Impact of the COVID-19 pandemic on intra-household gender disparities in the Middle East and North Africa region: A scoping review protocol

Malak Ghezzawi; Sasha Fahme; Salpy Naalbandian; Jocelyn DeJong; WOMENA Study Group

doi:10.1371/journal.pone.0313838

. 2024 Nov 18;19(11):e0313838. doi: 10.1371/journal.pone.0313838

Impact of the COVID-19 pandemic on intra-household gender disparities in the Middle East and North Africa region: A scoping review protocol

Malak Ghezzawi ¹, Sasha Fahme ¹, Salpy Naalbandian ², Jocelyn DeJong ^1,^*; WOMENA Study Group^1,^¶

Editor: Amin Nakhostin-Ansari³

PMCID: PMC11573154 PMID: 39556587

Abstract

Introduction

The Middle East and North Africa (MENA) is a global outlier both for its low female labor force participation and investment in early childhood development services, and consistently ranks lowest on global rankings of gender parity. While the impact of the COVID-19 pandemic on global gender inequity has been acknowledged, specific challenges faced by partnered-women in MENA are underexplored. Additionally, with over half of the region affected by conflict and displacement, exploring these impacts sheds light on understudied gender disparities in humanitarian contexts during the pandemic. This scoping review aims to examine intra-household gender disparities during the COVID-19 pandemic, adding to a more comprehensive understanding of this particular public health emergency’s worldwide ramifications. The hypothesis is that the pandemic has exacerbated women’s pre-existing constraints in the MENA region, worsening gender inequities in economic empowerment, healthcare access, and general well-being.

Methods

This review will explore intra-household gender disparities in decision-making, household labor division, economic independence, health, and access to resources and services during the COVID-19 pandemic that have been reported to have been affected by COVID-19 globally. Following PRISMA guidelines for Scoping Reviews, a comprehensive search will be conducted in APA PsycINFO, Arab World Research Source: Al Masdar, EconLit, Global Health, MEDLINE, Scopus, and Web of Science Core Collection, in consultation with an information specialist. Studies in English, French and Arabic from January 2020 to August 2024 will be included. Four independent reviewers will screen studies, and data will be charted, coded, and narratively synthesized.

Discussion

This review is expected to shed light on gender disparities in healthcare accessibility, mobility, and decision-making during the COVID-19 pandemic across low- and middle-income countries in the MENA region, adding to the global literature.

Introduction

The COVID-19 pandemic has significantly reshaped various aspects of society, with notable consequences on gender disparities within households [1]. Its impact encompasses employment losses, an increase in unpaid labor, educational disruptions, food security challenges, unmet health needs, and personal safety concerns [2–5] all of which affect gender relations within families and households. Households are the epicenter of social interactions, work, and caregiving responsibilities, the latter of which may disproportionately burden women [6]. Global evidence highlights women’s heightened vulnerability to social and economic hardships during the COVID-19 pandemic [7–9]. Understanding the pandemic’s impact on gender dynamics within households is crucial for identifying challenges and opportunities to propose targeted interventions to safeguard women’s health, empowerment, and well-being for a more resilient and equitable society [6].

In the Middle East and North Africa (MENA) region, the COVID-19 pandemic has been reported to have exacerbated pre-existing gender disparities, but until now these effects have been relatively understudied [10, 11]. The region is a global outlier both in terms of having the lowest female labor force participation [12, 13], and for its low investment in early childhood development [14], which is critical to support women’s employment [10, 11]. The region ranks fourth among the five regions covered by the SDG Gender Index with an average score of 60.8 [15]. Furthermore, MENA has the lowest score among the eight global regions on the Global Gender Gap Index, with a score of 62.6%, significantly trailing the highest-ranking region, Europe, which scores 76.3% [16]. In terms of economic participation and opportunity, MENA’s score of 44% is the second-lowest after Southern Asia’s 37.2%, compared to other regions that score above 65%, with North America leading at 77.6% [16]. Specific country rankings within MENA reveal stark disparities: Jordan ranks 5th regionally but 126th globally, Tunisia 6th regionally and 128th globally, and Lebanon and Egypt 8th and 10th regionally, and 132nd and 134th globally, respectively [16]. The UN Women’s Gender Gap Performance Index (GGPI) and Women’s Empowerment Index (WEI) further underscore significant disparities [17]. Countries like Egypt, Iraq, Jordan, Lebanon, Tunisia, and Yemen rank low on both indices, highlighting widespread gender inequality in economic participation, education, health, and political empowerment [17]. Meanwhile, other low- and middle- income countries (LMICs) in MENA, including Algeria, Djibouti, Libya, Morocco, Palestine, Somalia, Sudan, and Syria, have incomplete data, reflecting gaps in information and complicating efforts to address gender disparities [17]. This pattern underscores the persistent challenges faced by women in the MENA region and emphasizes the need for targeted interventions to improve gender equality [16, 17].

By September 2021, gender disparities in employment that predated the pandemic became more pronounced both globally and within the MENA region [10, 11]. Informal caregiving responsibilities increased during the pandemic because of school and childcare closures [18] and lockdowns enforced to slow the spread of the pandemic. Even among remote-working couples, an increase in gendered domestic work has been reported both globally and in MENA, exacerbating pre-existing differences [18, 19].

Available evidence suggests that amidst lockdowns, economic instability, and stress, couples experienced elevated anxiety both globally and in MENA [20–23]. Insufficient support structures and increased financial dependence on men exacerbated these stressors among women [20–23]. Gender gaps in income loss may have contributed to a surge in intimate partner violence (IPV) both worldwide [24] and in MENA [25]. Focusing on LMICs in MENA, this scoping review aims to uncover how the pandemic has impacted intra-household gender disparities, contributing to a comprehensive understanding of the global implications of the public health emergency. Our findings may guide targeted interventions and public policies to protect women during future crises.

The aim of this scoping review is to map and narratively explore the available literature on the association between the COVID-19 pandemic and intra-household gender inequality among LMICs in the MENA region. This scoping review asks the research question: “What are the types, characteristics, and implications of intra-household gender disparities identified during the COVID-19 pandemic in LMICs in the MENA region?” This review aims to characterize women’s experiences and unmet needs with respect to economic independence, health, and unpaid labor/care during the pandemic.

Methods

A scoping review will be undertaken to compile hits from seven databases and including peer-reviewed articles in Arabic, English, and French, which are the three most spoken languages in the region. These databases encompass both global and region-specific literature. MEDLINE (OVID) and Global Health (CAB) provide extensive coverage of medical and health-related research globally. APA PsycINFO (EBSCO) is essential for understanding changes in mental health, family dynamics, and gender roles during the pandemic. EconLit with Full Text (EBSCO) captures the economic dimensions of intra-household dynamics and gender inequality. Arab World Research Source: Al-Masdar (EBSCO) focuses on literature specific to the Arab region, offering insights that complement global databases. Scopus and Web of Science Core Collection ensure a broad and inclusive range of peer-reviewed literature across multiple disciplines, including social sciences, health, and humanities, covering both global and regional studies.

The development of this scoping review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [26], PRISMA guidelines for protocols (PRISMA-P) [27], the updated methodological guidance for the conduct of scoping reviews [28], and in consultation with an information specialist with expertise in library science.

Inclusion criteria

This scoping review focuses on peer-reviewed, data-driven articles that address the impact of the COVID-19 pandemic on intra-household gender disparities in LMICs within the MENA region, as defined by the World Bank (Algeria, Djibouti, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Occupied Palestinian territory, Somalia, Sudan, Syria, Tunisia, and Yemen) [29]. Several of these countries, including Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Somalia, Sudan, Syria, and Yemen, are experiencing varying degrees of conflict and instability. These conflicts may exacerbate gender disparities by changing gender roles and influencing socioeconomic tensions within households [30–32]. Conflict-affected settings are underrepresented in the COVID-19 literature, and this review will shed light on gender disparities arising in the context of compounding public health and humanitarian crises. The review will include both quantitative and qualitative studies, encompassing primary studies and secondary analyses that appropriately cite primary data sources, ensuring they are empirical and contribute directly to understanding gender disparities within households during the pandemic. Articles published in English, French, or Arabic and covering the period from January 2020 to August 2024 will be included. Themes and outcomes for the included studies must address at least one of the following defined areas:

Gender roles: The roles and responsibilities assigned to men and women within households during the pandemic, including characteristics of caregiving and employment roles. This theme is essential because the pandemic has significantly disrupted established gender roles, impacting family structures and gender equity. Understanding these reported roles and responsibilities is crucial for identifying shifts in household dynamics and evaluating their potential long-term effects on gender norms [24, 33].
Decision-making power: The authority within household decision-making during the pandemic, including shifts in influence over financial, health, and educational decisions. This theme is important for characterizing changes in gender relations and autonomy within households, highlighting how the pandemic has affected gender equity and individual roles in household management [24, 34].
Division of household labor: The allocation of household tasks during the pandemic, such as cleaning, cooking, and child-rearing, and their impact on gendered task distribution. Examining this theme helps to highlight any increases in the burden on women, who typically bear a larger share of domestic responsibilities. It is crucial for assessing how the pandemic has altered gendered divisions of labor and its implications for gender equality [24, 34].
Economic dependence: The degree of women’s economic reliance on men during the pandemic, including changes in income sources and employment status, and their impact on financial dependency. The economic impact of the pandemic has been profound, with many women experiencing job losses or reduced income. This theme seeks to evaluate financial vulnerabilities and dependencies exacerbated by the pandemic, particularly regarding gender disparities in financial independence [33].
Gender based violence: Incidence of gender-based violence within households during the pandemic, examining contributing factors and consequences. This theme is critical for understanding the implications of the pandemic on safety and gendered power dynamics, as studies reporting changes in violence prevalence will illuminate the effects of increased stress and economic hardship [10].
Health: Physical and mental health outcomes within households during the pandemic, including management of health concerns and gender disparities in health outcomes. This theme aims to investigate how the pandemic has differentially affected men and women’s health, emphasizing studies that report changes in health outcomes as a result of the crisis [35].
Access to resources and services: The availability and utilization of essential resources and services, such as healthcare and education, and their effects on gender roles and relationships within households during the pandemic. This theme seeks to explore disruptions in access and how these changes have influenced intra-household gender dynamics and disparities [10].

Exclusion criteria

Excluded texts will be those conducted in countries which do not fulfill our inclusion criteria. Grey literature, systematic reviews, meta-analyses, letters, books, book chapters, and conference abstracts will be excluded. Articles that report outcomes different than our outcomes of interest will be excluded.

Information sources and search strategy

The search will be conducted covering the period from January 2020 to August 2024. This is to capture studies conducted during the pandemic but published after the WHO-specified pandemic end date. Seven databases (MEDLINE (OVID), Arab World Research Source: Al-Masdar (EBSCO), APA PsycINFO (EBSCO), EconLit with Full Text (EBSCO), Global Health (CAB), Scopus, Web of Science Core Collection) will be used for this review. Refer to S1 Appendix for the MEDLINE search strategy. The search strategies will be developed in collaboration with an information specialist to ensure thorough and effective retrieval of relevant literature.

Data management

Search results will be imported into Covidence software [36] and de-duplicated. All articles will be screened in Covidence.

Selection process

Before commencing the actual selection process by the entire team, a pilot testing phase will be conducted to ensure consistency and clarity in applying the eligibility criteria. The pilot testing will follow the framework described below: a random sample of 25 titles and abstracts will be selected from the identified records using a random number generator. Two reviewers will independently screen the random sample of titles and abstracts using the pre-defined eligibility criteria. The team will meet to discuss any discrepancies or uncertainties that arise during the pilot testing. Based on the discussions and feedback, modifications to the eligibility criteria and definitions/elaboration document will be made to ensure clarity and consistency. The team will only begin the full source selection process when a consensus agreement of 95% or greater is achieved among the reviewers during the pilot testing. This threshold ensures that the team is aligned in their understanding and application of the inclusion criteria.

The first stage of screening will entail four independent reviewers assessing both the title and abstract for peer-reviewed articles, in duplicates. Following the first screen, articles marked for full text review will be read by four independent reviewers to ensure alignment with the inclusion criteria. This will also be done in duplicates. In cases where there are disagreements between the reviewers regarding the inclusion of a particular study, the reviewers will attempt to reach a consensus through discussion and mutual agreement. If a consensus cannot be reached, a third reviewer (JD or SAF) will be involved to make the final decision on the inclusion or exclusion of the study. For excluded sources, the reasons for exclusion will be clearly stated, ensuring transparency and reproducibility in the review process.

Data collection process and data extraction

A data extraction template will be used to compile information on categories of conceptualizations that appear in included papers and the bibliographic information of author(s), publication year, and publication title. Refer to S2 Appendix for the data extraction template. The development of the data extraction template will be led by one author and piloted using an initial set of included papers (n = 25). Before starting the extraction process, the review team will ensure that 95% or greater agreement is achieved during the pilot testing phase. The data extraction will be done by four members of the review team. Reviewers will be open to extracting any relevant data that aligns with the scoping review questions, even if not initially included in the charting table.

Data analysis

Data analysis will primarily involve descriptive mapping of the extracted results from the included sources. The focus will be on providing a clear overview of the key concepts, populations, characteristics, and outcomes related to intra-household dynamics during the COVID-19 pandemic. The analysis will involve mapping the occurrence of specific gender disparities such as those impacting gender roles, decision-making, and division of household tasks in each of the LMICs within the specified timeframe. Principles of framework synthesis will also be useful in organizing and categorizing findings/data from the included sources. By charting and sorting the extracted data against an a priori identified framework, the scoping review results will provide a structured overview of how the COVID-19 pandemic impacted gender inequality.

Ethical considerations

As this review involves a synthesis and presentation of available resources, it does not require ethics approval. Results will be published in a peer-reviewed journal, developed into easily disseminated infographics and shared at international conferences.

Status and timeline of the study

The search strategy for MEDLINE has been developed with the information specialist. The search on MEDLINE will be run along with that of other databases, followed by data screening (title-abstract and full-text) and data extraction within 3 months. Then, data analysis will be conducted, followed by the manuscript write-up.

Discussion

Data on the impact of the COVID-19 pandemic on gender disparities in the MENA region are lacking. Global studies on intra-household dynamics and gender disparities during the COVID-19 pandemic have often excluded MENA countries [10, 37] and/or are focused on high-income settings [38], leading to a lack of empirical evidence from LMICs within this area. Where data exist, scoping reviews have focused on either broader populations beyond the MENA region [39], or specific aspects of intra-household dynamics, such as domestic violence [40]. For instance, Moyano et al.’s scoping review investigated gender considerations in global health and social protection policies during the pandemic, highlighting adverse effects on gender roles and increased inequalities, including gender-based violence (GBV), but did not address the MENA region or its specific challenges [39]. A systematic review on intimate partner violence in the Gulf Cooperation Council Arab nations found varying prevalence rates of GBV (9.0–45.5% physical abuse, 22–69% psychological abuse and 6.9–19.2% sexual abuse), but did not isolate the COVID-19 period [41]. Another systematic review on economic conditions, health outcomes, and GBV globally revealed challenges faced by employed women in LMICs worldwide, including high job losses, GBV, limited access to health services, and increased mental health issues such as anxiety [35]. However, most LMICs in MENA were overlooked by these systematic reviews [35, 41].

The MENA region stands out due to its particularly high levels of gender inequality, which predate the pandemic [10, 11]. As noted, countries in this region frequently rank poorly on global gender equality indices, reflecting deep-seated disparities in economic participation, educational attainment, and health [16, 17]. Additionally, ongoing conflicts in several MENA countries, such as Syria, Yemen, and Libya, may further compound the impact of the pandemic and intensify the challenges faced by women. Despite the prevalence of these issues, the region remains underrepresented in global studies, which tend to focus on high-income and/or non-humanitarian settings.

This scoping review seeks to address this imbalance by providing a focused examination of intra-household gender disparities across all LMICs within the MENA region. By concentrating on this region, the review aims to fill a significant gap in the global literature and offer insights into how cultural, socio-economic, and conflict-related factors uniquely shape gender disparities during the pandemic. The findings will contribute to a more nuanced understanding of the pandemic’s impact on gender inequality and inform targeted interventions and policies.

Limitations

The reliance on specific databases for literature search may result in the omission of relevant peer-reviewed articles that are not indexed within these databases. Cross-referencing the included papers will be conducted to mitigate this limitation. Moreover, our study focuses exclusively on peer-reviewed literature, thereby excluding potentially valuable insights from grey literature sources such as conference proceedings, dissertations, and reports. This exclusion might lead to a bias towards published works or omission of relevant studies that are not widely disseminated. Though limiting our inclusion criteria to longitudinal studies would be ideal to examine change, there is a paucity of cohort studies in the region both generally and with respect to the COVID-19 pandemic [42–44]. Thus, this review will include cross-sectional data on perceived changes as reported by study participants as well as longitudinal studies that might be available.

Dissemination plans

The results will be published in a peer-reviewed publication and presented at international conferences. The team is continuing to engage with local and regional public sector actors throughout the review process, so the outcomes will be shared with them as well.

Supporting information

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol*.

(PDF)

pone.0313838.s001.pdf^{(136.5KB, pdf)}

S1 Appendix. Search strategy.

(DOCX)

pone.0313838.s002.docx^{(21KB, docx)}

S2 Appendix. Data extraction Instrument.

(DOCX)

pone.0313838.s003.docx^{(19.2KB, docx)}

Acknowledgments

We would like to thank the WOMENA Study Group for supporting the study work (Stephen McCall, Hala Ghattas, Rita itani, Myriam Dagher, Ali Abboud, Nisreen Salti, Ghada Saad).

Abbreviations

MENA: Middle East and North Africa
LMICs: low- and middle- income countries
WEI: Women Gender Equality Index
GGPI: Gender Gap Performance Index
PRISMA-ScR: PRISMA guidelines for Scoping Reviews
PRISMA-P: PRISMA guidelines for protocols
WHO: World Health Organization
GBV: gender-based violence

Data Availability

No datasets were generated or analyzed during the current study. All relevant data are available from within the manuscript as well as a supplemental information file.

Funding Statement

This study is supported by a 2-year grant from the International Development Research Centre (IDRC) in Canada under the reference number 110025. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0313838.r001

Decision Letter 0

Amin Nakhostin-Ansari

10 Jul 2024

PONE-D-24-14476Impact of the COVID-19 Pandemic on Intra-household Dynamics and Gender Inequality in the Middle East and North Africa region: A Scoping Review ProtocolPLOS ONE

Dear Dr. DeJong,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

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Kind regards,

Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a review of a scoping study protocal on the gendered effects of the pandemic in 11 LMIC countries in the MENA-region. I think the study potentially could offer important insights but further attention is needed to several issues before proceeding with the scoping review.

Framing/introduction:

1. The authors start quite broad in relation to the pandemic, which in my view could move straight away to the gendered aspects of the pandemic. Primarily because I am missing a logic/justifciation for the need to focus on the MENA region in the Introduction.

2. Moreover, it is not entirely clear from the Introduction which aspects of gender inequality will be considered. Several areas of concern are noted, including women’s (reproductive) health, but the authors then state they will focus on intra-household gender dynamics. In such a short overview, it would be helpful to have an argument that clearly outlines the issues at stake specific to intra-household gender dynamics and the need for further study.

Case study selection/inclusion criteria:

3. The authors focus on 11 LMIC countries in the MENA region. How many countries are there in the MENA region? And why focus on these 11? In other words, greater justification for case study selection (inclusion criteria) is needed.

4. (Greater) justification of the outcome variables of interest is needed. Why these variables and not others? What does this mean for which studies may be included/excluded in the scoping review?

5. The inclusion of studies in English, French and Arabic is a strong advantage of the study and should be emphasized in the Abstract.

6. The authors argue that searching until 3 months past the end of the pandemic allows for studies on the pandemic published after its end to still be included. Arguably, many studies are still coming out, particularly those with longitudinal and/or comparative data. Would it not be better to have the longest time frame possible, including the entire year of 2023 and the first months of 2024? The justification therefore does not currently align with the timeframe.

7. Greater explanation is needed for how many databases were considered and why the choice was given to focus on these 7.

8. Greater detail is needed on data management – how will articles be assessed/screened?

Discussion:

9. To clarify the contribution to the literature, I would encourage the authors to do more to explain why greater insights on the MENA region are needed. While in principle I agree that there is a significant gap (and an over-abundance of empirical data on North America and Europe, the existence of a gap is in and of itself insufficient justification for a study.

Reviewer #2: This manuscript describes an interesting and worthwhile scoping review. I think it is promising but have a few small concerns.

1. Two small textual issues: if MENA is spelled out then LMIC also should be spelled out at its first appearance, and “worldwide” at the end of the first sentence of the second last paragraph of the Introduction should be removed.

2. It's unclear why the literature search should end at July 2023. The issue here is not when the pandemic ended but when research on it was being published. Surely relevant work carried out in 2022 and early 2023 could still going through the data analysis, write-up, and editorial review processes long after the pandemic ended. I would be inclined to extend the study period another year to reduce the risk of excluding relevant articles. If relevant articles aren't being published after July 2023 the researchers will be able to determine this empirically.

3. Not much detail is given on how the various themes (e.g.., "changes in gender roles") will be defined at the inclusion stage. Some of them are a little vague (e.g., "health") so to ensure replicability it would be good to be clearer on defining each theme.

4. The research question is about change in household dynamics but there seems to be no requirement that the studies to be reviewed are longitudinal or panel studies. Without data of this kind it's unclear how change can be assessed, except unreliably by recollection or by comparison to some external baseline data. The manuscript should specify whether (A) all included studies will be longitudinal or panel; and (B) explain why other kinds of data should be included to evaluate "change" if they are to be included; and (C) explain how findings of "change" based on different kinds of data will be integrated in the review.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2024 Nov 18;19(11):e0313838. doi: 10.1371/journal.pone.0313838.r002

Author response to Decision Letter 0

27 Aug 2024

Journal: PLOS One

PONE-D-24-14476

24-08-2024

Dear Editor,

On behalf of all co-authors, we would like to thank you and the reviewers for the time spent on reviewing our work, as well as the valuable comments that helped us improve the quality of our manuscript titled “Impact of the COVID-19 Pandemic on Intra-household Dynamics and Gender Inequality in the Middle East and North Africa region: A Scoping Review Protocol”. All comments have been addressed, as can be seen in the point-by-point response to the comments by reviewers below.

All authors confirm that the manuscript is not under consideration by any other journal and that authors have no conflict of interest. All authors have read and approved the submission of this revised manuscript.

Yours sincerely,

Jocelyn DeJong, PhD

Associate Provost and Professor at the Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

Email: Jd16@aub.edu.lb

Journal requirements

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Thank you for your comment. We have carefully reviewed the PLOS ONE style requirements and ensured that our revised protocol complies with these guidelines.

2. Thank you for stating the following financial disclosure:

“This study is supported by a 2-year grant from the International Development Research Centre (IDRC) in Canada under the reference number 110025.”

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

Thank you for your comment. The following statement ‘The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript’ has been added to the manuscript.

Thank you for your comment. Since our manuscript is a scoping review protocol, it does not involve original data collection; there are no raw datasets to be shared. We understand and comply with your open data policy where applicable. If there are specific requirements or additional steps needed for making the review protocol and its components accessible, please let us know, and we will ensure that these requirements are met.

Reviewer #1

We would like to thank the Reviewer for the time reviewing our work and the valuable comments.

This is a review of a scoping study protocol on the gendered effects of the pandemic in 11 LMIC countries in the MENA-region. I think the study potentially could offer important insights but further attention is needed to several issues before proceeding with the scoping review.

Framing/introduction:

1. The authors start quite broad in relation to the pandemic, which in my view could move straight away to the gendered aspects of the pandemic. Primarily because I am missing a logic/justification for the need to focus on the MENA region in the Introduction.

Thank you for this comment. We have revised the Introduction to more directly address the gendered aspects of the pandemic (lines 80-100).

Thank you for this insightful comment. We’ve revised the manuscript to indicate that we will be focusing on gender disparities in several areas of women’s health, wellbeing, and economic in/dependence, including division of household labor, decision-making power, and access to resources and services (lines 69-78; lines 109-122).

Case study selection/inclusion criteria:

This study is part of a larger study which focuses on the 11 countries chosen. We accept the reviewers’ comments about the justification of these 11 countries in relation to this study in particular, and have decided to include the other three low-and-middle-income countries in the region that had previously been excluded. The focus of this scoping review has been expanded to now include all 14 low- and middle-income countries (LMICs) as defined by the World Bank in the MENA region: Algeria, Djibouti, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Palestine, Somalia, Syria, Sudan, Tunisia, and Yemen. This broader inclusion ensures that the review comprehensively represents the economic and geographic diversity within this category of countries in the region. The manuscript has been edited accordingly (lines 143-149).

4. (Greater) justification of the outcome variables of interest is needed. Why these variables and not others? What does this mean for which studies may be included/excluded in the scoping review?

Thank you for your valuable feedback. We appreciate the opportunity to provide further justification for the outcome variables of interest and their relevance to our scoping review. The outcome variables chosen for this scoping review are carefully selected to capture a comprehensive understanding of how the COVID-19 pandemic has impacted intra-household gender disparities in LMICs within the MENA region. These variables were identified based on their significance in the existing literature and their relevance to understanding gender inequality within households during the pandemic.

• Gender Roles: This variable is essential because the pandemic has caused significant disruptions to traditional gender roles and responsibilities within households. Understanding these reported changes is crucial for identifying ways in which to protect women’s well-being during public health shocks.

• Decision-Making Power: Reported shifts in decision-making authority within households can indicate changes in power dynamics. These shifts are critical for understanding how the pandemic has affected gender relations and individual autonomy within households.

• Division of Household Labor: The allocation of household tasks and unpaid care is a key indicator of gender equity. Investigating reported changes in this area helps highlight any increases in the burden on women, who often handle a larger share of domestic work.

• Economic Dependence: The pandemic’s economic impact has been profound, with many women losing their jobs or experiencing reduced income. Examining these reported changes helps to understand the financial vulnerabilities and dependencies that have been exacerbated by the pandemic.

• Health: Both physical and mental health impacts are crucial for understanding the overall well-being of individuals within households and gender differences. The pandemic has placed significant stress on health systems and health status, making this an important area of focus.

• Access to Resources and Services: Access to essential resources such as healthcare, education, and social support services has been disrupted during the pandemic. Understanding these reported disruptions is vital for assessing the broader impact on intra-household gender parity.

These outcome variables were selected to ensure a comprehensive analysis of the multifaceted impacts of the COVID-19 pandemic on intra-household gender equity. By focusing on these key areas, our scoping review aims to capture a wide range of relevant studies that address these critical aspects of gender inequality. This approach allows us to include studies that provide empirical data on these variables, thereby contributing to a more holistic understanding of the pandemic's impact on gender dynamics within households.

Further detail on these outcome variables and the justification for their inclusion has now been added to the text (lines 158-204).

5. The inclusion of studies in English, French and Arabic is a strong advantage of the study and should be emphasized in the Abstract.

Thank you for your comment and we agree that this is a strength. This point has been added in the abstract (lines 58-59).

Thank you for your valuable feedback. We appreciate your observation regarding the timeframe for including studies related to the pandemic. We had chosen this cut-off date, three months after the WHO declared the COVID-19 pandemic to be over, to capture studies conducted and submitted for publication during the pandemic period. In response to your comment, we agree that extending the search period would provide a more comprehensive inclusion of relevant studies published after that date, particularly those with longitudinal and comparative data. We will therefore revise our search strategy to include studies published up until August 2024. This extension will ensure that our review captures the most recent and relevant research related to the pandemic and its impacts. For practical reasons due to research funding, we are not able to extend the period beyond that. The manuscript has been edited accordingly (line 155).

7. Greater explanation is needed for how many databases were considered and why the choice was given to focus on these 7.

Thank you for your comment. For this review, based on the guidance of our information scientist, seven databases will be used to ensure a thorough search encompassing health, psychological, social, economic, and regional perspectives:

MEDLINE (OVID) and Global Health (CAB) offer extensive coverage of medical and health related research.

APA PsycINFO (EBSCO) covers literature in psychology and related disciplines, which is essential for understanding changes in mental health, family dynamics, and gender roles during the pandemic.

EconLit with Full Text (EBSCO) is the primary database for economic literature. Its inclusion ensures a more comprehensive understanding of the economic dimensions of intra-household dynamics and gender inequality.

Arab World Research Source: Al-Masdar (EBSCO) focuses on literature specific to the Arab region, offering insights that might not be covered in global databases.

Scopus and Web of Science Core Collection offer comprehensive coverage of the peer-reviewed literature across multiple disciplines, including social sciences, health, and humanities, ensuring a broad and inclusive range of studies.

The manuscript has been edited accordingly with more explanation of these chosen databases (lines 128-136).

8. Greater detail is needed on data management – how will articles be assessed/screened?

Thank you for your comment. Details on how the articles will be assessed and screened are present in the 'Selection Process' and 'Data Collection Process and Data Extraction' paragraphs that follow the 'Data Management' paragraph (lines 219-257).

Discussion:

Thank you for your valuable feedback. We have addressed your concerns in the Discussion section. We emphasize that the MENA region is characterized by significant gender inequality, as highlighted by global gender parity rankings such as the SDG Gender Index, Global Gender Gap Index, UN Women’s Gender Gap Performance Index (GGPI), and Women's Empowerment Index (WEI). The COVID-19 pandemic has exacerbated these inequalities, although to our knowledge, a systematic examination of the literature has not been conducted. Furthermore, global studies on gendered aspects of the pandemic often overlook the MENA region, leading to an imbalance in empirical evidence, especially from LMICs. Examples of global studies that exclude this region are cited in the text. In addition, over half of the LMICs included in this scoping review are experiencing protracted conflict and/or forced displacement. Examining gender disparities in the context of these compounding crises and underrepresented humanitarian settings is crucial for improving women’s health and well-being in unstable settings. These points have been incorporated into the discussion to strengthen the rationale for focusing on the MENA region (Lines 303-309).

Reviewer #2

We would like to thank the Reviewer for the time spent on our work and the valuable comments.

Thank you for your comment. These points have been addressed in the manuscript.

Thank you for your valuable feedback. We appreciate your observation regarding the timeframe for including studies related to the pandemic. We had chosen this cut-off date because it was 3 months after the official end of the pandemic, as declared by WHO. In response to your comment, we agree that extending the search period would provide a more comprehensive inclusion of relevant studies published after that date, particularly those with longitudinal and comparative data that may have been published after the pandemic's official end. We will therefore revise our search strategy to include studies published up until August 2024. This extension will ensure that our review captures the most recent and relevant research rel

PLoS One. doi: 10.1371/journal.pone.0313838.r003

Decision Letter 1

Amin Nakhostin-Ansari

11 Sep 2024

PONE-D-24-14476R1Impact of the COVID-19 Pandemic on Intra-household Gender Disparities in the Middle East and North Africa region: A Scoping Review Protocol

PLOS ONE

Dear Dr. DeJong,

Please submit your revised manuscript by Oct 26 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Comment from the PLOS editorial office: When you resubmit your manuscript, could you please ensure that you remove "(Please note that this is a revised title from the initial submission)" from the title of your submission?

We look forward to receiving your revised manuscript.

Kind regards,

Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a review of a revised scoping study protocol. I think the authors have given careful consideration to the comments from myself and another reviewer, which have significantly improved the intended scoping review. I think this has the potential to be a very important study, providing a much needed contribution to the literature. I would be happy for the authors to proceed, with just two minor comments.

As noted by R2, the first mention of LMIC should be spelled out fully. This currently takes place on p4, but is not spelled out until p5.

On p7, the authors provide a careful outline of the themes to be included in the review. However, no references are provided. These should be included to understand the basis for including these themes.

Reviewer #2: The revised versions is largely responsive to my original comments. I'll discuss each in turn, numbered in the same way.

1. Dealt with appropriately.

2. This is a positive change and should increase the yield of useable studies.

3. These are much improved. I was only seeking clarification on what each theme was intended to cover, and the new text also provides a rationale for doing so, but I see the other reviewer requested this so I am satisfied with it.

4. I appreciate that there may be a paucity of longitudinal studies and that it is therefore reasonable to include cross-sectional studies with proper acknowledgement of their limits in capturing change. Having said that, I am still a little concerned about how change will be inferred in this review, as the inclusion criteria make no reference to studies having to be about change (just "impact", which is vaguer). Besides using the word "impact" the only relevant inclusion statement is "contribute directly to understanding gender disparities within households during the pandemic", which doesn't entail any reference to change during or as a result of the pandemic, real or perceived. Studies that merely contribute to understanding disparities in the pandemic's present (disparities that may have been pre-existing) will therefore meet inclusion criteria. So I remain a little uncertain how the findings will illuminate change unless the included studies at the very least examine perceived change from before to during (or after) the pandemic. That doesn't currently seem to be a strict requirement of included studies, so I remain a little doubtful how the review will clarify change or impact unless the inclusion criteria are tightened a little.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. 2024 Nov 18;19(11):e0313838. doi: 10.1371/journal.pone.0313838.r004

Author response to Decision Letter 1

16 Oct 2024

Journal: PLOS One

PONE-D-24-14476

15-10-2024

Dear Editor,

On behalf of all co-authors, we would like to thank you and the reviewers for the time spent on reviewing our work, as well as the valuable comments that helped us improve the quality of our manuscript titled “Impact of the COVID-19 Pandemic on Intra-household Gender Disparities in the Middle East and North Africa region: A Scoping Review Protocol”. All comments have been addressed, as can be seen in the point-by-point response to the comments by reviewers below.

Yours sincerely,

Jocelyn DeJong, PhD

Associate Provost and Professor at the Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

Email: Jd16@aub.edu.lb

Journal requirements

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Thank you for the comment. The references have been revised.

Reviewer #1

We would like to thank the Reviewer for the time reviewing our work and the valuable comments.

As noted by R2, the first mention of LMIC should be spelled out fully. This currently takes place on p4, but is not spelled out until p5.

Thank you for your comment. The manuscript has been edited accordingly (p. 4, line 106).

Thank you for your valuable feedback. We have incorporated relevant references on page 7 to support the themes outlined in the review. These citations provide a clear rationale for the selection of these themes, drawing on key studies and existing literature that highlight their importance (Lines 176-255).

Reviewer #2

We would like to thank the Reviewer for the time spent on our work and the valuable comments.

Reviewer #2: The revised versions is largely responsive to my original comments. I'll discuss each in turn, numbered in the same way.

1. Dealt with appropriately.

Thank you for your comment.

2. This is a positive change and should increase the yield of useable studies.

Thank you for your comment.

Thank you for your insightful feedback regarding our inclusion criteria and the inference of change in our review. In light of your comments, we have refined our research question and themes to ensure a clearer focus on both the characterization of the present data and the identification of studies that report change related to intra-household gender disparities during the COVID-19 pandemic. Our revised research question now explicitly asks: “What are the types, characteristics, and implications of intra-household gender disparities identified during the COVID-19 pandemic in LMICs in the MENA region?” (Lines 128-132).

Attachment

Submitted filename: R2 - Protocol_Response to Reviewers.docx

pone.0313838.s004.docx^{(35.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0313838.r005

Decision Letter 2

Amin Nakhostin-Ansari

1 Nov 2024

Impact of the COVID-19 Pandemic on Intra-household Gender Disparities in the Middle East and North Africa region: A Scoping Review Protocol

PONE-D-24-14476R2

Dear Dr. DeJong,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for addressing all of the reviewer comments. I am satisfied that all issues have been addressed and look forward to seeing the study.

Reviewer #2: The authors have responded reasonably to my final concern, essentially by backing away from the claim that they will be examining change. The new question -- “What are the types, characteristics, and implications of intra-household gender disparities identified during the COVID-19 pandemic in LMICs in the MENA region?” -- doesn't require that the disparities emerged during or in response to the pandemic. That's ok, but I do hope when writing up the research they are careful when making claims about whether or not they have really documented changes or just, perhaps, pre-existing tendencies.

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Reviewer #1: No

Reviewer #2: No

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PLoS One. doi: 10.1371/journal.pone.0313838.r006

Acceptance letter

Amin Nakhostin-Ansari

7 Nov 2024

PONE-D-24-14476R2

PLOS ONE

Dear Dr. DeJong,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Amin Nakhostin-Ansari

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: Recommended items to address in a systematic review protocol*.

(PDF)

pone.0313838.s001.pdf^{(136.5KB, pdf)}

S1 Appendix. Search strategy.

(DOCX)

pone.0313838.s002.docx^{(21KB, docx)}

S2 Appendix. Data extraction Instrument.

(DOCX)

pone.0313838.s003.docx^{(19.2KB, docx)}

Attachment

Submitted filename: R2 - Protocol_Response to Reviewers.docx

pone.0313838.s004.docx^{(35.6KB, docx)}

Data Availability Statement

No datasets were generated or analyzed during the current study. All relevant data are available from within the manuscript as well as a supplemental information file.

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PERMALINK

Impact of the COVID-19 pandemic on intra-household gender disparities in the Middle East and North Africa region: A scoping review protocol

Malak Ghezzawi

Sasha Fahme

Salpy Naalbandian

Jocelyn DeJong

Roles

Abstract

Introduction

Methods

Discussion

Introduction

Methods

Inclusion criteria

Exclusion criteria

Information sources and search strategy

Data management

Selection process

Data collection process and data extraction

Data analysis

Ethical considerations

Status and timeline of the study

Discussion

Limitations

Dissemination plans

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Amin Nakhostin-Ansari

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Author response to Decision Letter 0

Decision Letter 1

Amin Nakhostin-Ansari

Roles

Author response to Decision Letter 1

Decision Letter 2

Amin Nakhostin-Ansari

Roles

Acceptance letter

Amin Nakhostin-Ansari

Roles

Associated Data

Supplementary Materials

Data Availability Statement

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