IH CONNECT

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.

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.

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.

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

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.