Intimate partner violence (IPV) negatively affects women’s mental health all over the world. Public health studies conducted in the USA, Brazil, Vietnam and Ethiopia report strong associations between physical, sexual and psychological IPV and mental symptoms, such as depression and anxiety, memory and concentration problems, and suicidal thoughts and completed suicides. The recently released findings from the World Health Organisation (WHO) multi-country study on violence against women and its association with suicide attempts further underline the importance of investigating women’s mental health status particularly in countries where general life circumstances, such as poverty, food insecurity, lack of education and gender inequality can give rise to family and interpersonal stress.
Studies indicate that the more severe and frequent the abuse, the more it impacts on women’s well-being, and cumulative and concurrent exposure to physical, sexual and psychological abuse seems to be most detrimental to women’s overall mental health. The prevalence of intimate partner violence against women is higher in societies where gender roles are unequal and families live in disadvantaged neighbourhoods and among low socio-economic status families, especially where husbands are unemployed. All these factors contribute to elevate individuals’ psychological distress. A recent study described how neighbourhood disorder, such as fighting, drug use, community conflicts, prostitution and gang-related activity, may increase partner violence and augment poor psychological health and create lower overall quality of life among individuals.
Pakistan is a low-income Muslim country with approximately 176 million inhabitants. Only 36 percent of Pakistani women can read and write, and the employment rate for women is 22.2 percent, as compared with an average of 77.8 percent for men, with higher rates in urban areas. Pakistani society is male dominated, and the majority of women are pressured to accept arranged marriages. A certain degree of partner violence is normative, often deployed to secure male dominance within the marriage and avoid social stigma. In daily life, women are financially dependent on their husbands and discouraged from entering into paid work to earn an income. The few social or legal organisations that do support women are mainly active in upper socio-economic neighbourhoods, severely limiting the scope of service to all Pakistani women. There have been few population-based studies on IPV and its related health effects from Karachi, even though facility-based studies indicate a high prevalence. These studies report a prevalence of physical violence ranging between 16 and 76 percent, and for sexual violence it was 12-16 percent. For psychological violence the prevalence found was from 23 percent and upwards to extremely high levels (>60 percent).
This community-based study focused on low-income and middle-income women in urban Karachi. It aimed to investigate the mental health effects and women’s coping behaviours, such as disclosure rates and patterns of healthcare seeking, associated with husbands’ use of physical, sexual and psychological violence.
This cross-sectional study was performed in Karachi. The study included 759 married women aged 25-60 years, living in two towns with approximately 720,000 inhabitants. The response rate was 93.7 percent.
Due to the restrictive attitudes about women’s movements and decision-making in Pakistani society, it was necessary to link up with a health organisation that maintains a health data surveillance system and whose health workers were familiar to the community. Government health facilities were contacted initially, but as they lacked resources, we were advised to contact the Health and Nutrition Development Society (HANDS). HANDS’ facilities are equipped with trained people who shoulder full responsibility for local health services at the primary care level (maternal and child health, immunisation, oral rehydration therapy, control of diarrhoeal diseases, nutrition counselling, growth monitoring and treatment of minor illnesses), and field sites have been established for healthcare follow up. Community midwives (CMs) with 18 months of training are available at the facilities to provide general antenatal and postnatal care, to assist during deliveries and to provide family planning services. We trained these midwives to collect data for this study. HANDS shoulders the responsibility for health facilities in Gadap and Bin Qasim towns and has established 10 health field sites in these towns. For this study, six of these sites were randomly chosen for data collection. The population belongs mainly to the lower and middle socio-economic strata and includes different ethnic groups. The data gathered from these two towns can therefore be generalised mainly to the lower and middle socio-economic groups of Karachi.
To detect an increase in risk of 1.6 times of physical/sexual/psychological violence, with 80 percent probability and an estimated prevalence of this exposure of 20-30 percent in the study sample, we calculated that we needed a sample size of about 660 individuals. We decided to aim for 800 respondents; however, 810 were approached and eventually 759 women were included in the study.
Lifetime exposure to violence exercised by the husband was assessed by items forming composite measures for physical, sexual and psychological violence respectively. Physical abuse was defined as slapping, throwing things, pushing or shoving, hitting, kicking, dragging, beating or burning. Sexual abuse was defined by two items: physically forced intercourse by the husband and performing sexual acts against the woman’s will. Psychological abuse was defined by four items: insults or making the woman feel bad about herself, belittlement or humiliation in front of others, scaring or intimidating her on purpose and threatening to hurt her or someone she cared about.
The women were asked about their general health using a five-point scale (excellent, good, fair, poor or very poor). The scale was later dichotomised into two categories: ‘good and excellent’ and ‘fair, poor and very poor’. All women were also asked about six mental health symptoms experienced during the past 12 months, the response categories being ‘yes’ and ‘no’. The symptoms were ‘difficulties in performing usual activities’, ‘memory or concentration problems’, ‘difficulties in decision making’, ‘loss of interest in previously enjoyable things’, ‘feeling worthless’ and ‘experiencing suicidal thoughts’.
The ethical principles for violence research spelt out by WHO were strictly followed. All respondents were informed about their free choice to participate and to withdraw whenever they wished during the research phase. Data collectors secured written consent from all respondents preceding the interview. Those women who disclosed experiences of violence and expressed a need for support were referred to the Pakistan Women Lawyers Association and the Women’s Social Security Department for consultations with mental health professionals and lawyers, free of charge. Women from the community were also provided with awareness sessions on women’s rights by lawyers. The study was approved by the Institutional Ethical Review Committee of the Aga Khan University. Linking up with the HANDS organisation facilitated the data collection process greatly, as the data collectors were somewhat known in the area. Unfamiliar women introducing themselves as data collectors would hardly have been accepted by the families. Furthermore, data collectors unfamiliar to the households might have been put at personal risk.
Of the 759 women, the majority (59 percent) was between 25 and 35 years old. Fewer women than men had attended school (52.4 percent and 63.8 percent respectively). Most of the women were housewives and practised Islam. Almost all of the husbands (98 percent) were employed, and most of them (66 percent) were unskilled workers. Only 14.5 percent of the women were in paid employment. The prevalence of lifetime physical, sexual and psychological violence was 57.6, 54.5 and 83.6 percent respectively. In the entire study population, the adverse mental health condition most commonly reported was suicidal thoughts (58.8 percent), followed by feelings of worthlessness (42.3 percent) and difficulties in decision-making (35.3 percent). ‘Fair, poor or very poor general health’ was reported by 48.7 percent.
The prevalence of poor mental health was considerably higher among women exposed to any form of violence as compared to women not exposed to violence, with statistically significant differences for most of the health conditions included.
Suicidal thoughts were reported by as many as 74.1 percent, 75.8 percent and 65.3 percent of the women subjected to physical, sexual and psychological violence respectively. The category of ‘feelings of worthlessness’ was also highly prevalent, reported by 47.8 percent of those subjected to physical violence, by 51.7 percent of those subjected to sexual violence and by 49.2 percent of those reporting exposure to psychological violence.
In the multivariate analysis, after adjusting for socio-demographic variables, all of the health variables displayed statistically significant associations with physical violence. In the case of sexual violence, only ‘memory and concentration problems’ did not display statistically significant odds ratios, and ‘loss of interest in previously enjoyable things’ did not emerge as a statistically significant factor for psychological violence.
A striking finding was the strong associations found between the three forms of violence and suicidal thoughts. In the case of physical and sexual violence, the risk of suicidal thoughts was elevated four times (adjusted odds ratio [aOR] for physical violence 4.41; 3.18-6.12, and for sexual violence 4.39; 3.17-6.07) compared to those not exposed to any of the forms of violence. In the case of psychological violence, the aOR was 5.17 (3.28-8.01).
As suicidal thoughts were extremely prevalent in the total study population and strongly associated with all forms of violence, an attempt was made to investigate some underlying reasons. Women subjected to any of the forms of violence reported ‘family problems’ (45 percent) as the most important reason for suicidal thoughts, followed by ‘household work’ (9 percent) and ‘husband’s behaviour’ (6 percent). A few reported reasons such as son’s death, quarrel in the family, fed up with life, childlessness, illness and depression.
In situations of abuse, an important coping mechanism can be to confide in someone, if it can be done without fear of repercussion. Only 177 (27.4 percent) out of the 646 women who were subjected to any form of violence confided in someone, mainly in the parents (132; 20.4 percent), followed by friends (34; 5.3 percent) and in-laws (7; 1.1 percent). Only 24.9 percent (161) had actively sought help and protection, and this was mainly from the parents (128; 19.8 percent) but also from the in-laws (29; 4.5 percent), brothers and sisters (10; 1.5 percent), friends (10; 1.5 percent) and children (7; 1.1 percent). Only a few sought the assistance from any official body such as the healthcare services, any judicial authority or a religious leader (10, 1.5 percent). Of these, just one woman had turned to the healthcare services, two had contacted the social services, one had sought legal advice and six had turned to religious leaders.
Extracted from Tazeen S Ali, Ingrid Mogren and Gunilla Krantz’s research paper ‘Intimate partner violence and mental health effects: a population-based study among married women in Karachi, Pakistan’ published in the International Journal of Behavioral Medicine.