PHX Perspectives | April 26th, 2018

On March 26, the 47th birthday of Bangladesh, my native country, a picture flooded my Facebook newsfeed. In the colors of Bangladesh flag, the picture displayed the lifeless body an adolescent girl. Her body, dressed in a ruby red salwar kameez, lay on a green field carved in the shape of Bangladesh. Her name was Beauty. She was 16 years old. Beauty was raped by a man whose courtship she had rejected. Later she was murdered and abandoned for public discovery.

A few days earlier, however, Bangladesh made news for a starkly different cause. Childhood deaths from diarrhea and other enteric diseases have fallen by 90 percent in the past two decades in the country, according The Economist’s report, “Bangladesh Shows How to Keep Children Alive.”

So, on its birthday, Bangladesh found itself at a crossroad: Is the country an example for its low-cost, high-return public health programs, or an epitome of the state of women worldwide?

Gender-based violence is common worldwide. Spousal violence is the most common form of violence experienced by women, and is defined as the threatened, attempted, and completed physical, sexual, or emotion violence between partners in an intimate relationship. Globally, one in five women experience a form of spousal violence during pregnancy, one in three over a lifetime. These statistics are even worse among women in low-income countries. For example, in Bangladesh, one in two married women aged 15-49 experienced physical or sexual violence during their lifetime.

Gender-based violence is concerning to us all, primarily on the ground of its human rights violations. For me, it’s also a personal matter. It’s just a matter of random chance at birth that I am privileged to talk about Beauty and not live her life. So why should we, as public health professionals, worry about women being abused by their husbands or a girl like Beauty being assaulted by a male neighbor? Let’s consider this for a start: Spousal violence is likely a cause or consequence of any public health problem you are passionate about, whether it is HIV; ART adherence; women’s health; adverse pregnancy outcomes; premature birth; child health, nutrition, growth, and development; fertility; birth spacing; sexually transmitted diseases; mental health, illness, and suicidality; substance use; or obesity, hypertension, and other non-communicable diseases.

This reality implies that public health interventions could potentially yield greater or more lasting effects on health or health-related behavior (e.g., ART adherence) if the interventions were to simultaneously address the causes and consequences of spousal violence, or if they were to be implemented in a context where violence prevention and/or mitigation measures are in effect.

Too ambitious an idea? Not if we address some of the outstanding concerns pertinent to violence research, especially in low-income countries.

Spousal violence is common yet hard to measure. This is mostly because of the nature of the topic of inquiry at hand, as well as the tools of inquiry available to researchers. Spousal violence entails “socially undesirable” behaviors; it’s a “private matter” between intimate partners in an ongoing relationship. Administrative data on spousal violence rarely exists in low-income countries. Instead, victims’ self-reports, collected via face-to-face interviews, provide the bulk of data on spousal violence in low-income settings. Unfortunately, retrospective self-reports can be inaccurate or unreliable. Reality is too complicated to automatically assume that the woman’s report is 100 percent accurate, and to use it as the “gold standard” measure of IPV. A perpetrator can frighten his partner into complying to demands not to report violence. The net effect is biased and underestimates violence prevalence, making it difficult to know with whom to intervene or whether violence prevention programs are effective.

Further, prior research and practice have largely ignored non-spousal violence occurring concurrently with spousal violence. Yet, women and girls experience violence in public spaces, on public transport, in the workplace, and at school. Abuse commonly takes the form of leering looks, offensive gestures or remarks, unwanted touching, and sexual assault. In Bangladesh, slitting dresses with a sharp object with an intention to expose women’s bodies has emerged as a new form of abuse. Non-spousal violence can also have detrimental effects on women’s health: Women’s potential to seek health care or earn a living or a degree may be severely compromised if she does not feel safe leaving home to go to clinics, work, or school.

The good news is that major global health donors are increasingly persuaded that violence against women must end. For instance, Melinda Gates announced a $170 million plan to fund women’s equality globally, arguing that women’s equality reduces vulnerability to violence. Since 2013, the United States’ support for violence prevention programs globally totaled approximately $153 million per year. The World Bank now supports $128 million in development projects aimed at violence prevention. We also now have a tremendous opportunity at hand to offer help to women who are victims of violence or at-risk. Globally, more and more women are seeking ANC care, attending school, and participating in the labor force. Therefore, women are increasingly coming into contact with health providers, educators, and employers. Finally, the norms of victim-blaming are changing globally. All this will likely improve feasibility of implementation of violence prevention programs globally.

However, for global health investments to optimally affect the health and well-being of women worldwide, we need to resolve the fundamental problems of identification of victims and violence prevalence. Women’s self-reports will remain the primary data source for spousal violence for the foreseeable future in low-income countries, where women rarely disclosure spousal violence to police or health providers. Therefore, it is as important to improve the validity and reliability of the self-report measures of IPV in low-income countries as it has been in high-income countries.

Nafisa Halim, Research Assistant Professor of Global Health, and Monica Onyango, Clinical Assistant Professor of Global Health, will teach Gender-Based Violence: Research Methods and Analysis this June 11–13 as part of the Population Health Exchange Summer Institute.

This article was originally published by Boston University School of Public Health on 4/20/2018.

The PHX Perspectives blog is a platform that creates an opportunity to share public health stories and viewpoints. Anyone interested in submitting a piece, which should be 600-800 words long, should contact phx@bu.edu. Population Health Exchange reserves the right to reject or edit submissions. The views expressed are solely those of the author and are not intended to represent the views of Population Health Exchange or Boston University School of Public Health.