1). The study selection process was reported using a PRISMA flow diagram.

2.2. Figures, Tables and Schemes

All figures and tables should be cited in the main text as Figure 1, Table 1, etc.

Firstly, the researchers of sub-team 1 (RH, SMA) independently reviewed the unique 439 articles, screening by title and abstract to determine records that qualify for inclusion in the full-text review. Researcher PMK was assigned as the arbiter for any conflicting decisions. Secondly, after excluding 384 articles, 54 were selected for full-text eligibility by sub-team 2 (PMK, ZG), and 20 were excluded. Researcher AG was assigned as the arbiter for any conflicting decisions.

Interrater Reliability:

Expressed as the Cohen's Kappa correlation coefficient, this term represents reviewer agreement. We included an assessment of the interrater reliability to verify the process validity and reliability of our scoping review. Inter-reviewer reliability (Cohen's Kappa) of the screening phase by title and abstract: A member of sub-team 1 (RH) screened each article and then compared this to the findings from the other member of sub-team 1 (SMA)—Cohen kappa value: 0.85. After full-text analysis and hand-searching of the remaining 34 articles, a total of 17 articles were identified for inclusion in the scoping review. The first co-author (ZG) and senior investigator (PMK) conducted the full-text review and data extraction due to these authors' disciplinary, research, and clinical expertise. The last and corresponding author (AG) served as arbiter.

2.1.4. Arksey and O'Malley Framework: Stage 4- Extracting, Mapping, and Charting the Data

First, we determined the variables of interest for data extraction per our review question by discussing the variable candidates with all team members. Then, we pooled the preliminary results to produce a cross-disciplinary analytical framework for data charting.

Our included articles were charted in Microsoft Excel for Mac 2021 version 16, using the following eight subheadings: 1) "Author's Information" (full APA citation); 2) "Sample Information: (Country of origin, Sample size, Location, Gender [M&F], Class [level of education, socioeconomic status/SES], Generation [Age range], and "Research Design"; 3) "Aim of the Study"; 4) "Focus Area"; 5) "Refugee personal pos-resettlement attitudes towards DV"; 6) "Refugee personal post-resettlement behaviors towards DV"; 7) "Refugee community attitudes and/or behaviors towards DV"; and 8) "Research, practice, and/or policy recommendations." Table 2 displays the charted data, except for the limitations. Data in each of the columns were extracted by three authors independently and compared to ensure rigor and consistency.

2.1.5. Arksey and O'Malley Framework: Stage 5- Collating, Summarizing, and Reporting the Data

The main challenge of Arksey and O'Malley Framework's stage 5 is that it lacks clear guidance on accomplishing this. We followed the Levac et al. (2010) suggested three distinct steps for stage five: (5.1) conduct quantitative descriptive analysis and qualitative thematic analysis, (5.2) report the results within the context of the research question(s) and purpose, and (5.3) interpret the findings within the context of future research, practice, and policy. These customizations emphasize the benefit of integrating a mixed method framework into the scoping review methodology. (Levac, Colquhoun, and O'Brien 2010). Importantly, these steps allow us to (1) develop a framework or template to summarize and analyze the results, (2) analyze the data: quantitative and/or qualitative analysis and thematic analysis, (3) relate the results to the research question and/or purpose, (4) present findings within the context of future research, policy, and practice, (5) provide additional level of depth to the data from the inter-disciplinary expertise of our team, and (6) prioritize findings to emphasize implications for future research.

Finally, we used thematic analysis to identify patterns in meaning through our data set. Through triangulation meetings, we discussed, across our disciplines, possible meanings and interpretations generating new insights from data. We utilized a shared thematic analysis table to ensure all themes, subthemes, and quoted text were captured for utilization.

3. Results

During the identification stage of the review, 724 articles were identified. After removing 285 duplicates through Covidence, 439 remained for screening. After screening based on title and abstract, 384 articles were removed, leaving 54 to be screened and assessed for full-text eligibility. After excluding 27 articles for reasons such as wrong study design, population, setting, and indicator, we identified seventeen studies from the literature review (Figure 1).

A summary of the included articles is included in Table 2. Eleven studies were qualitative, two were quantitative, and four were literature reviews. Studies included refugees from Afghanistan, Iraq, Syria, Libya, Palestine, Pakistan, Egypt, Morocco, and other countries. Some studies (n=3) included mixed-gender samples, but most focused only on women (n=10), excluding literature reviews. Overall, studies aimed to explore refugee (and immigrant) women's understanding, attitudes, experiences, and perceptions of domestic violence (DV) or intimate partner violence (IPV). Articles also explored the barriers facing refugee women's help-seeking behaviors for DV and IPV. Several articles assessed community interventions and resources for women, and some delved into the DV-related needs of refugee women who have settled in host countries. Most studies focused on either DV or IPV, and most had a secondary focus on evaluating perspectives, experiences, behaviors, or barriers of women in refugee populations.

3.1. Thematic Analysis

Three main categories were identified for a thematic analysis: refugee women's attitudes toward DV, refugee women's help-seeking behaviors in case of domestic violence , and stakeholders' attitudes and/or behaviors towards DV.

3.1.1. Refugee Women’s Attitudes Toward Domestic Violence

Among the studies that focused on domestic violence among Afghan and Arab refugee women, different perspectives and awareness about DV were reported. Afrouz et al. reported that Afghan women have different levels of understanding and define DV differently. Women without sound knowledge of DV might perceive violence as normal (Afrouz, Crisp, and Taket 2021b). Abdel Meguid, M. B. and colleagues also reported a wide range of responses on the definition of abusive words and abusive actions; as an example, women agreed that "men making fun of their wives in front of others or calling them names" are examples of emotional abuse, and most agreed that physical abuse is not acceptable; however actions like "forced intercourse or refusing to have sex with the wife if she is not obedient" were reported as less abusive (Meguid and Bakry 2006). Wachter K. et al. reported that women believed DV had several impacts on their physical and mental well-being, and some felt worthlessness and failure as women and wives (Wachter, Dalpe, and Heffron 2019). Women's internalized patriarchal values impact their views on marital relationships and DV. This leads to women accepting DV and the shame of seeking help when abused. Some of the examined articles emphasized the impact of the new environment on the refugee women's attitude toward DV; for example, Afrouz and colleagues reported that resettlement in a new environment impacts women's perspectives on DV, viewing DV as abnormal and unacceptable (Afrouz, Crisp, and Taket 2021a). In another study, change in women's attitudes was reported to depend on their education level, English proficiency, personal experience of DV, years of living in the host country, connecting with the host society, and pursuing education in the new home (Afrouz, Crisp, and Taket 2021b). Tlapek, S. M. and colleagues also reported that refugee women in the host countries encounter new gender roles that can increase daily relational confrontations; refugee women may stand up to their partners, ask for shared decision-making, and no longer tolerate inadequate pre-resettlement gender norms (Tlapek, Monk, and White 2020).

3.1.2. Refugee Women’s Help-Seeking Behaviors in Case of Domestic Violence

Most studies we examined highlighted that although refugee women acknowledged the acts of DV, their help-seeking approach and action-taking may vary based on several individual, communal, and structural factors. Wachter et al. mentioned that women stay silent in the case of abuse to respect cultural norms (Wachter et al. 2021); for many women, family is the building block of society and should be preserved at all costs (Abu-Ras 2007). Women felt that their children and families were more important than themselves and that if they rejected DV, they would harm the family. Afrouz et al. reported that Afghan culture dictated that a good woman did not disclose marital problems to others and that those who did so deserved negative judgments (Afrouz, Crisp, and Taket 2023). The study by Kulwicki et al. on Arab Immigrants highlighted that the patriarchal and patrilineal culture may cause women to accept DV and avoid the shame of seeking help (Kulwicki et al. 2010). A similar study on Middle Eastern immigrants also reported that Arab American women have internalized patriarchal perspectives, impacting their value of marital relationships. The study by Salam. A. et al. on second-generation Arab American immigrants also highlighted that culture plays negative (shame, secrecy sacrifice) and positive roles (the foundation of family, marriage, virginity, etc.) in shaping women's perspectives about themselves and DV (Aboulhassan and Brumley 2019). They also mentioned that internalized beliefs on gender roles highly impact women's perspectives on DV.

Financial instability and challenges of supporting their children were also reported as determinants of women's decision-making and help-seeking. Afrouz et al. mentioned that seeking help post-resettlement through service providers may not be possible considering financial barriers, children, and language barriers (Afrouz, Crisp, and Taket 2023). Participants in the Wachter et al. reported a lack of knowledge about resources and a lack of ability to access resources are determinant factors; meanwhile, even if women know about the services, they will not take action due to language barrier and financial instability. Kulwicki et al. also reported a lack of awareness about the services and complicated access path to the resources as a barrier to women seeking help; women also reported a negative perspective toward Western community DV resources and counted them as disturbing family structures (Kulwicki et al. 2010). Immigration status and financial instability were also highlighted in the study by Salam et al. as a reason that women may not seek through service providers (Aboulhassan and Brumley 2019). Another study also emphasized that Survivors might prefer not to separate as they worry about how the community will treat them if they divorce and fear financial challenges (Wachter, Dalpe, and Heffron 2019). Afrouz et al. also discussed immigration status (visa status) and economic instability as the major barriers to women's action. They highlighted that "for women entering Australia on a spouse visa, visa restrictions could place them in a vulnerable situation in which they are subject to control by their husbands (Afrouz, Crisp, and Taket 2021b)."

3.1.3. Stakeholders’ Attitudes and/or Behaviors Toward Domestic Violence

In analyzing the role of stakeholders in women's action-taking toward DV, articles highlighted the role of several stakeholders, including the refugee community, service providers, healthcare providers, and law enforcement. Most studies highlight the role of community perspectives and support in how women take action. Afrouz et al. mentioned that knowledge and belief about DV are not enough to act when the community and partners have different perspectives and definitions, and when the greater community normalizes DV, women may not get the support and assistance they need (Afrouz, Crisp, and Taket 2021b). Watchter et al. mentioned that Women could go to the elder community member for support back in their country of origin which may not be the same post-resettlement (Wachter et al. 2021). In the new environment, women have less trust and take their marital challenges from the family. Most women do not share their DV or relationship challenges with providers, only with trusted family or friends (Tlapek, Monk, and White 2020). Abdel Meguid et al. also mentioned that women prefer family members as the first source of help-seeking, followed by friends and then the Imam, and last to get help from formal authorities and shelters. However, Kulwicki et al. mentioned that religious leaders in Western communities are not trained in DV and cannot provide appropriate support (Kulwicki et al. 2010). Kulwicki et al. also mentioned that although family is the only support system most women utilize, family and culture push women to return to abusive relationships (Kulwicki et al. 2010). Salam et al. also mentioned that the community may not encourage other women to support DV victims, and friends and families are advised not to destroy family structures (Aboulhassan and Brumley 2019). Among other stakeholders, Shalabi et al. mentioned that law enforcement may see DV in the Arab community as a cultural issue, avoid it, and not look at it as a post-resettlement problem (Shalabi, Mitchell, and Andersson 2015).

3.1.4. Recommendations for Future Work

Several studies recommended future steps in understanding and approaching to support refugee women in the case of DV. Afrouz et al. suggested expanding the community definition of DV to include various forms of abuse through long-term and consistent community education, and training should be delivered in collaboration with community members (Afrouz, Crisp, and Taket 2021b). Changes should include systemic level: religious leaders' approach to DV, community support for DV laws, and agencies' organizational approach to DV and improve the cultural diversity of available supportive services (Afrouz, Crisp, and Taket 2021a). Training should use spiritual and Islamic teaching to raise DV awareness and to stop violence against women (Abu-Ras 2007). Arab Muslim women's help-seeking process differs from Western women's and has specific characteristics. Providers of professional services should educate themselves about different backgrounds and cultural perspectives. Training Muslim social workers is also needed to increase workforce diversity (Meguid and Bakry 2006). Public service providers and religious and ethnic leaders should be aware of shifting gender roles and social status post-migration, increasing conflict between partners (Holtmann 2016). There is a need to increase knowledge of religious diversity for service providers. Women can be the best allies to support each other (Holtmann 2016). Also, healthcare providers and law enforcement need cultural competency training. Mental health providers and social workers should learn more about these communities' family structure, patriarchal values, and stigma about mental health and how these factors impact the normalization of DV and help-seeking behaviors (Balice et al. 2019).

4. Discussion

4.1. Key Points

In this study, we developed a deeper understanding of Afghan and Arab refugee women's perceptions and actions toward domestic violence and the community and providers' attitudes and roles toward supporting the survivors of domestic violence. We examined the complex interactions of gender relations, power dynamics, and cultural and structural factors in shaping women's help-seeking behaviors. The fear of community judgment highly impacts women decision of leaving the relationship or staying with the marriage, while dealing with ongoing threats, intimidation, degradation, and isolation. The findings highlight gendered acculturation's subtle yet significant impact on Afghan women's perspectives of domestic violence. While not overtly examined, the transformative influence of the new environment on refugee women's perspective regarding DV seemed prominent in the studies. Although most studies reported that women acknowledged DV in their lives and within their families (Meguid and Bakry 2006; Wachter, Dalpe, and Heffron 2019), the responses and action-taking toward DV were highly varied. Refugee women may develop changes in their roles and perceptions, which act as polyfactorial determinants of action change (Afrouz, Crisp, and Taket 2021a; Afrouz, Crisp, and Taket 2021b; Tlapek, Monk, and White 2020). While women viewed DV as unacceptable, they also had to work to keep their families together in the new environment. Studies reported a large consideration for culture, shame, social stigma, and self-blame among women (Afrouz, Crisp, and Taket 2023; Kulwicki et al. 2010; Balice et al. 2019; Shalabi, Mitchell, and Andersson 2015). A great deal of women's thought was put into avoiding social shame and community exclusion while bearing cultural and religious self-blame if one wanted the abuse to stop. Women may justify DV as a result of gender norms and the husband's rights of control over the wife or believe children and family are more important than a woman's self (Abu-Ras 2007; Kulwicki et al. 2010; Aboulhassan and Brumley 2019; Mojahed et al. 2022). Looking at the help-seeking decisions and factors that shape these decisions, studies reported that women were also less likely to seek help due to a lack of awareness of and access to DV services in their new environment (Afrouz, Crisp, and Taket 2021b; Holtmann 2016; Kulwicki et al. 2010; Shalabi, Mitchell, and Andersson 2015). However, acculturative changes were facilitators of taking action (Afrouz, Crisp, and Taket 2021a; Abu-Ras 2007; Holtmann 2016; Anahid Dervartanian Kulwicki 1999; Meguid and Bakry 2006; Wachter, Dalpe, and Heffron 2019). Several women reported stronger disapproval of DV and had positive experiences when accessing DV services and interventions.

Communities often still had a patriarchal normalization of DV, which normalized and perpetuated further abuse and control of refugee women (Afrouz, Crisp, and Taket 2021a; Afrouz, Crisp, and Taket 2021b; Afrouz, Crisp, and Taket 2023; Wachter et al. 2021; Aboulhassan and Brumley 2019; Mojahed et al. 2022). Communities also push a 'family first' rhetoric and believe that families should be kept together no matter what and that divorce is not an option (Afrouz, Crisp, and Taket 2023; Abu-Ras 2007; Holtmann 2016; Aboulhassan and Brumley 2019; Shalabi, Mitchell, and Andersson 2015); which result, in an immense fear of retribution by the community (Abu-Ras 2007; Holtmann 2016; Wachter et al. 2021; Kulwicki et al. 2010; Wachter, Dalpe, and Heffron 2019; Shalabi, Mitchell, and Andersson 2015). Blame, shame, marginalization, and inadequate social support are all potential consequences of the separation of women by their community, and very few documented instances of facilitators of help-seeking behaviors within the community.

Moreover, the role of religious leaders emerges as a critical factor in shaping women's perceptions of domestic violence and their help-seeking behavior (Afrouz, Crisp, and Taket 2021a). The contrast between the perspectives of religious leaders back in the origin country and in the new environment further demonstrates the evolving influence of cultural context on religious interpretations, urging for shifts in religious perspectives and norms to drive systemic change and endorse women's rights (Kulwicki et al. 2010). Findings regarding help-seeking behaviors and mental health support are also insightful (Abu-Ras 2007). While many participants sought services for DV, the reluctance to seek mental health support stands out (Abu-Ras 2007). This highlights the stigma surrounding mental health within these communities and underscores the need for culturally sensitive services and culturally sensitive mental health services that cater to the specific needs and expectations of Afghan women (Balice et al. 2019).

Finally, looking at approaches or solutions suggested by these studies, there is a need for further research, specifically around pre- and post-acculturative changes in views on the utilization of DV services (Aboulhassan and Brumley 2019). Several studies provide practice recommendations in the form of expanding the community view on and response to DV (Afrouz, Crisp, and Taket 2021b; Abu-Ras 2007), promoting tiered changes in the community (Afrouz, Crisp, and Taket 2021a; Kulwicki et al. 2010), cultural competence (Afrouz, Crisp, and Taket 2021a; Meguid and Bakry 2006; Aboulhassan and Brumley 2019), multi-partner collaboration (Kulwicki et al. 2010; Balice et al. 2019; Anahid Dervartanian Kulwicki 1999; Meguid and Bakry 2006; Shalabi, Mitchell, and Andersson 2015), practicing responsive prioritization (Afrouz, Crisp, and Taket 2023), and providing network-oriented interventions (Holtmann 2016; Wachter et al. 2021). Lastly, while there were ample research and practice recommendations, none of the selected review articles made any specific policy recommendations.

4.2. Limitations

The purpose of this study was not to generalize nor to blame a community or a group; it rather was to better understand refugee women's choices of action and their barriers to affecting these choices. To propose effective interventions and support systems it is necessary to understand and incorporate refugee women's voices and perspectives, which often diverge from the traditional views of community or of service providers. Research manuscripts reporting large datasets deposited in publicly available databases have not always specified where the data have been deposited and have not provided the corresponding access numbers. Additionally, most studies have been qualitative and included limited sample sizes. Lastly, the wide range of countries of origin and of post-resettlement, host locations, have made it hard to combine studies for more streamlined inferences.

5. Conclusions

Given an accelerated globalization with massive population mobility, the disparity in accessing and receiving support in the case of domestic violence in refugee and migrant populations comes at a high medical and social cost. The public health relevance of the present study consists in identifying a paucity of research literature on supportive policy changes acceptable to both mainstream systems and refugee communities to ensure a full uptake and implementation. This knowledge gap points out an important direction for future research. Nevertheless, our data analysis reveals a multitude of interwoven structural and personal barriers that prevent abused women to respond proactively to violence. Some of the identified structural barriers include refugee community collectivistic cultural and religious norms in regard to family, decision-making processes in case of domestic violence and divorce, a Western individualistic conceptual framework for legal and social services for DV, etc. Some of the main personal barriers to seeking help appear to be internalized patriarchal values accepting and rationalizing DV, financial dependence on husband, especially when having children, poor awareness of rights and available services, challenges navigating help and supportive resources, insufficient autonomy, fear of social shame, blame, and exclusion. The insights we have gathered suggest the need for an ecosystemic, interprofessional collaborative approach to DV prevention by engaging refugee families, communities, religious leaders, service providers, mental health and health care providers, law enforcement, and policymakers to produce a strong support system for women at all levels. However, our findings also suggest a need for more research on DV interventions that attempt to bridge between Western norms and policies and refugee community rights to self-regulatory autonomy.