Artículo de revista: GÓMEZ-CASILLAS, Amalia; LOZANO, Mariona; RENTERÍA, Elisenda (2021) “Expected years lived with intimate partner violence: a new approach for public health”. Global Health Action, 14 (1): 1-7 (ISSN: 1654-9716). https://doi.org/10.1080/16549716.2021.1976442 To link to this article: https://www.tandfonline.com/doi/full/10.1080/16549716.2021.1976442 GLOBAL HEALTH ACTION 2021, VOL. 14, 1976442 https://doi.org/10.1080/16549716.2021.1976442 ORIGINAL ARTICLE Expected years lived with intimate partner violence: a new approach for public health Amalia Gomez-Casillas , Mariona Lozano and Elisenda Rentería Centre d’Estudis Demogràfics (CED-CERCA), UAB, Cerdanyola Del Vallès, Spain ABSTRACT ARTICLE HISTORY Background: Intimate Partner Violence against women (IPV) is a major public health pro­ Received 4 February 2021 blem. However, mainstream indicators used in public health are not designed to fully capture Accepted 31 August 2021 the pervasive and enduring impact of IPV. RESPONSIBLE EDITOR Objective: We propose a new indicator that considers the burden of IPV in women during Stig Wall their middle life years, estimating the number of years that women are expected to live under IPV, and provide estimates for 151 countries. KEYWORDS Methods: Prevalence rates of physical and sexual IPV for a given year are taken from the Intimate partner violence Global Database on the Prevalence of Violence Against Women. Annual period life tables are (IPV); years expected to live constructed using data from the World Population Prospects. We use Sullivan’s method to with IPV; violence against estimate partial life expectancy between the ages of 15 and 49 lived suffering from physical women; women’s health; international comparison and sexual IPV in each country. The final indicator measures the number of years 15 to 49- year-old women are expected to live with IPV (YLIPV) in a given year. Results: Based on data from surveys representative of 92.0% of the global female population aged between 15 to 49, we find that ever-partnered women aged between 15 to 49 are expected to live 4.1 years (Low Bound: 2.3; Upper Bound: 7.1) suffering from violence during this age range. By regions, women are expected to suffer from IPV during 6.0 years (3.7–9.2) in Africa; 4.3 years (2.4–7.8) in Asia; 3.4 years (2.1–5.6) in Oceania; 2.6 years (1.5–4.2) in the Americas; and 1.7 years (0.9–3.1) in Europe. Conclusions: YLIPV is a useful indicator to display the burden of IPV. Similarly to the main­ stream public health indicators rationale, YLIPV accounts for the time women are exposed to IPV during their lifespan and it is standardized by age exposure. Background shown a strong association between HIV infection Intimate Partner Violence (IPV) is among the leading and IPV [11,12]. Among the psychological conse­ causes of morbidity and mortality in women with quences, IPV is associated with depression, post- over a third of female homicides perpetrated by inti­ traumatic stress disorder, anxiety, memory loss, and mate partner [1]. Past studies have found that a third sleep disorders among others [13]. of ever-partnered women had suffered from physical Since the World Health Organization (WHO) and sexual IPV during their lives [2,3]. The global declared IPV as a key public health issue [14], it has prevalence of IPV and its repetitive nature are related gained increasing visibility in public health studies, to victim’s co-residence or the close relationship with and it has recently been incorporated in the Global the perpetrator [4,5] and explain the long-lasting Burden of Disease (GBD) estimates of Disability- health consequences for the victim. This urges public Adjusted Life-Years (DALY) and Health-Adjusted health scholars to account for the global burden of Life Expectancy (HALE) [15,16]. Despite these IPV. Previous efforts to provide an overview of IPV’s remarkable efforts to explain the burden of IPV, implications on public health mainly involved neither DALY nor HALE indicators can fully account accounting for IPV’s geographical extent [6], its for the pervasive and enduring IPV experience and its effects on mortality – either due to homicide [1] or impact on women’s quality of life, as they particularly victims’ suicide attempts [7], health consequences [8], measure the disabling effects of IPV. The burden of and its determinants [9]. IPV is neither limited to a sequence of assaults [17], Women suffering from IPV face multiple health nor fully explained by its health consequences alone. problems. There is a wide range of negative conse­ Additionally, IPV also wrecks women’s lives through quences such as gastrointestinal, gynecological, and a day by day eroding experience of increasing fear, mental health problems [8,10]. Past studies have also constant threats which lead victims to be CONTACT Amalia Gomez-Casillas agomez@ced.uab.cat Centre d’Estudis Demogràfics (CED-CERCA), UAB, Carrer De Ca n’Altayó, Edifici E-2, Campus De La UAB, Cerdanyola Del Vallès 08193, Spain Supplemental data for this article can be accessed here © 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 A. GOMEZ-CASILLAS ET AL. continuously alert and to feel despair, guilt, shame, gathered in the WHO’s Global Database. Based on and confusion [17–19]. IPV is a repetitive cycle that a systematic review of studies conducted between begins with a first phase of tension building, leading 2000 and 2018 (available by 2019), the WHO and to a second phase of violent episodes, and a final the associated groups created population-based phase of loving contrition [20]. In this repetitive nationally and sub-nationally representative database. cycle, violence tends to escalate, turning women’s Further, the prevalence of IPV is assessed using acts- fear into terror, and generating acute feelings of dis­ based IPV measures (act-based questions entail ask­ empowerment and loss of self-respect. This process ing women if they suffer violent acts such as pushing, constitutes an ‘emotional career’ [18] where IPV grabbing, kicking or other violent behaviours). In this erodes women’s quality of life daily. regard, the collected data on IPV were adjusted using The objective of this paper is to propose an easy-to complex models to finally obtain a unique estimate -read indicator that fully captures the burden of IPV for each of the relevant measures that was represen­ in a woman’s life. It measures the number of years tative for the whole period. More information about that women are expected to live suffering from IPV. the inclusion criteria for the studies and the proce­ While life expectancy in most societies has increased, dure underlying the modeled prevalence is available there is a debate whether the current indicators cap­ in the WHO related documents [24,25]. Available ture the quality of these years gained beyond just the data refer to ever-partnered women and girls aged number [21]. This process has led to the development from 15 to 49 years old. Perpetrators are current or of indicators such as Healthy Life Expectancy (HLE), former intimate partners involved in any formal or which measures the number of years that a person is informal relationship (marriage, cohabitation or any expected to live without activity limitation or health other form of union). problems. To illustrate the gradual incorporation of Country-wise female life tables (organized in per­ quality indicators in the policymaking agenda, it is iods of five years) are taken from the World worth mentioning the incorporation of HLE to moni­ Population Prospects database [26]. We select the tor progress in European policies, such as the 2000 2010–2015 life table for analysis as it matches with Lisbon strategy [22]. This paper builds on these the median point of the period of reference of IPV initiatives by proposing a new indicator called Years prevalence data for all countries [25]. We estimate the expected to Live with Intimate Partner Violence regional aggregates for the Sustainable Development (YLIPV), that aims to highlight the persistence of Goals Super Regions, which are Africa, the Americas, IPV in women’s lifespan, and complements previous Asia, Europe, and Oceania. To estimate the expected public health indicators that did not fully capture the number of years lived with IPV (YLIPV) for regional pervasive condition of IPV. YLIPV could be espe­ aggregates we need the proportion of ever-partnered cially helpful for policy design and funding allocation, women in each country. However, this information as well as for increasing awareness of all the possible was not available for all the studied countries. Thus, unmeasured burdens of IPV in women’s quality of we use data on female population from the World life. We use YLIPV to show international inequalities Population Prospects (July the 1st 2012) [27] to in 151 countries based on the modelled prevalence weight each country and calculate the regional and data recently released by WHO. global mean estimates of YLIPV. These weights are designed for female populations aged from 15 to 49 years old. Therefore, global results for YLIPV Methods were based on the 92.0% of the female population worldwide in 2012. To double check that the regional Data sources means were not biased by weighted estimates, we also Data for prevalence of physical and sexual intimate weight results using the female population currently partner violence are taken from the WHO’s Global married or cohabiting [28]. The relative difference Database on the Prevalence of Violence Against between the two was 2.4%, and it goes up to 11.1% Women [23]. These data provide aggregated esti­ per continent (see the supplementary materials). mates of the proportions of ever-partnered 15 to 49- year-old women and girls by five-year age groups. Statistical analysis These women and girls have been subjected to phy­ sical and/or sexual violence by a current or former We calculate the number of years the female popula­ intimate partner in the previous 12 months. The Inter tion between 15 and 49 years old is expected to live Agency Working Group on Violence against Women under IPV using the Sullivan’s method [29]. We Estimation and Data supported by the Technical analyze data for 151 countries and territories and Advisory Group (TAG) developed a statistical mod­ estimate the burden of IPV on women’s lives. eling framework [24] aiming to provide prevalence Sullivan’s method uses prevalence data (IPVx) on estimates at global, regional, and national levels ever-partnered women that have experienced physical GLOBAL HEALTH ACTION 3 and/or sexual violence in the last 12 months in each Figure 1 indicates that women are most affected in of the five-year age groups (x, x + 5), applied to the the Democratic Republic of Congo, where they are person-years indicator (5 Lx ) to re-estimate the life expected to live 11.4 years (LB 7.4-UB 16.0) with IPV, expectancy spent under IPV or YLIPV [28]. which equals 34.9% (LB 22.6-UB 48.9) of their 15–49 Formally, our indicator is calculated as: lifespan (country-estimations are available in the sup­ plementary material Table 2A). In Equatorial Guinea, 1X 50 Zambia, Ethiopia, Liberia, South Sudan, and Uganda YLIPV ¼ IPVx � 5 Lx (1) lx x¼15 YLIPV is over 8 years on average, and women in where lx is the number of survivors at exact age x. these countries are expected to live between 25.5% We estimate the partial life expectancy from ages and 28.2% of their 15–49 lifespan as victims of phy­ 15 to 49 (more details can be found in the supple­ sical and sexual IPV. mentary materials) because the prevalence data are In South and North America women are expected available for this age range only. We also calculate the to live 2.6 years (LB 1.5-UB 4.2) suffering from IPV. proportion of life expectancy between age 15 and 49 The highest figures of YLIPV are recorded in Bolivia, spent under IPV (life expectancy while living with where women are expected to live 6.4 years (LB violence). Lower and upper bound estimates of IPV 3.9-UB 9.6) with IPV, which equals 18.8% (LB for each country are obtained using the 95% uncer­ 11.5-UB 28.2) of their 15–49 life expectancy. tainty intervals (UI) that WHO provides along with Women in Colombia and Haiti are expected to live the prevalence estimates. We opt for this approach to 4.1 years suffering from IPV (11.9% and 12.5% of the overcome the limitation of the WHO modelled sam­ 15–49 lifespan, respectively) as shown in Figure 1. ples. Lower bound and upper bound estimates are The lowest numbers are found in Canada (1.0 year; reported as LB and UB, respectively. LB 0.6-UB 1.6). In Asia, women are expected to suffer from IPV for 4.3 years (LB 2.4-UB 7.8) between the ages of Results 15–49. As shown in Figure 1, we find that the highest prevalence of IPV is estimated in Based on prevalence data from 151 countries, women Afghanistan, where women are expected to live in our study are expected to live with IPV (YLIPV) 11.4 years under IPV between the ages of 15 and for 4.1 years based on population weighted mean (LB 49. This represents 34.3% (LB 21.6-UB 49.9) of 2.3 – UB 7.1). Table 1 shows that this estimate is their life expectancy between these years. In India obtained for 92.0% of the world total reference popu­ women are expected to live 6.2 (LB 3.8-UB 9.6) lation of ever-partnered females aged between 15 and years suffering from IPV, which equals 18.3% (LB 49. YLIPV is 4.2 years if results are weighted using 11.2-UB 28.3) of their 15–49 life expectancy. In the total population of women who are either cur­ Bangladesh, YLIPV is 7.9 (LB 5.1-UB 11.6), and rently married or in a union. Hence, the difference 9.4 (LB 6.3-UB 13.5) in Timor-Leste. In between both weighting strategies is merely 0.1 years. Singapore, Japan, and Sri Lanka, YLIPV is recorded We consider this difference to not bias our results. under 2.0. In China, women lived 2.8 years (LB Our data represent 90.7% of women in the African 1.1-UB 6.6) on average as victims of this form of continent, 68.9% of the women in the European violence, which equals 8.1% of their 15–49 lifespan population, 99.4% of the women in South and (LB 3.2-UB 19.0). North America, 94.3% of the women in the Asian In Europe, women suffer from violence for population, and 98.0% of the women in the popula­ 1.7 years (LB 0.9-UB 3.1) on average. As shown tion from Oceania. in Figure 1, the highest numbers of YLIPV are In Africa, women are expected to suffer from IPV found in the Republic of Moldova (3 years; LB for 6 years (LB 3.7-UB 9.2) on average. Table 1. Regional prevalence of intimate partner violence and number of years expected to live with intimate partner violence (YLIPV) among ever–partnered females, 2000–2018. Population coverage (women Region aged from 15 to 49 years old) YLIPV (years) Summary for 151 countries 92.0% 4.1 (2.3–7.1) Africa (based on 43 countries) 90.7% 6.0 (3.7–9.2) Americas (based on 28 countries) 99.4% 2.6 (1.5–4.2) Asia (based on 32 countries) 94.3% 4.3 (2.4–7.8) Europe (based on 38 countries) 68.9% 1.7 (0.9–3.1) Oceania (based on 10 countries) 98.0% 3.4 (2.1–5.6) Note: Low and Upper Bound estimates in brackets. Methods section provides more information on how these measures are estimated. Source: authors’ elaboration. 4 A. GOMEZ-CASILLAS ET AL. Figure 1. Expected years suffering from IPV estimated as number of Years expected to Live with Intimate Partner Violence (YLIPV) among ever-partnered females aged 15 to 49 years, for 151 countries and territories, 2000–2018. Notes: TTO: Trinidad and Tobago; MDV: Maldives; TLS: Timor-Leste; COM: Comoros; MLT: Malta; VUT: Vanuatu; FJI: Fiji; SLB: Solomon Islands. Source: Authors’ elaboration. 1.7-UB 5.2), Ukraine (2.9; LB 1.7-UB 4.6), and [2,3]. Our study confirms that certain central African Finland (2.9; LB 2.0-UB 4.0). These equal, respec­ countries also have the highest prevalence rates of tively, to 8.7%, 8.4%, and 8.3% of women’s 15–49 IPV and the largest YLIPV numbers. However, the lifespan. The lowest numbers are found in comparison between our results and the previous Switzerland (0.7 years; LB 0.3-UB 1.4), and studies comparing cross-country IPV rates is challen­ Iceland (0.9; LB 0.6-UB 1.6). ging due to data coverage, the type of indicator con­ In Oceania, women are expected to live 3.4 years sidered, and the complex relationships between lethal (LB 2.1-UB 5.6) of their lives suffering from IPV. In and non-lethal IPV victimization. In addition, the Australia, women are expected to live 1.0 year (LB relationship between life expectancy and IPV preva­ 0.6-UB 1.7) as victims of physical and sexual IPV, but lence for a given year is not straightforward because it this goes up to 10.3 (LB 6.3-UB 15.4) and 10.1 years depends on union formation and dissolution (LB 5.4-UB 16.7) in Papua New Guinea and Vanuatu, dynamics [5], the probability of women escaping respectively. from the violent relationship [5], and the probability of them being murdered by their partners. In those countries where IPV homicide [1] rates are higher, Discussion prevalence may be expected to be downsized because Our results indicate that, on average, women are murdered women are not captured in the samples. expected to suffer from IPV for 4.1 years, but there IPV can also cause the victim’s death due to suicide are important differences in the experience of IPV [7], which also reduces IPV prevalence. Mortality amongst the 151 countries. Global inequalities in rates among males may also affect these results. One YLIPV found in this study point to a difference of could expect lower rates of IPV for populations with 10.7 years of life between the highest and the lowest higher proportions of female widows, and larger exposure to this type of violence. The longest time deaths among perpetrators. In addition, YLIPV can exposure to IPV is found in Afghanistan and in the be lower in those countries with higher mortality Democratic Republic of Congo (YLIPV in both coun­ rates in general, because life expectancy in those tries is 11.4 years), while the lowest is found in countries will be shorter. Nonetheless, using the per­ Switzerland (0.7). Overall, our data confirm the estab­ centage of YLIPV over Life Expectancy amends this lished pattern of IPV exposure, with women in the problem. Finally, we use all women between 15 and Middle East and Southern Asia being exposed to 49 as our reference population, and this might alter a larger prevalence of IPV. This translates into the results as well. Women who were in a union at a greater proportion of their lives spent suffering the time of the survey or who have recently separated from this type of violence. are at a higher risk than those who had experienced Previous studies on IPV have pointed out that the a union dissolution a long time ago. highest rates of physical and/or sexual IPV from the Cross-country comparisons of YLIPV show that age of 15 were found in Central Sub–Saharan Africa women in countries with lower socioeconomic GLOBAL HEALTH ACTION 5 conditions have spent a larger number of years suf­ and recall biases [30]. Underestimation of the real fering from IPV. This is contrary to the results found prevalence is also linked to surveys using small sam­ by the Global Burden of Disease studies [15,16] that ple sizes, skewed sample frames, the method used to estimated HALE at a global scale while considering contact the respondents, questions wording, the all diseases. Although their estimates cannot be com­ number of questions in the questionnaires and the pared to ours because they use different indicators order in which they are asked [4,30], sex of the and weighting structure, the GBD study shows that interviewers, their skills, attitudes and their training years of functional health lost, estimated by subtract­ to address these sensitive issues [31]. Moreover, in ing HALE from Life Expectancy, are higher in high- the prosecution of IPV cases, cultural acceptance and income countries because these countries combine law enforcement play a role in IPV disclosure. Thus, higher life expectancies and a greater prevalence of prevalence results must be understood as low bound less fatal diseases. Hence, women live longer but also estimations of physical and sexual IPV. Also, in order more years in poorer health. With IPV estimates, the to display improved estimates, women aged 50 or association goes in the opposite direction, and the over should be incorporated in the analysis. For countries with lower socioeconomic conditions are future analysis, while this indicator considers a great showing a larger number of years suffering IPV, call­ deal of the gender-based violence victimization, other ing attention to the fact that women’s health in low- forms of violence should be further incorporated. income countries is being deteriorated by this type of Finally, relying in the lower and upper bounds of violence. each age group could be artificially widening the This paper advances the current knowledge on uncertainty range of our estimates, meaning that the IPV by suggesting a synthetic indicator, YLIPV, that real uncertainty levels could be, in fact, lower. At the shows in a single number the impact of this form of same time, we did not consider any uncertainty com­ violence in each of the studied countries, contributing ing from the life table estimates. to the literature on measuring gender–based violence To sum up, this study suggests a new indicator to in two ways. First, the relevance of our indicator lies measure global trends in IPV. YLIPV accounts for the in its capacity to display the burden of IPV, similarly number of years that women are expected to live with to the mainstream public health indicators rationale. IPV during their lives, and it has the advantage of Our indicator accounts for the time women are standardizing country-level data to display global exposed to IPV during their lifespan and is standar­ inequalities, which makes comparison between coun­ dized by age exposure. Hence, YLIPV captures the tries and over time easier. In other mainstream indica­ magnitude and relevance of IPV as a comprehensive tors, such as HALE, IPV is characterized only by its and persistent experience contributing to the global health consequences, underestimating the burden of description of IPV. Second, while several studies have the ‘emotional career’ [18] of IPV over women’s lives. already addressed IPV as a global burden from dif­ In conclusion, YLIPV contributes to raise awareness of ferent perspectives, our contribution lies in measur­ IPV’s global scope and constitutes a first step to integrate ing, for the first time, the length of this type of the comprehensive and pervasive experience of IPV. violence during the central years of life. This allows us to better capture the impact of IPV in women’s lives. As a result, YLIPV complements other main­ Acknowledgments stream indicators improving public health policy assessment. We want to thank Joan Sales for his help with the map and the anonymous reviewers who provided very useful com­ This study, however, comes with some limitations, ments to improve this paper. mostly related to cross-country comparability of IPV prevalence. Differences in survey design methodol­ ogy, definitions, questionnaires, question wording Author contributions and survey designs hamper the comparability of the ER and ML envisioned the study. AGC led and organised results [4,24]. These restraints led the WHO to the research. AGC and ER analyzed the data. All authors develop a methodological framework for providing contributed to the manuscript writing. modelled estimates based on a systematic review of prevalence studies. These studies need to meet var­ ious minimum requirements, such as being represen­ Disclosure statement tative at a national or subnational level and using The authors report no conflicts of interest. acts-based measures, among others [24;25]. Despite these methodological improvements [24], self- disclosure related problems remain a drawback for international comparisons. IPV is widely recognized Ethics and consent to be underreported due to its stigma, shame, fear, N/A 6 A. GOMEZ-CASILLAS ET AL. Funding information domestic violence: an observational study. Lancet. 2008;371:1165–1172. This work was supported by the Spanish Ministry of [9] Heise L, Kostsadam A. Cross-national and multilevel Science, Innovation and Universities, National R&D&I correlates of partner violence: an analysis of data from Plan GLOBFAM; under [Grant RTI2018-096730-B-I00 to population-based surveys. Lancet Glob Health. ML]; the ‘Plan Estatal de Investigación Científica y Técnica 2015;3:332–340. y de Innovación 2013-2016 Programa Estatal de [10] Campbell JC. Health consequences of intimate partner Promoción del Talento y su Empleabilidad, Subprograma violence. Lancet. 2002;359:1331–1336. 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