Women who have experienced domestic violence are more likely to die

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Women who have experienced domestic abuse appear to be more than 40 percent more likely to die from any cause compared to the general population, a study led by the Universities of Warwick and Birmingham suggests.

The researchers have also identified an increased risk of developing cardiometabolic diseases such as cardiovascular disease and type 2 diabetes in those who have experienced domestic abuse, although more research is required to determine what other factors specifically lead to an increase in their mortality.

Domestic abuse, consisting of physical, psychological, sexual, financial and emotional abuse, is thought to be an extremely common phenomenon, with an estimated 1 in 3 women globally and about 1 in 4 women in the UK having experienced it at some point in their life.

The research, which is part of a wider research agenda into the health impacts of domestic abuse, is published today (17 February) in the Journal of the American Heart Association and explores the association between exposure to domestic abuse in a female population and the subsequent development of cardiometabolic disease (cardiovascular disease, hypertension and type 2 diabetes) and all-cause mortality.

Using medical records from UK GP surgeries between 1995 and 2017, the team were able to identify 18,547 women with a recorded code relating to exposure to domestic abuse.

These were matched to 72,231 like for like women (similar in terms of age, body mass index, deprivation level and smoking status) who did not have such an experience recorded.

The researchers then followed both groups whilst they were contributing to the dataset and calculated the risk of developing cardiometabolic illness and all-cause mortality.

They found that the risk of developing cardiovascular disease was increased by 31% and type 2 diabetes by 51% in the exposed group.

There was no association found with hypertension. They also found that all-cause mortality (i.e. due to any cause throughout the study period) among women exposed to domestic abuse was 44% higher.

Although the team were not able to confirm the reason for the increased mortality, it may be partly explained by the increased cardiovascular risk.

It is important to note that during the study period, the number of patients who died was relatively few (948 out of a total cohort of 91,778) likely due to the age at cohort entry being young (37 years old).

The adjusted relative risk increase was 44%, with the absolute risk of death being 6 per 1,000 women per year in the exposed cohort (recorded exposure to domestic abuse) compared to 3.1 per 1,000 women per year in those without such a record in their medical notes.

However, the research published using GP records has identified a discrepancy found between the abuse reported in GP practices and the national survey data, with an estimated prevalence of 1 in 4 women in survey data who have experienced domestic abuse compared to about 0.5% coded as such in GP data.

This means that many of those not coded as exposed to domestic abuse may have actually experienced some abuse. If this is the case, then it would suggest that the displayed results may be an underestimation.

Better linkage and data sharing between public services, such as the NHS and police, could help inform GPs to further support the mental and physical health needs of their patients who have experienced domestic abuse.

Better linkage and data sharing between public services, such as the NHS and police, could help inform GPs to further support the mental and physical health needs of their patients who have experienced domestic abuse.

Lead author Dr Joht Singh Chandan, from Warwick Medical School and the University of Birmingham’s Institute of Applied Health Research, said:

“As further in-depth detail of the traumatic experiences is not available in these records it was not possible to assess whether the severity of domestic abuse was associated with a different risk impact.

It is important to note that not all cases of domestic abuse go onto develop adverse health outcomes, but from this study we can see that within this dataset, the cohort of women recorded to have experienced domestic abuse are at a greater risk than those without such records present.

“Considering the prevalence of domestic abuse, there is a public health burden of cardiometabolic disease likely due to domestic abuse.

Although our study was not able to answer exactly why this relationship exists, we believe that it is likely due to the effects of acute and chronic stress.

Additionally, we know that exposure to domestic abuse may be associated with other lifestyle factors (such as poor diet, alcohol and smoking as seen in our study).

Although we made attempts to account for the impact of this on our results, these lifestyle factors still contribute risk for the development of cardiometabolic disease, therefore need public health approaches to manage this in women who have experienced domestic abuse.

“Not every woman experiencing domestic abuse will go on to develop a long-term illness. Our understanding of the physical and mental health effects of domestic abuse is arguably still in its infancy.”

“The introduction of the recently formed violence reduction units could play a role in supporting survivors of domestic abuse, as would the Domestic Abuse Bill which would give survivors the rights and support they clearly need.”

Senior co-author Dr Krish Nirantharakumar of the University of Birmingham’s Institute of Applied Health Research, said: “It is important for us to highlight to the government and public sector bodies to not only continue funding and supporting initiatives that prevent domestic abuse, but also invest in those services which can provide the support and care for survivors who have experienced such trauma, to prevent the development of these negative consequences which can be debilitating and disabling for life.

Therefore, this research clearly supports the promotion of a public health approach to abuse and violence.”

This work adds to the growing research published by the team at the two Universities exploring the physical and psychological effects of domestic abuse.

In 2019, the team published research that showed that women who have experienced domestic abuse are almost twice as likely to develop fibromyalgia and chronic fatigue syndrome, while a previous study published in June 2019 showed that UK survivors of domestic abuse are three times more likely to develop severe mental illnesses.


At some point in their lifetime, 1 in 3 women worldwide will have experienced intimate partner violence.[1]

Intimate partner violence against women (IPVAW) is defined by the World Health Organization (WHO) as women’s self-reported experience of physical, sexual or psychological harm or threats of such harm at the hands of their intimate partners or ex-partners.

The growing recognition of IPVAW as a prevalent global issue was informed by the WHO’s Multi-Country Study on Women’s Health and Domestic Violence Against Women.

The WHO Multi-Country Study found a lifetime physical violence ranging from 13% to 61%, sexual violence from 6% to 59%, and psychological violence from 21% to 90%.[1]

IPVAW has serious and negative social, medical and economic consequences for individuals and families.[2] IPVAW is associated with food insecurity,[3] lower birthweight of newborns,[4] delay in initiation of childcare,[5] and child maltreatment.[6]

Previous work found that IPVAW is associated with sociodemographic characteristics, such as young age, lower education, and other health behaviors, including alcohol use.[7]

Because of the correlation between sociodemographic factors and individual health, IPVAW is recognized as a human rights violation and an important public health issue.[8]

Brazil criminalized violence against women in 2006.[9] The 2006 legislation, commonly referred to as the Maria da Penha Law,[9] also expanded a network of services (i.e. police, justice system) and promoted research studies, program implementation, and educational campaigns.[10]

Furthermore, Brazil codified the mandatory reporting of IPVAW by healthcare providers in 2003[11] and created a standardized notification form in Brazil’s national health database, Sistema de Informação de Agravos de Notificação(SINAN), [12] in 2009.[13]

In Brazil, the estimated lifetime prevalence of physical violence throughout the country is as high as 16.7% and 2.4% for sexual violence.[14] This 2017 estimate was higher than previous nationwide estimates from the Brazilian National Alcohol and Drugs Survey in 2012 estimating physical violence at 6.3%.[15]

Prevalence estimates varies not only over time but also by region and by type of violence. In the southern state of Paraná, our region of interest, IPVAW clustered mostly around the southern part of the state with one cluster in the northern mesoregion. [16]

In the southeastern city of São Paulo, lifetime prevalence of physical violence was 27.2% compared to the rural northeastern province of Zona da Mata de Pernambuco (33.8%). In both these areas, physical violence was more prevalent than sexual violence (10.1% in São Paulo and 14.3% in Zona da Mata de Pernambuco). [17]

Physical violence was found to be particularly high (30%) in the southeast city of Rio de Janeiro in women with children. [18]

While previous studies have estimated prevalence of IPVAW and associated sociodemographic characteristics in Brazil, these studies have focused on either physical violence [19] or sexual violence[16].

Only one study in Brazil has examined psychological aspects of violence in addition to physical and sexual violence. [20] This study in the state of São Paulo found the lifetime prevalence of IPVAW in any form was 55.7% with 53.8% psychological, 32.2% physical, and 12.4% sexual.

To have a more encompassing scope of IPVAW in Brazil, the current study estimates the prevalence of three forms of IPVAW using a cross-sectional design in the urban city of Maringá. Our second aim was to identify victim sociodemographics associated with IPVAW.

Discussion

In this cross-sectional study in the southern Brazilian city of Maringá, we found that lifetime prevalence of at least one form of IPVAW was 56%. Compared to the cross-sectional WHO Multi-Country Study on Women’s Health and Domestic Violence, this prevalence is higher than the lifetime prevalence of at least one form of IPVAW in the southeast city of São Paulo (46.4%) and the rural northeast region of Zona da Mata de Pernambuco (54.2%).[27]

Despite being an urban area, Maringá interestingly has a higher lifetime prevalence similar to a rural region. Our finding suggests that this community is particularly vulnerable to IPVAW.

This study also supports prior work on the distribution between three types of violence that women experience: lifetime psychological violence as the most common, physical and lastly, sexual.[28]

Our study is further consistent with prior work in other countries in that few of our participants experienced physical and sexual violence without also experiencing psychological violence. Thus, future interventions may benefit from addressing psychological violence in addition to other forms of IPVAW.

Women in this community who experienced IPVAW have sociodemographic characteristics similar to and different from other women in the world who experience IPVAW. Women in this community who experience IPVAW are more likely to be employed, have more children, and not cohabiting with their partner.

Employment status has had mixed associations in studies throughout the world [2932] and not associated with IPVAW in northeastern Brazil. [33] The unclear association of women’s employment status may be due to the complex interplay of socioeconomics and gender norms. Women who are employed may violate normative gender roles, leading the relationship to have more psychological stress. This strain, in turn, may lead to more violence in order to exert control over the relationship. However, independent income for women may also provide resources to prevent and end violent relationships. The theoretical complexity of women’s employment status and its implication on relationship dynamics mirrors the inconsistent associations found in previous studies.[32,34]

In this study, having 4 or more children was found to be associated with lifetime experience of physical violence.

While studies have not established why having more children is associated with more violence between parents, it can be surmised that parenting could create economic insecurities as well as feelings of stress or jealousy within the violent partner. [635]

Additionally, previous studies have established the prevalence of co-occurring child maltreatment and IPVAW in the U.S, [636] suggesting violence is not isolated to partners but may be the result of underlying harmful family dynamics.

Because of this relationship, pediatricians and other health care providers have a unique position to screen for IPVAW. [37]

Interestingly, cohabitation with one’s partner was found to be protective factor of IPVAW. This finding is in contrast to a previous studies throughout the world, including in Brazil. [3842] It would be of interest to explore the role of marital status and cohabitation in IPVAW in this community.

Surprisingly, these IPVAW prevalence findings were not associated with educational level and income. These findings contrast previous studies that have shown lower levels of education and per capita income as risk factors for IPVAW [19,20,38,43,44].

Our study suggests that while economic disadvantages may create stressors and vulnerabilities that contribute to the experience of IPVAW [2845], focusing primarily on poverty reduction strategies may not address other underlying causes of IPVAW in this setting.

These underlying causes may include patriarchal constructs, perceived threats to dominance, permeation of normative power dynamics within intimate relationships, childhood exposure to IPVAW or other precipitating factors, such as substance or alcohol use, stress or feelings of jealousy [194346].

The strengths of this study were having community health agents accompany our researchers and communicate with participants in the national language of Portuguese.

This already established connection provided participants with a sense of familiarity and safety about personal information. The involvement of community health agents further developed a sense of rapport and grew existing health networks within the community.

Participants’ openness during the study is suggested by a low rate of missing survey data.

The findings presented in this study should be interpreted in the context of some limitations. Underreporting may still exist because of fear of retaliation, of being discovered, shame, or women who have died from intimate partner violence.[1047]

Convenience sampling may have produced unmeasured bias and a sample not representative of the population, especially in a heterogeneous population. [48] Using multistage cluster sampling methods in future studies may result in a more representative sample to allow for generalizability of results. [19]

The median age of our participant population was 51 years and were unemployed, which may reflect the time survey data were collected (between the 8am and 5pm on weekdays) to minimize contact with working spouses.

However, this also meant that working women may have been inadvertently excluded due to the sampling method. This study is also limited by the use of cross-sectional data that highlight associations but not causations.

Our findings were also not tracked in time to evaluate associations between IPVAW and changes related to participants’ age, relationships with their partners, and societal changes. Lastly, the questionnaire was aimed at women who survived violence. Self-reporting behavior influences the data collected and may still lead to underreporting.

The findings from this study demonstrates IPVAW is a problem affecting the majority of women in this community. The sociodemographic associations are not entirely consistent with other studies in Brazil and other LMIC. Larger studies are needed to understand why this community is particularly vulnerable to IPVAW.


Source:
University of Warwick

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