In West Africa’s Ivory Coast (Côte d’Ivoire), as many as 60 percent of women experience physical or sexual violence at the hands of their male partners at some point in their lifetime.
The statistic is stunning, but does not fully convey all of the immediate and deferred public health issues that arise when women become the victims of violence inside their homes or within their relationships.
The challenge for public health practitioners is how to address — and meaningfully reduce — the incidence of such violence in countries and cultures around the world where poverty, cultural attitudes surrounding gender and, frequently, external political violence or warfare contribute to an environment that is perilous for women, even within the confines of home and family.
“Intimate partner violence is a huge public health issue” in Ivory Coast — and worldwide, says Jhumka Gupta, assistant professor in the Department of Chronic Disease Epidemiology. A social epidemiologist, she has studied the far-reaching health implications of intimate partner violence (IPV) among inner-city residents, refugees and immigrants in the United States and among populations in countries as diverse as Bangladesh, Colombia, Haiti and Nepal.
Globally, anywhere from 15 percent to 75 percent of women experience physical or sexual IPV at some point in their lifetime, according to the World Health Organization. In the United States, despite numerous laws and services in place to protect women, the number is as high as 25 percent, the National Violence Against Women Survey has found.
Health and IPV
Gupta recently completed an evaluation of a two-year program aimed at reducing IPV against women in Ivory Coast’s rural villages that have been impacted by war and conflict.
The challenges are enormous. Very little research has been done on IPV in such settings, and evidence suggests that it is an issue that is often overshadowed by other, more pressing needs.
“In those kinds of settings IPV is very much neglected and is not a high-enough priority, since other important public health issues tend to be the focus,” Gupta says. “If gender-based violence against women is addressed, it generally focuses on sexual violence perpetrated by armed groups, with little attention to the violence a woman faces from her partner. I’m not trying to minimize violence by armed groups, but IPV is a very chronic issue. It happens before a war, during a war and after a war. And it occurs inside a woman’s home or inside what is perceived as protected space. So the [public health] needs of women experiencing this aren’t getting addressed.”
Prior to her academic research career, Gupta worked for women’s health programs in regions affected by conflict, including Haiti. She saw the horror of IPV firsthand — women who ended up in the hospital with knife or machete wounds inflicted by their husbands.
“IPV is deeply rooted in cultural norms and gender inequalities that disfavor women,” she says. “In areas impacted by conflict, you also have a breakdown in infrastructure, lack of services and laws, economic disruption and trauma, all of which can contribute to IPV in these settings.” Additionally, Gupta’s prior research has shown that men who experience political violence are more likely to be violent against women later in life.
These factors, compounded by a tendency of funding agencies and governments to overlook IPV in conflict-affected settings, contribute to an environment where silence around IPV is encouraged and it is difficult to fully address the health needs of women, Gupta says. “There are obvious health consequences, such as injury and death — but IPV is also linked to a whole host of other public health consequences, such as HIV/AIDS, because a woman cannot control her sexual relations with her partner, cannot say ‘no’ and cannot demand protection, so she’s going to be vulnerable to HIV. There is a greater risk of unwanted pregnancies, poor birth outcomes and poor mental health.”
Gupta says that the health impacts of IPV may be more detrimental than the exposure to war-related violence. Preliminary analyses from Gupta’s Ivory Coast study suggest that IPV was a greater predictor of poor mental health among women than exposure to war-related violence such as threats, injury and sexual violence from armed perpetrators.
Existing evidence also suggests that initiatives that empower women economically, combined with programs that challenge gender inequalities and prevailing notions of masculinity, lead to a decrease in levels of IPV, Gupta says. But the application of this research to areas of conflict is just beginning. Gupta’s latest project is the result of a partnership with the International Rescue Committee, a humanitarian organization that started a village savings and loan association program in rural villages in Ivory Coast two years ago. About 1,200 women signed up for the two-pronged program, which provided them with access to a savings and loan association and participation with their partners in discussion groups about gender attitudes.
The State and Peace-Building Fund, administered by the World Bank, is supporting both the intervention and Gupta’s randomized controlled trial. Gupta’s research partners include Kathryn L. Falb, a postdoctoral associate at the Yale School of Public Health; Jeannie Annan, director of research and evaluation at the International Rescue Committee; and Innovations for Poverty Action, a nonprofit dedicated to helping the world’s poor. The program’s gender dialogue group is designed to challenge traditional male-dominated household norms.
“It starts off with a discussion of who contributes to the household and includes different exercises, role playing and homework,” Gupta says. “This is a very comprehensive curriculum that was developed by the International Rescue Committee. They talk about how to make a budget together, how to make a decision about a household purchase together and who contributes what to the household. The aim is to get the idea [across] that women also do contribute to the household — to really try to change norms, which we hope will translate into a reduction of IPV.”
Gupta says the program is designed “not to alienate men,” but to work with them to change gender patterns. “It’s a very subtle approach,” she says.
Gupta recently completed a rigorous evaluation of the program. The results are not in yet, but if the evaluation shows a decrease in the rates of IPV against women, Gupta says it will have very important implications for public health programming. “We’re definitely hoping for a promising outcome, particularly because it’s among the first [types of] interventions to focus specifically on IPV in a conflict-affected country.’’
In the short term, Gupta hopes to reduce the incidence of IPV among women in Ivory Coast and, ultimately, to improve their health. “In the longer term, we hope to take lessons learned from Ivory Coast and apply them to programming in other regions plagued by conflict to reduce IPV and improve the lives of women and communities.”
Also, she says, “We want to show that, despite the numerous challenges of doing research in an area that is impacted by conflict, it is possible to conduct a rigorous randomized trial and we can tackle IPV despite the obstacles.” The International Rescue Committee, meanwhile, which works in over 40 conflict-affected countries, is eager to apply effective strategies as it develops programs to reduce IPV worldwide.
Gupta says she has also applied for research funding to explore the feasibility of conducting this intervention in Ivory Coast’s financial capital, Abidjan. “The current intervention very much relies on the closeness of participants. In rural villages, where “people behave like a large family,” IPV is far more commonplace than in urban settings that are typically more fragmented,” she says.
During her last visit to Ivory Coast, Gupta says she had the opportunity to hear from women in Abidjan who shared the challenges they face from both IPV and food insecurity as well as their desire to have more programs in their city that focus on these issues.
“Traditionally IPV was seen as something solely in the realm of the criminal justice world, not so much as a public health issue,” Gupta says. “The world is slowly starting to wake up to the fact that intimate partner violence is a pressing public health concern.”
Gupta recently started a clinic-based randomized control trial in Mexico City to train nurses to ask about IPV and provide referrals to women at public health clinics. She also plans to conduct IPV research in urban slums in Latin America and would like to implement similar research interventions within communities in New Haven, including those impacted by community violence and those with growing immigrant populations.
Gupta became interested in public health while earning a bachelor’s degree in biology (with a minor in Spanish) at the University of Maryland. Working as a volunteer with families impacted by HIV in the Washington, D.C., area, she became aware of the tremendous impact that IPV had on many of their lives, and she wanted to help to get to the root of the issue. Her path to public health, however, actually began much earlier. As a daughter of immigrant parents, she learned about the hardships faced by her mother’s family as refugees during post-partition violence in Bangladesh. This led to Gupta’s interest in working with populations experiencing adverse circumstances.
“I got to be where I am today, in part, because my father was a very progressive thinker who encouraged my potential for contributions, regardless of what traditional norms dictated,” she says. “However, I saw that this was not the case for many of the women I encountered — and these women and their communities deserve better. We in the public health field have an enormous responsibility to apply our talents to ensure that this happens.”
This article originally appeared in the Spring 2013 issue of Yale Public Health magazine. To view the full digital edition, click here.