Pooled analysis of the association between mental health and violence against women: evidence from five settings in the Global South

OBJECTIVES

To describe associations between men's poor mental health (depressive and post-traumatic stress symptomatology) and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV), and women's mental health and their experiences of IPV and NPSV in five settings in the Global South.

DESIGN

A pooled analysis of data from baseline interviews with men and women participating in five violence against women and girls prevention intervention evaluations.

SETTING

Three sub-Saharan African countries (South Africa, Ghana and Rwanda), and one Middle Eastern country, the occupied Palestinian territories.

PARTICIPANTS

7021 men and 4525 women 18+ years old from a mix of self-selecting and randomly selected household surveys.

MAIN OUTCOME MEASURES

All studies measured depression symptomatology using the Centre for Epidemiological Studies-Depression, and the Harvard Trauma Scale for post-traumatic stress disorder (PTSD) symptoms among men and women. IPV and NPSV were measured using items from modified WHO women's health and domestic violence and a UN multicountry study to assess perpetration among men, and experience among women.

FINDINGS

Overall men's poor mental health was associated with increased odds of perpetrating physical IPV and NPSV. Specifically, men who had more depressive symptoms had increased odds of reporting IPV (adjusted OR (aOR)=2.13; 95%CI 1.58 to 2.87) and NPSV (aOR=1.62; 95% CI 0.97 to 2.71) perpetration compared with those with fewer symptoms. Men reporting PTSD had higher odds of reporting IPV (aOR=1.87; 95% CI 1.44 to 2.43) and NPSV (aOR=2.13; 95% CI 1.49 to 3.05) perpetration compared with those without PTSD. Women who had experienced IPV (aOR=2.53; 95% CI 2.18 to 2.94) and NPSV (aOR=2.65; 95% CI 2.02 to 3.46) had increased odds of experiencing depressive symptoms compared with those who had not.

CONCLUSIONS

Interventions aimed at preventing IPV and NPSV perpetration and experience must account for the mental health of men as a risk factor, and women's experience.

Factors associated with female students' past year experience of sexual violence in South African public higher education settings: A cross-sectional study

BACKGROUND

Intimate partner sexual violence and non-partner rape experiences are widely reported by female students in South African higher education institutions, as they are globally. However, limited research has focused on investigating vulnerability factors, which is vital for informing interventions.

OBJECTIVE

To describe the factors and inter-relationships associated with female students' increased vulnerability to past year experience of partner sexual violence and non-partner rape in South African higher education settings.

METHODS

We interviewed 1293 female students, i.e., 519 students in six Technical Vocational Education and Training (TVET) college campuses and 774 students at three university campuses. Participants were volunteers aged 18-30. The measured vulnerability factors included childhood sexual abuse, other trauma, mental ill-health, risky sexual behaviours, food insecurity, partner violence, and controlling behaviours. We used bivariate analysis, logistic regression, and structural equation modelling methods.

RESULTS

Twenty percent of participants experienced past-year sexual violence (17% partner sexual violence and 7.5% non-partner rape). Childhood sexual abuse had direct effects on experiencing past year sexual violence and physical, emotional partner violence or controlling behaviours. Risky sexual behaviours mediated the relationships of childhood sexual abuse or harmful alcohol use and past-year sexual violence experience. Mental ill-health mediated the relationships between childhood sexual abuse, other traumatic exposures, food insecurity, physical, emotional partner violence or controlling behaviours, and past-year partner sexual violence or non-partner rape experience.

CONCLUSIONS

Risky sexual behaviours, gender inequitable relationship dynamics, mental ill-health, and food insecurity are related and amenable vulnerability factors associated with female students' sexual violence experiences. Therefore, addressing these through comprehensive campus interventions, which are implemented when students first enrol in higher education and are most vulnerable to sexual violence, is critical. Society-wide sexual violence prevention is also imperative.

Social support factors associated with psychological resilience among women survivors of intimate partner violence in Gauteng, South Africa

BACKGROUND

Women's experiences of intimate partner violence (IPV) increase their risk for mental ill health. However, some women exposed to IPV and adversity are psychologically resilient and function well despite these exposures.

OBJECTIVES

We conducted a study to investigate the factors that are associated with psychological resilience among abused women, using data collected in a household survey conducted in Gauteng province of South Africa.

METHODS

Data is from a cross-sectional study. A multi-stage random sampling approach was used to select a sample of 501 women. The World Health Organization (WHO) Multi-Country Study on Women's Health and Domestic Violence Questionnaire was used to measure lifetime experience of physical and sexual IPV. Only 189 women who had experienced lifetime IPV were included in this secondary analysis. Resilience was measured as scoring below the threshold for the Centre for Epidemiological Studies Depression Scale and the Harvard Trauma Questionnaire. Other explanatory factors measured included child sexual abuse, non-partner rape, other traumatic life events, social support indicators, binge drinking and socio-demographic variables. Multivariable regression analysis was used to test factors associated with resilience.

RESULTS

Forty two percent of women scored below the threshold for post-traumatic stress disorder (PTSD) or depressive symptoms at the time of the survey and so were categorized as resilient. Social support indicators were associated with increased resilience. Women who perceived that their communities were supportive and they would easily find money in an emergency were more likely to be resilient. Women who binge drank, experienced severe IPV in the past 12 months, received negative reactions to disclosure and utilized medical or psychosocial services were less likely to be resilient.

CONCLUSION

Social support indicators including social connectedness, stronger network ties and perceived supportive communities are key factors in fostering resilience among abused women. Interventions should aim to promote stronger and supportive social networks and increase women's utilization of formal support services.

Mental ill health in structural pathways to women's experiences of intimate partner violence

Background

Depression, post-traumatic stress disorder (PTSD), and binge drinking are among mental health effects of child abuse and intimate partner violence (IPV) experiences among women. Emerging data show the potential mediating role of mental ill health in the relationship of child abuse and IPV. There is evidence that PTSD, depression and alcohol abuse are comorbid common mental disorders and that a bidirectional relationship exists between depression and IPV in some settings. Furthermore, the temporal direction in the relationship of alcohol abuse and women’s IPV experiences from different studies is unclear. We undertook a study with women from the general population to investigate the associations of child abuse, mental ill health and IPV; and describe the underlying pathways between them.

Methods

Data is from a household survey employing a multi-stage random sampling approach with 511 women from Gauteng, South Africa. IPV was measured using the WHO Multi-country Study on Women's Health and Domestic Violence Questionnaire. Child abuse was measured using a short form of the Childhood Trauma Questionnaire. Depression was measured using the Centre for Epidemiologic Studies Depression Scale (CESD). PTSD symptoms were measured using the Harvard Trauma Questionnaire. Binge drinking was measured using the Alcohol Use Disorders Identification Test (AUDIT) scale. All data analyses were conducted in Stata 13. Regression modelling was used to test the association between variables. Structural equation modelling with full information maximum likelihood estimation accounting for missing data was done to analyse the underlying pathways between variables.

Results

Fifty percent of women experienced IPV in their lifetime and 18% experienced IPV in the 12 months before the survey. Twenty three percent of women were depressed, 14% binge drank and 11.6% had PTSD symptoms. Eighty six percent of women had experienced some form of child abuse. Sociodemographic factors associated with recent IPV in multivariate models were younger age and foreign nationality. Depression, PTSD and binge drinking mediated the relationship of child abuse and recent IPV. Depression, PTSD and binge drinking were also effects of recent IPV. Other factors associated with recent IPV experience included relationship control, having a partner who regularly consumed alcohol and experiencing other life traumatic experiences

Conclusion

Mental ill health plays a mediating role in the relationship of child abuse and recent IPV experiences among women. Conversely, IPV also negatively affects women’s mental health. Interventions to reducing the incidence of IPV could help alleviate the burden of mental ill health among women and vice versa. Effective integration of mental health services in primary health care, detection of symptoms, brief interventions and strengthened referral mechanisms for sustained community-based care are necessary in responding to victims of intimate partner violence. Response for abused children needs to take similar approaches and reduce the long-term mental health effects associated with violent exposures.

Structural Pathways between Child Abuse, Poor Mental Health Outcomes and Male-Perpetrated Intimate Partner Violence (IPV)

BACKGROUND

Violent trauma exposures, including child abuse, are risk factors for PTSD and comorbid mental health disorders. Child abuse experiences of men exacerbate adult male-perpetrated intimate partner violence (IPV). The relationship between child abuse, poor mental health and IPV perpetration is complex but research among the general population is lacking. This study describes the relationship and pathways between history of child abuse exposure and male-perpetrated IPV while exploring the potentially mediating effect of poor mental health.

METHODS

We analysed data from a randomly selected, two-stage clustered, cross-sectional household survey conducted with 416 adult men in Gauteng Province of South Africa. We used multinomial regression modelling to identify associated factors and Structural Equation Modelling (SEM) to test the primary hypothesis that poor mental health (defined as abusing alcohol or having PTSD or depressive symptoms) mediates the relationship between child abuse and IPV perpetration.

RESULTS

Eighty eight percent of men were physically abused, 55% were neglected, 63% were emotionally abused and 20% were sexually abused at least once in their childhood. Twenty four percent of men had PTSD symptoms, 24% had depressive symptoms and 36% binge drank. Fifty six percent of men physically abused and 31% sexually abused partners at least once in their lifetime. Twenty two percent of men had one episode and 40% had repeat episodes of IPV perpetration. PTSD symptomatology risk increased with severity of child trauma and other trauma. PTSD severity increased the risk for binge drinking. Child trauma, other trauma and PTSD symptomatology increased the severity of depressive symptoms. PTSD symptomatology was comorbid with alcohol abuse and depressive symptoms. Child trauma, having worked in the year before the survey, other trauma and PTSD increased the risk of repeat episodes of IPV perpetration. Highly equitable gender attitudes were protective against single and repeat episodes of IPV perpetration. There was a direct path between the history of child trauma and IPV perpetration and three other indirect paths showing the mediating effects of PTSD, other trauma and gender attitudes.

CONCLUSIONS

Child trauma is a risk factor for both poor mental health and male-perpetrated IPV among men in Gauteng. Male-perpetrated IPV in these settings should be explained through a combination of the Trauma, Feminist, and Intergenerational Transmission of Family Violence theories. Prevention interventions for male- perpetrated IPV in South Africa need to incorporate strategies and therapies to address poor mental health conditions.