Understanding Domestic Violence and Its Consequences: Contributions of the Demographic and Health Surveys

1. Understanding Domestic Violence and Its Consequences: Contributions of the Demographic and Health Surveys Breaking the Cycle of Violence Against Women: Understanding the Impact of Violence Against Women on Development November 25 through December 10, 2006 ~ Washington, DC Kiersten Johnson, PhD ORC Macro/Demographic & Health Surveys

2. Overview • What is violence against women? • Historical context • Data • Creation of survey instrument • Logistical/ethical challenges and sensitivities • Extent, correlates and consequences • Use of findings • Continuing evolution

3. What is violence against women? Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life Article 1, United Nations Declaration for the Elimination of Violence against Women

4. Gender-Based Violence Over the Life Cycle: • Violence by states (e.g. rape in war) • Trafficking • Acid throwing • Non-partner rape/harassment/violence • Dowry deaths/honor killings • Differential access to food/medical care Psychological abuse; Coerced sex/rape/harassment; Physical violence; Violence during pregnancy • Female infanticide; FGM • Sex-selective abortion • Differential access to food/medical care • Violence in pregnancy • Physical and sexual violence • Psychological abuse Others Family members Intimate partner Prebirth/ Infancy Adolescence Reproductive Elderly age (adapted from Watts and Zimmerman, 2002)

5. Setting the context: • Within the past 30 years: • developing awareness of the importance of women’s social status in relation to key outcomes • violence against women (VAW) as an indicator of status • Early research: • demonstrated a relationship between VAW and reproductive health • raised awareness of the problem, health consequences • 1995 Beijing World Conference on Women Platform of Action: • explicitly recognizes that VAW: • creates an obstacle to the achievement of the objectives of equality, development and peace at the national level • violates the human rights of women at the individual level. • recognized that the lack of data and statistics on the incidence of violence against women is an impediment

6. Problem: Lack of data and statistics Solution: Demographic and Health Surveys (DHS)- Nationally-representative household surveys with large samples - Provide data in the areas of population, health, and nutrition- Comparable across countries and over time

8. History of violence measurement in the DHS • Earliest efforts: • Country-specific questions (Colombia 1990 & 1995) • Questions developed and implemented as part of topic-specific studies • 1993 Philippines Safe Motherhood Study • 1995/96 Uganda Negotiating Reproductive Outcomes Study. • In 1993, DHS hired a WID specialist to introduce and measure women’s status in the DHS on a pilot basis. • WS module developed in 94-95, implemented in 1995 Egypt DHS • Included questions that measured freedom from violence • Special efforts were made in the 1998 Nicaragua DHS • develop a set of questions that increased the validity of the DV measure • provide related information such as help seeking • The current module • result of the lessons learned from the Egypt and Nicaragua exercises • accompanied by guidelines (adapted from WHO guidelines) on its ethical implementation

9. Challenges • Defining ‘what’ violence you want to measure • Ensuring safety and ethical standards • Ensuring validity of the measures • Analysis concerns • Treading carefully

10. What to Measure... • Types of violence • Economic • Emotional/Psychological • Physical • Sexual • During pregnancy • Issues of severity: Act vs. Outcome • Which perpetrators to include? • Which women are in the denominator?

11. Safety and Ethical Concerns • Confidentiality • Respondent and interviewer safety • Emotional burden of such research • The Do Good vs. Do No Harm principles • A need to balance concerns with information needs

12. Validity of Data • No catch-all term to capture violence Recommendation: Ask about different types of violent acts separately, specifically • Risk of underreporting of violence Recommendations: Build rapport, ensure privacy, provide multiple opportunities to reveal abuse

13. Spousal violence • Physical and sexual violence • Does/Did your (last) husband ever: • Push you, shake you, or throw something at you? • Slap you or twist your arm? • Punch you with his fist or with something that could hurt you? • Kick you or drag you? • Try to strangle you or burn you? • Threaten you with a knife, gun, or other type of weapon? • Attack you with a knife, gun, or other type of weapon? • Physically force you to have sexual intercourse with him even when you did not want to? • Force you to perform other sexual acts you did not want to?

14. Spousal violence (contd.) • Additional questions: Give additional opportunities for disclosure and provide a measure of health consequences • Did the following ever happen because of something your (last) husband did to you: • You had bruises and aches? • You had an injury or a broken bone? • You went to the doctor or health center as a result of something you husband did to you?

15. Spousal violence (contd.) • Emotional violence • Does your husband ever: • Say or do something to humiliate you in front of others? • Threaten you or someone close to you with harm?

16. Violence by others • From the time you were 15 years old has anyone (other than your current/last husband) hit, slapped, kicked, or done anything to hurt you physically? • Can include ex-husbands of women married more than once • Violence during pregnancy also uses similar question • Can include current husbands • At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts? How old were you the first first time you were forced to have sexual intercourse or perform any other sexual acts?

17. Other questions • Marital control • Now I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner? • He is jealous or angry if you talk to other men? • He frequently accuses you of being unfaithful? • He does not permit you to meet your female friends? • He tries to limit your contact with your family? • He insists on knowing where you are? • He does not trust you with any money? • Violence by women against their spouse • Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) husband when he was not beating or physically hurting you? • Help seeking

18. Africa Cameroon 2004 Egypt 1995 & 2005 Kenya 2003 Liberia 2006/07* Malawi 2004 Mali 2006* Namibia 2006* Rwanda 2005 South Africa 1998 Uganda 2006* Zambia 2001/02 Zimbabwe 2005/06* Asia/South Asia Bangladesh 2004 Cambodia 2000 & 2005* India 1998/99 & 2005/06* Latin America/Caribbean Bolivia 2003 Colombia 1990, 1995, 2000, 2005 Dominican Republic 2002 Haiti 2000 & 2005* Honduras 2005* Nicaragua1997/98 Peru 2000 & 2004 Eurasia Azerbaijan 2006* Moldova 2005* Turkmenistan 2001* Ukraine 2007* Domestic violence data in the DHS * Data not yet available.

19. Prevalence of domestic violence in DHS countries (ever experienced) HT 29 DR 22 EG 34 IA 19 NC 30 KE 47 CO 44 CM 42 KH 18 BO 53 RW 34 PE 42 ZM 48 MW 27

20. Specific acts of physical violencePercentage of women who have ever experienced specific acts by their spouse

21. Specific acts of sexual violencePercentage of women who have ever experienced specific acts by their spouse

22. Specific acts of emotional violencePercentage of women who have ever experienced specific acts by their spouse

23. Violence during pregnancy

24. Consequences of husband’s actPercentage of women who have ever experienced specific consequences of violence

25. Role of husband’s drinking habitsAdjusted odds of women reporting violence in the past yearReference category: Husband does not drink (ns) (ns) (ns) Baseline risk (1.0)

26. Intergenerational aspects of violenceAdjusted odds of women reporting violence everReference category: Respondent’s mother not hit by respondent’s father Baseline risk (1.0)

27. Health outcomes: pregnancy terminationAdjusted odds of ever-experience of pregnancy termination Reference category: Never experienced domestic violence Baseline risk (1.0)

28. Health outcomes: experience of STIsAdjusted odds of experience of STI/symptom of STI in past 12 monthsReference category: Never experienced domestic violence Baseline risk (1.0)

29. Health outcomes: unwanted birthAdjusted odds of experience of unwanted birth in the past 5 yearsReference category: Never experienced domestic violence (ns) Baseline risk (1.0)

30. Use of findings • Advocacy • Demonstrate health consequences • Estimate DALYs, economic costs • Legislation

31. Remaining Gaps and Challenges • Doing more to minimize under-reporting • Recognize the limitations of large scale surveys • Doing more in-depth and longitudinal studies to fill in gaps • Going beyond the measurement of prevalence • Analysis, dissemination, action • Measurement of men’s experience of violence from women

32. measuredhs.com

33. For specific questions: sunita.kishor@orcmacro.com kiersten.johnson@orcmacro.com Photo credits: Photos courtesy of M/MC Photoshare at jhuccp.org/mmc