This is the second part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.
Written by: Marsha Trego MPH and Dr. Heather de Vries McClintock PhD MSPH MSW
Intimate partner violence (IPV) is a pervasive form of violence (most often against women, although men are victims too) which occurs in all regions of the world. Goal 5 of the 2015 Sustainable Development Goals, Achieving Gender Equality, calls for the elimination of all forms of violence against women and girls. However, not all individuals are equally at risk for physical, emotional, or sexual abuse within their relationships. Understanding risk factors for IPV is imperative for the mobilization of resources to end violence against women. Global research and cooperation has identified risk factors for IPV at all levels of society, including factors within relationships, such as controlling behavior. This work has helped us to identify patterns in IPV perpetration and victimization around the world and how they fit within the context of culture and social change, with the ultimate goal of reducing the global incidence of IPV.
Risk factors at the individual level pertain to both the victim and to the perpetrator and include sex, the presence of sexually transmitted infections, mental health status, and substance abuse. The issue of IPV against men and within same-sex partnerships should not be overlooked even if  the frequency and outcomes of IPV against men are less severe and not well studied. The majority of research has focused on male partners acting against females. Research has identified a relationship between IPV and sexually transmitted infections (STIs). For example, cohort studies have found that women who experienced IPV were significantly more likely to contract HIV. The spread of STIs may be a result of high HIV risk among violent men and limited sexual and reproductive health autonomy among women in violent relationships. Recognition of this relationship may serve as a useful tool for identifying IPV within the healthcare setting.
Mental health is closely tied with IPV, and research has shown that mental health issues, such as depression, are associated with IPV victims in both directions, i.e. that women who are victims of IPV are more likely to have depressive symptoms and women who have depressive symptoms are more likely to experience IPV. Likewise, mental health is an important consideration for perpetration of IPV, such that men and women who struggle with depression, generalized anxiety disorder, or panic disorder are more likely to use violence against an intimate partner. Additionally, substance abuse has been implicated as a risk factor for perpetrators and victims of IPV alike. The western-centric focus of much of the existing IPV research is a limitation, and the role of mental health in identifying risk factors for victims and perpetrators of IPV may vary by country with differing mental health care resources and diagnostic capacity.
It is imperative to acknowledge that individual level factors occur within the context of social norms and traditional gender roles within the relationship and the larger community. Our behaviors are informed by those around us and our past experiences. For example, women who have witnessed parental IPV in childhood or who have previously been victims of violence are over three times as likely to experience current IPV. Furthermore, women who report that wife beating is justified in response to their behaviors, such as burning the food or neglecting the children, are more likely to be victims of abuse. Neither women nor men ever deserve to be abused in their relationships, yet this belief is widely held across many regions, with over 70% of women believing beating is justified in Burkina Faso, Democratic Republic of Congo, Guinea, Mali, Niger, and Uganda.
Violent behaviors may be symptomatic of long-held beliefs about patriarchal family structures. Accompanying power imbalances in the home and community may support or condone the use of violence by men. Our recent research has focused on the relationship between IPV and controlling behavior, characterized by use of jealousy, threats, and accusations to limit a partner’s social contact and financial independence. Controlling behavior may be used in relationships to express or maintain power, and has been identified as a risk factor for IPV. Prior studies of controlling behavior have been limited to the association with one or two types of IPV within single countries or limited geographical regions. We carried out the first known study to examine the role of controlling behavior in IPV in multiple sub-Saharan African countries, including several dimensions of controlling behavior and three types (physical, emotional, and sexual) of IPV. We also considered the cumulative experience of multiple types of IPV and incorporated partner characteristics, such as partner education and occupation. In our study of 37,115 women aged 15 to 49 years in eight sub-Saharan African countries (Cameroon, Democratic Republic of the Congo, Côte d’Ivoire, Namibia, Rwanda, Sierra Leone, Togo, and Zambia), we found that women who reported controlling behavior by their partner were 3.7 (confidence interval = 3.5-4.0) times more likely to have experienced any form of IPV than women whose partners were not controlling, even when accounting for multiple demographic and economic factors. Controlling behavior is not just harmful on its own but may also be indicative of potentially serious marital conflict and violence.
The slow yet steady progress of women’s empowerment around the world has brought traditional social rules into question. Particularly as developing nations increasingly implement policies supporting gender equity and the advancement of women, men may perceive a threat to the traditional, hegemonic expression of masculinity as breadwinner and leader. Potentially due to the evolving role of masculinity and gender in society, a counterintuitive relationship between women’s socioeconomic status has been found, such that women with higher levels of education or who are employed may be more likely to experience IPV. Although poverty has been associated with IPV, people of all socioeconomic gradients are affected by violence in intimate relationships. In cultures where men are expected to be providers, it may be that earning differentials between partners are a greater risk factor for IPV. In fact, relationships in which the woman is the primary earner are especially prone to expression of IPV, and unemployment among males is a risk factor for perpetration of IPV. Despite the challenges of transition and change, we must continuously strive to support gender equality worldwide to give women agency over their bodies and their relationships.
Although global research on IPV is still in progress, one conclusion that can be drawn is that the factors that precede physical, emotional, and sexual violence within an intimate relationship are complex and interwoven. Socialization of IPV within the community and efforts to maintain traditional gender norms and power balances feed into individual and interpersonal risk factors, such as witnessing intergenerational IPV, justification of beating, and controlling behaviors.  Thus, we see that there is no single target for IPV prevention, but rather that risk factors occur on a continuum across all levels of the ecological model. This means that there is no simple recipe for identifying someone at risk for IPV. Yet, given the emerging picture of IPV, interventions that support women’s empowerment while engaging both women and men in discourse on gender equality may prove effective as our world continues to evolve.
A first step in IPV prevention is education, and the World Health Organization provides several useful educational tools on violence and injury prevention, including a free, downloadable intimate partner and sexual violence prevention short course designed to teach people who are actively engaged in policy, prevention, and funding about IPV risk factors and prevention. The 2016 report, Community-Based Approaches to Intimate Partner Violence, by the Global Women’s Institute and the World Bank Group is a methodological guide that outlines how to address IPV risk factors and strategies for adapting IPV prevention programing in different communities around the world. With these tools and others and a genuine collaborative effort between researchers, policy makers, and community members to learn, grow, and share, we will get closer to ending global IPV.
Please stay tuned for Part III in this series: Outcomes of Intimate Partner Violence
Marsha Trego, MPH is a recent graduate from Arcadia University’s MPH program where she completed her master’s thesis on understanding food insecurity among cancer survivors. Marsha began her career path with a B.S. in food science and minor in nutrition from Penn State University. There, she developed an interest in the close relationship between health and food, which ultimately led her to public health research as a way to strengthen our health systems from a fundamental level. Her research interests are varied and include nutrition and chronic disease, women’s health, intimate partner violence, and the leveraging of policy to achieve public health goals. Marsha is currently interning at the Psychology of Eating and Consumer Health Lab at the University of Pennsylvania, where she collaborates on studies of the effects of the Philadelphia beverage tax and food labeling interventions on food and beverage purchasing and consumption. Her global health experience includes travel to San Pedro, Belize with Arcadia University to conduct door-to-door community health screenings. In her free time, she takes a French class and enjoys reading and travel.
Dr. Heather F. de Vries McClintock, is an IH Section Member and Assistant Professor in the Department of Public Health, College of Health Sciences at Arcadia University. She earned her Master of Science in Public Health from the Department of Global Health and Population at the Harvard School of Public Health. Dr. McClintock received her PhD in Epidemiology from the University of Pennsylvania with a focus on health behavior and promotion. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in Sub-Saharan Africa. Prior to completing her doctorate she served as a Program Officer at the United States Committee for Refugees and Immigrants and a Senior Project Manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania. At the University of Pennsylvania she led several research initiatives that involved improving patient compliance and access to quality healthcare services including the Spectrum of Depression in Later Life and Integrating Management for Depression and Type 2 Diabetes Mellitus Studies.
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