Sexually Transmitted Infections in Sub-Saharan Africa

By: Samantha Dulak BS and Heather McClintock PhD MSPH MSW

This is the first part of a IH Blog series featured this summer, Sexually Transmitted Infections in Sub-Saharan Africa: Determinants, Outcomes, and Interventions.

Part I: Sexually Transmitted Infections in Sub-Saharan Africa

Sexually transmitted infections (STIs) are common acute conditions that while exacting a tremendous toll on health and well-being currently receive minimal media coverage and attention. This is likely due to resources being allocated to other new and emerging conditions, the stigma associated with people who are perceived to be able to contract STIs, and a lack of education about STI symptoms and treatment. STIs range from curable (syphilis, gonorrhea, chlamydia, and trichinosis) to incurable (HPV and HIV/AIDS) infections. The nearly 30 STIs are most commonly transmitted through sexual encounters, but contact with blood and mother to child transmission during pregnancy are other ways STIs can be spread (Newman et al., 2015). Comparing the four curable STIs globally, sub-Saharan Africa had the highest incidence and prevalence of syphilis and gonorrhea (Chesson, Mayaud, & Aral, 2017). Unfortunately, STIs can raise HIV transmission up to four times which is why controlling STIs is at the top of the public health professional’s radar (Stillwaggon & Sawers, 2015). The highest prevalence of HIV is found in sub-Saharan Africa with 53% of the world’s HIV population living there and 56% of those individuals being women (UNAIDS, 2018). Although incidence rates are falling globally, 1.8 million people were newly diagnosed in sub-Saharan Africa in 2017; there is much more work to be done to reach the 2020 goal of less than 500,000 new cases in this region (UNAIDS, 2018). The current estimates state that 66% of all new global HIV infections occur in sub-Saharan Africa (UNAIDS, 2018).

STIs affect people of all socioeconomic classes in every country. Without proper precautions, no one is immune from these infections. STIs in sub-Saharan Africa are particularly important because the largest estimates are reported in this region and public health advances can provide insight and hope to other countries that are affected. Combating the negative stigma around STIs will increase the amount of people who will know their status, subsequently increasing treatment for those infections that are treatable. Furthermore, globalization perpetuates the spread of STIs across geographic boundaries highlighting the importance of acknowledging and addressing STIs on a broad scale.

STIs cause major pregnancy complications such as ectopic pregnancies, infertility, and spontaneous abortions (Chesson, Mayaud, & Aral, 2017). In both men and women, liver cancer, central nervous system diseases, and arthritis are all common comorbidities (Aral, Over, Manhart, & Holmes, 2006). Due to insufficient diagnosis and treatment in many lower and middle income countries, the rates of complications are much higher. This inadequacy can be attributed to the asymptomatic nature of some STIs, lack of education on the topic, or poor care-seeking behaviors (Mayaud & Mabey, 2004).

There are many at-risk groups for contracting STIs, including men who have sex with men, female sex workers, children born to women with STIs, and intravenous drug users. An interesting connection to be made exists for women who experience intimate partner violence (IPV). IPV can include physical or sexual violence, stalking, and psychological control over one’s spouse or dating partner (Centers for Disease Control, 2019). Women are already disproportionately affected by STIs, and these rates are greatest in women who also have reported cases of IPV. One answer for this is that women who have experienced IPV are more likely to have high-risk partners (Miller, 1999). Abusive partners may express coercive behaviors both within and outside of the relationship (Miller, 1999). Additionally, people experiencing IPV can suffer psychological trauma leading them to have impaired decision-making skills and experience increased risk-taking behavior (Miller, 1999).

As of 2018, the World Health Organization has been utilizing the Joint United Nations Programme on HIV/AIDS (UNAIDS) Global AIDS Monitoring system to quantify cases of STIs at the country level and the Gonococcal Antimicrobial Surveillance Programme (GASP) to follow antimicrobial resistance for the treatable STI, gonorrhea (Wi et al., 2017). For GASP to have continued success, international collaboration must be strengthened to develop advanced screening procedures and novel antibiotic treatments. By continually improving both monitoring systems, there may be hope for new vaccines for STIs we are still not protected from. Since antimicrobial resistance is not evolving at the same time across all countries, sharing data and laboratory methods for new pharmaceutical development is imperative to control the spread of STIs in sub-Saharan Africa (Wi et al., 2017).

References

Aral, S.O., Over, M., Manhart, L., Holmes, K.K. (2006). Sexually Transmitted Infections. In Jamison, D.T., Breman, J.G., Measham, A.R, Alleyne, G., Claeson, M., Evans, D.B., Jha, P., Mills, A., Musgrove, P. (Eds), Disease Control Priorities in Developing Countries, second edition. 311–30. Washington (DC): World Bank and Oxford University Press.

Center for Disease Control [CDC]. (2019). Preventing Intimate Partner Violence. Retrieved May 27, 2019, from https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

Chesson, H.W., Mayaud, P., & Aral, S.O. (2017). Sexually Transmitted Infections: Impact and Cost-Effectiveness of Prevention. In Holmes, K.K., Bertozzi, S., Bloom, B.R., & Jha, P. (Eds.), Major Infectious Diseases, third edition. Washington (DC): The International Bank for Reconstruction and Development and The World Bank.

Mayaud, P., Mabey, D. (2004). Approaches to the Control of Sexually Transmitted Infections in Developing Countries: Old Problems and Modern Challenges. Sexually Transmitted Infections, 80(3), 174–182. doi: 10.1136/sti.2002.004101

Miller, M. (1999). A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care, 11(1), 3-20. doi:10.1080/09540129948162

Newman, L., Rowley, J., Hoorn, S. V., Wijesooriya, N. S., Unemo, M., Low, N., . . . Temmerman, M. (2015). Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLos One, 10(12). doi:10.1371/journal.pone.0143304

Stillwaggon, E., & Sawers, L. (2015). Rush to judgment: The STI-treatment trials and HIV in sub-Saharan Africa. Journal of the International AIDS Society, 18(1), 19844. doi:10.7448/ias.18.1.19844

UNAIDS. UNAIDS: Data 2018. 2018. https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf (accessed 26 May 2019).

Wi, T., Lahra, M. M., Ndowa, F., Bala, M., Dillon, J. R., Ramon-Pardo, P., . . . Unemo, M. (2017). Antimicrobial resistance in Neisseria gonorrhoeae: Global surveillance and a call for international collaborative action. PLoS Medicine, 14(7). doi:10.1371/journal.pmed.1002344

Samantha Dulak

Samantha Dulak is a recent graduate from Arcadia University. She received her Bachelor of Science in Biology and a Minor in Global Public Health. Her enthusiasm for medicine and disease prevention perfectly intertwine these two fields of study. Her current public health interests are in maternal and child health and nutrition. Since graduation, Samantha has applied to naturopathic medical school with a goal of becoming a pediatric physician. In her free time, she enjoys reading, playing sports, and baking.

Dr. Heather F. McClintock PhD MSPH MSW

Dr. 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.

Interventions and Strategies for Addressing Global Intimate Partner Violence

This is the fourth part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.

Written by: Ewinka Romulus MPH and Dr. Heather de Vries McClintock PhD MSPH MSW

Intimate Partner Violence (IPV) continues to be a serious global public health concern affecting millions of women (and in some cases, men). IPV refers to any harmful behavior within an intimate relationship that includes physical, psychological or sexual harm. Existing research suggests that different types of violence often coexist. For instance, we tend to see physical IPV often accompanied by sexual IPV and emotional abuse. While the extent of IPV varies across regions, higher prevalence exists amongst poorer countries and within communities of a lower socioeconomic level. The World Health Organization (WHO) reports a higher prevalence of IPV among African, Eastern Mediterranean, and South-East Asia Regions (approximately 37%). Whereas, lower rates of IPV are found among women in European and Western Pacific regions.

To date, different theories and models have been used to explain IPV behavior within communities. The most widely used model for understanding intimate partner violence is the Social-Ecological Model which considers the complex interaction between the individual, relationship, community and societal factors that may influence IPV. The societal level identifies broad societal factors including social and cultural norms, health, economic, educational, and social policies, which may create an environment where IPV is either encouraged or inhibited. Researchers are continuously examining the factors associated with IPV at these different levels and factors.

Relying on this conceptual framework interventions and strategies to address IPV globally require a multi-level approach. Accordingly, the World Health Organization’s Global Plan of Action to Address IPV 2016, calls for a multi-sectoral approach in which strategies for addressing IPV occur on all levels of the Social-Ecological Framework (e.g. individual, relationship, community, etc.). The goal of this plan is to strengthen the role of the health system in all settings and within a national multisectoral response to develop and implement policies and programmes, and provide services that promote and protect the health and well-being of everyone, and in particular, of women, girls and children who are subjected to, affected by or at risk of interpersonal violence. The plan calls for several actions that respond to and prevent gender-based violence against women and girls (VAWG). These include “creating an enabling legal and health policy environment that promotes gender equality and human rights, and empowers women and girls; provision of comprehensive and quality health-care services, particularly for sexual and reproductive health; evidence-informed prevention programmes promoting egalitarian and non-violent gender norms and relationships; improving evidence through collection of data on the many forms of VAWG and harmful practices that are often invisible in regular surveillance, health and crime statistics.”

Several countries, such as Uganda, India, and Nigeria have integrated multiple approaches encompassing the key principles mentioned above. For instance, in Uganda, an organization called Raising Voices works to prevent violence against both women and children. Raising Voices focuses on transforming attitudes and behaviors to promote gender equity in communities through a tool called SASA!. SASA! is a well-known intervention that has been adapted and implemented across regions, namely, the Caribbean, the Middle East, and Southeast Asia. The SASA! intervention includes four steps: Start, Awareness, Support, and Action which focus on educating communities through a series of activities that address the importance of power and awareness in relationships. A recent evaluation of SASA! in Uganda demonstrated a significant reduction in the reported level of physical partner violence against women. In Haiti the MDG Achievement Fund  partnered with local women’s organization to establish health clinics and provide counsel and care for victims of violence. Local leaders are trained to educate and spread awareness about domestic violence within communities and to report a witnessed crime to local authorities. The MDG Achievement Fund partners with UN Women to create educational and socio-economic opportunities for vulnerable women to increase economic independence and autonomy. There has also been an increase in the number of One-Stop Crisis centers worldwide to help recent victims of violence.

Contextual factors shape the etiology and manifestation of IPV and thus effective interventions differ within communities and across countries. Programs that employ models that are specific to cultural norms while including community members have been found to be effective in addressing IPV. In addition, structural and systematic intervention strategies (economic, social, political, and physical) to reduce IPV or its impact may also be essential to reduce IPV’s global burden (Bourey C, 2015). An example, of an issue embedded in underlying structural and systemic inequities is that may be potentially modified to improve IPV is that of literacy.  Regions with lower literacy levels show a higher prevalence of IPV among women. One study conducted in Ethiopia (Deyessa, 2010) found illiterate women were more likely to justify the reasons for a man beating his wife, compared to literate women. The study also found that literate women with a literate spouse were least likely to have experienced physical violence compared to literate women with an illiterate spouse. Similar findings were reported in a study in India (Ackerson, 2008) in which women residing in neighborhoods with high literacy rates were were less likely to experience IPV. Literacy can also have an important impact on other indicators of well-being entwined with outcomes for IPV such as contraceptive knowledge and use. In our recent work we found that literacy was significantly associated with the utilization of modern contraceptives (adjusted odds ratio (AOR) = 1.166, 95% CI = 1.015, 1.340). Thus, interventions that seek to modify systemic and structural components that influence literacy may have important implications for IPV.

Intimate partner violence is a common problem worldwide that needs to be addressed incorporating contextual needs. The World Health Organization calls for a collaborative, coordinated and integrated response for addressing this significant public health issue. It is evident that interventions should be multi-sectoral and a comprehensive approach should aim to address IPV implications on individual, relationship, community and societal levels.

Screen Shot 2018-08-17 at 11.00.41 AM.pngEwinka Minerva Romulus, MPH is a recent graduate from Arcadia University’s MPH program. Her master’s thesis focused on the influence of literacy on contraceptive knowledge and use among women in Swaziland. Prior to her graduate career, she studied Bio-behavioral Health at the Pennsylvania State University where she gained an understanding of the interactions among biological, behavioral, psychological, sociocultural, and environmental variables that influence health. Ewinka gained interest in global health after observing the existing issues around poverty, health, and inequality in her own country – Haiti.  She is planning on continuing her studies at Drexel University in the fall of 2018 to obtain a certificate in Epidemiology and Biostatistics. Her current interests are in women’s health, global health, and nutrition. Her global health experience includes traveling to Guatemala with Mayanza Organization to provide health education and health screenings to school-children. She is also involved in organizations in Haiti with a mission of eradicating many communicable diseases. During her free time, Ewinka enjoys reading, traveling, and learning to play the guitar.

McClintock.PictureDr. 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.

 

Outcomes of Global Intimate Partner Violence

This is the third part of a IH Blog series featured this summer, Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.

Written by: Erica Hartmann MPH, MMS (c) and Dr. Heather de Vries McClintock PhD MSPH MSW

Intimate partner violence (IPV) is defined by the Center for Disease Control (CDC) as physical violence, sexual violence, stalking and psychological (or emotional) aggression by a current or former intimate partner (Violence Prevention, 2017). Consequences of intimate partner violence (IPV) can be immediate, long lasting, and invisible. The physical impact of  IPV includes broken bones, lost teeth, hearing damage, and vocal cord damage due to attempted strangulation (Garcia-Moreno C et al., 2005). The World Health Organization’s multi-country study showed that women who were ever abused by their partner were twice as likely to report poor health and physical and mental problems when compared to women who were never abused (Garcia-Moreno C et al., 2005). Diagnoses resulting from IPV include irritable bowel syndrome, fibromyalgia, chronic pain syndromes, and asthma exacerbation (Crofford, 2007; Heise,Garcia Moreno, 2002). Additionally, violence during pregnancy is associated with miscarriage, late entry into prenatal care, stillbirth, premature labor, fetal injury, and low birthweight (Bailey, 2010; Garcia-Moreno C et al., 2005; Silverman, Decker, Reed, and Raj, 2006). IPV can have lasting, and often unseen consequences.

Intimate partner violence can be harmful to the victim and to the children in the home where violence is occuring. Studies from around the globe find that IPV is a leading predictor of child maltreatment (Hunter, et al., 2000; Family Violence Prevention Fund, 2006). Growing up in a home where the mother experienced violence is considered an adverse childhood experience, and is associated with greater likelihood of poor outcomes in later life such as alcoholism, drug abuse, and suicide attempts (Felitti, 1998).

Intimate partner violence (IPV) has previously been linked with child mortality in countries including Bangladesh, the United States, India, Malawi, and Timor Leste (Hossain, Sumi, Haque, Bari, 2014; Mwale, 2004; Silverman et al., 2011; Taft, Powell, and Watson, 2015; Garoma, Fantahun,and Worku, 2012). A recent study using data from the Timor Leste’s 2013 Demographic Health Survey (DHS) showed that women who experienced physical violence were 30% more likely to experience child loss (the death of one or more children), and women who experienced combined forms of violence were 45% more likely to experience child loss when compared with women who had not experienced violence (Taft, Powell, and Watson, 2015).

We sought to uncover the relationship between intimate partner violence and child loss using the Togo demographic health survey (DHS) administered between 2013-2014. In addition, we investigated the effect of emotional violence which to our knowledge, has not been investigated in associated with child loss.  The Demographic Health survey is a nationally representative household survey that is administered by the United States Agency for International Development (USAID). This survey provides a wide range of monitoring and impact evaluation indicators and is developed in collaboration with the surveyed country. The Togo 2013-2014 DHS survey was translated into 13 languages and was administered by 90 highly trained individuals after gaining privacy and consent of the participant. The DHS survey assessed lifetime victimization of physical, emotional, and sexual violence (yes/no), and child loss (difference between the number of childbirths and number of living children, 1 or more coded as yes/ 0 coded as no). Covariates assessed included age, education, marital status, wealth index, employment, justification of wife-beating, and urban/rural residence. Data were weighted and analyzed through a bivariate logistic regression adjusting for covariates using SPSS version 14.

In total, 4842 Togolese women completed the domestic violence module of the Demographic health survey. In all, 36.5% of women reported victimization of physical, sexual, or emotional IPV in their lifetime. Women who experienced any form of IPV were 1.415 times as likely to experience child loss when compared to women who never experienced IPV (adjusted odds ratio (AOR) =1.415, 95% confidence interval (CI)=1.227,1.633). Women were significantly more likely to experience child loss if they experienced physical IPV (AOR=1.340, 95% CI = 1.135,1.582), sexual IPV (AOR=1.488, 95% CI = 162,1.905) or emotional IPV (AOR= 1.325, 95% CI = 1.143,1.536). Women who experienced combined forms of violence were at significantly increased odds of experiencing a child’s death when compared to women who never experienced violence (AOR=1.479, (95%CI = 1.231,1.778). We saw a significant association between all forms of intimate partner violence and child loss among this population of Togolese women. This finding indicates a need for child mortality interventions that address intimate partner violence to reduce Togo’s child mortality rate.

Addressing IPV requires strategies implemented at the individual, community, and policy levels. Screening for intimate partner violence during prenatal visits and providing social worker counseling to future mothers reduces recurrent episodes of IPV and improves childbirth outcomes (leading to higher birth weights and fewer premature births) (Kiely, Elmohandes, El-khorazaty, & Gantz, 2011). Data also indicates that policies including support programs for survivors such as shelters, housing programs, legal services, have been effective in reducing negative outcomes. The World Health Organization outlines strategies through which policy can most effectively reduce the burden of IPV suggesting that the healthcare and other sectors should have minimum standards for addressing this issue. These standards include establishing clear working protocols encompassing clear referral pathways for survivors of IPV (WHO Response to IPV, 2016). The degree to and nature in which countries follow these recommendations varies dramatically with some countries aggressively attempting to address the issue while others failing to even acknowledge its existence. The consequences of IPV are vast and impact people all over the world. Public health professionals are at the forefront of tackling this issue and will continue to play a critical role in reducing the global burden of IPV.

Please stay tuned for Part IV in this series: Interventions and Strategies for Addressing Global Intimate Partner Violence.

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Erica Hartmann, MMS (c), MMS (c) 2020 is a student at Arcadia University who hopes to prevent violence by serving as a physician assistant specializing in primary care in communities with limited access to healthcare. Erica worked under Dr. Heather McClintock to uncover links between IPV and child loss in Togo, and hopes to continue researching global violence prevention interventions after graduating from Arcadia.

McClintock.PictureDr. 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.

References:

Bailey, B. A. (2010). Partner violence during pregnancy: prevalence, effects, screening, and management. International Journal of Women’s Health, 2, 183–197.

Crofford LJ. (2007) Violence, stress, and somatic syndromes. Trauma Violence Abuse; 8:299–313.

Garcia-Moreno C et al. (2005). WHO multi-country study on women’s health and domestic
Violence.

Garoma, S., Fantahun, M., & Worku, A. (2012). Maternal Intimate Partner Violence Victimization and under-Five Children Mortality in Western Ethiopia: A Case-Control Study. Journal of Tropical Pediatrics, 58(6), 467-474. doi:10.1093/tropej/fms018

Heise L, Garcia Moreno C. (2002). Violence by intimate partners. In: Krug EG et al., eds.

Hunter WM et al. (2000). Risk Factors for Severe Child Discipline Practices in Rural India. Journal of Paediatric Psychology, 25: 435–447.

Hossain, Sumi, Haque, Bari. (2014). Consequences of Intimate Partner Violence Against Women on Under- Five Child Mortality in Bangladesh. Journal of Interpersonal Violence, 29(8) 1402-1417.

Family Violence Prevention Fund (2006). Programs: Children and Domestic Violence. Family Violence Prevention Fund. Available at: http://endabuse.org/ programs/children/.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . .
Marks, J. S. (1998). Relationship of Childhood Abuse and Household Dysfunction to
Many of the Leading Causes of Death in Adults. American Journal of Preventive
Medicine, 14(4), 245-258. doi:10.1016/s0749-3797(98)00017-8

Kiely, M., El-mohandes, A. A. E., El-khorazaty, M. N., & Gantz, M. G. (2011). An Integrated Intervention to Reduce Intamate Partner Violence in Pregnancy: A Randomized Controlled Trial, 115, 273–283. https://doi.org/10.1097/AOG.0b013e3181cbd482.AN

Mwale (2004). Infant and Child Mortality in Malawi. Neonatal and Child Mortality. pp 123-132.

Runyan D et al. (2002). Child Abuse and Neglect by Parents and Other Caregivers. In: Krug EG et al. (Eds). World Report on Violence and Health. Geneva, World Health Organization, pp 59–86.

Silverman, J. G., Decker, M. R., Reed, E., & Raj, A. (2006). Intimate partner violence
victimization prior to and during pregnancy among women residing in 26 U.S. states:
Associations with maternal and neonatal health. American Journal of Obstetrics and
Gynecology, 195(1), 140-148. doi:10.1016/j.ajog.2005.12.052 

Taft, A. J., Powell, R. L., & Watson, L. F. (2015). in Timor-Leste, (July 2014), 177–181.
https://doi.org/10.1111/1753-6405.12339

Violence Prevention. (2017). Retrieved October 03, 2017, from
https://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

 

Risk Factors for Global Intimate Partner Violence

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

Screen Shot 2018-07-11 at 1.19.09 PM.pngMarsha 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.

McClintock.PictureDr. Heather F. de Vries McClintockis 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.

A Global Overview of Intimate Partner Violence

This is a guest blog post by Evangeline Wang, a public health student at Arcadia University and Dr. Heather F. de Vries McClintock PhD MSPH MSW, IH Section Member and Assistant Professor in the Department of Public Health in the College of Health Sciences at Arcadia University. It is the first in a three-part series the IH Blog will feature this summer called Intimate Partner Violence: Global Burden, Risk Factors and Outcomes.

Part I: A Global Overview of Intimate Partner Violence

Intimate partner violence, or IPV, as defined by the Centers for Disease Control (CDC), is violence that manifests as physical, sexual, or psychological harm inflicted by a current or former partner/spouse (CDC, 2018).

For my friend, it was psychological abuse. Last fall, my friend, a headstrong, independent woman, had just gotten out of an emotionally abusive relationship. As we were discussing it, she stated that although she knew some aspects were bad at the time, she found it difficult to leave the relationship. In this relationship, her partner would text her repeatedly, asking where she was, who she was with, and accusing her of unfaithfulness when she did not respond. She justified this behavior because she thought the constant text messages meant he was in love with her and was showing commitment toward her. One day during a fight he followed her home and despite her protests, entered her home spewing hurtful language. It was at this point she realized how harmful the relationship was and that she could not be in the relationship anymore. She decided to end it. When talking to me about it she expressed how challenging it was to leave and her thankfulness for having done so. She related to other victims and their challenges in ending an abusive relationship with a manipulative partner.  Unfortunately, like many others, my friend fell victim to intimate partner violence, a pervasive global public health issue.

Globally, in 2016, the World Health Organization (WHO) reported that 30% of women are physically and/or sexually abused by their partner as the global lifetime prevalence. This means that nearly 1 in 3 women will experience intimate partner violence during their lifetime. In the United States, the median prevalence of physical abuse is 30% (Violence Info, 2018). The prevalence of physical abuse is much higher in countries like Ethiopia (45%), Jordan (43%), and Bosnia and Herzegovina (76%).

Regional estimates range from 24.6% in the WHO Western Pacific region to 37.7% in the WHO South East Asia region. A more nuanced assessment by sub regions shows that the highest prevalence of lifetime intimate partner violence is found in central sub-Saharan Africa, with a prevalence of 65.6%. All regions in sub-Saharan Africa have lifetime prevalence estimates that are greater than the global average (WHO Global and Regional Estimates, 2013).  

The consequences of intimate partner violence are severe with research showing that exposure to intimate partner violence ultimately increases risk for disability and death. Persons exposed to intimate partner violence are more likely to experience physical and psychological trauma and stress. Such experiences are often characterized by musculoskeletal injuries, genital trauma, mental health problems, substance abuse, non-communicable diseases, somatoform disorders and/or many other adverse consequences. Concurrently, victims may have compromised access to health care due to a lack of autonomy as well as limited decision making power regarding their sexual and reproductive health. Intergenerational effects are common with victims experiencing greater risk for having premature and low birth weight babies as well as pregnancy loss (WHO Global and Regional Estimates, 2013).

Intimate partner violence is a pervasive public health problem that discriminates against no one. From underdeveloped countries to developing countries, this is a major public health issue that cannot be ignored. However, many people lack knowledge about the basic components of intimate partner violence. Furthermore, professionals seeking research on this topic have struggled to compile and access comprehensive information. Greater accessibility of knowledge can enhance global prevention, management and treatment efforts.

The World Health Organization developed an interactive app in response to these needs. This app allows for the public to access online violence studies by country and type of violence (e.g. physical abuse, sexual abuse, and psychological abuse). The purpose of the app is to consolidate and centralize academic journals and various reports about violence in order to make this information more accessible and easier for the public to understand. Not only does it allow journal article access, but it provides important information like prevalence, risk factors, consequences as well as prevention and response strategies. The prevention tab is especially helpful because it allows the user to see the effectiveness of given prevention initiatives based on prior research. Additionally, there are multiple graphs and other visuals that users can click on for more information making this an interactive and user-friendly app. This app can be accessed here: WHO Violence Info App.

Please stay tuned for Part II in this series: Risk Factors for Global Intimate Partner Violence

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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.

evangeline wang

Evangeline Wang is a public health major at Arcadia University. She is the president of the Public Health Society and has volunteered and interned with various public health agencies such as Prevention Point Philadelphia and HIPS in Washington D.C. After graduation, Evangeline hopes to attend graduate school and continue her studies in global public health.