Comment
Achieving gender equality to reduce intimate partner violence against women This year marks 20 years since 189 countries signed the Beijing Declaration and Platform for Action and committed to prioritisation of women’s empowerment and gender equality. Yet a recently released UN analysis1 shows that violence against women persists at “alarmingly high levels”. Worldwide, one in three women reports sexual or physical violence from a male partner at some point in their lifetime, and such experiences have been linked with harmful effects on health, including maternal morbidity, poor mental health, and vulnerability to HIV/AIDS.2 The UN report also contends that progress towards gender equality has been slow.1 Effective and scalable interventions to reduce intimate partner violence remain scarce, and questions remain about what drives individual violence and why prevalence differs across settings and countries. Lori Heise and Andreas Kotsadam’s study in The Lancet Global Health, is thus very timely, and is a major advance in the understanding of worldwide intimate partner violence. This analysis of data from 44 countries suggests that gender inequality at the macro-level (ie, country-level) serves as a key driver in women’s individual risk of violence and provides insight into why prevalence of intimate partner violence varies across countries.3 Heise and Kotsadam make important contributions. Their study goes beyond individual-level factors (eg, age, education) for intimate partner violence and incorporates the importance of place in affecting intimate partner violence towards women. Gender inequality at the macro-level, including societal norms supporting male authority over women and discriminatory ownership rights, was associated with population levels of intimate partner violence across countries. These data offer support for policy-level interventions, such as the US International Violence Against Women Act, that aim to address these very macro-level factors. They also illuminate an important gap: although an emerging evidence base of effective programming exists to prevent or respond to intimate partner violence at the individual, family, or community levels,4 a large knowledge gap exists regarding the effect of macro-level interventions. The investigators also note that, at the macro-level, lower gross domestic product might be a marker for www.thelancet.com/lancetgh Vol 3 June 2015
women’s status in countries as opposed to a direct determinant of intimate partner violence.3 A crucial factor to consider in future work is how conflict and fragility might affect the association between women’s status (including intimate partner violence) and socioeconomic development. Gross domestic product will increasingly indicate state fragility because estimates suggest that two-thirds of the world’s poorest population will reside in a fragile state by 2030.5 Reflections on progress made since the Beijing conference note that conflict-affected countries had even slower, and in some cases, a reversal in progress of gender equality indicators.1 In the study by Heise and Kotsadam, less than a fifth of surveys were drawn from fragile situations.6 This low representation likely shows the absence of population-based data for intimate partner violence in such settings because intimate partner violence research in conflict-affected populations is in its nascent stage. The few existing studies,7 however, suggest a high prevalence. Thus, further understanding of the associations between poverty, gender equality, and intimate partner violence are needed in such settings. Previous research suggests that women’s economic empowerment has the potential to both amplify and diminish the risk of abuse.8 Heise and Kotsadam’s findings underline the need to examine how macro-level socioeconomic development and gender norms affect this association at the individual level. There is a need to expand the evidence base beyond the few promising interventions that have targeted both economic empowerment and traditional gender norms.9,10 Future research should aim to understand potential pathways of change and how programming effectiveness might vary across settings because interventions might be enhanced or hindered by macro-level indicators of gender equality. Other macro-level factors, such as rights of indigenous groups or those with disabilities, might also be important determinants of intimate partner violence because progress towards gender equality in marginalised groups has been particularly stagnant.1 Moving forward, intimate partner violence research must recognise that women and girls might
See Articles page e332
e302
Comment
simultaneously exist in other socially marginalised categories to more fully understand intimate partner violence determinants and intervention opportunities. Through analyses of data from surveys that used similar measures, methods, and ethical standards across 44 countries, Heise and Kotsadam have taken an important step towards an improved understanding of intimate partner violence and informing interventions. However, much work remains to be done. In view of the existing gaps in evidence,4 a need for significant investment to test interventions that address this crucial public health issue exists. We also know that evidence alone is insufficient. Within these efforts, intimate partner violence must be recognised as an urgent public health priority in and of itself, rather than merely as a contributing factor to other public health issues. Donors and governments must work alongside civil society and grassroots efforts to recommit to gender equality in both stable and fragile states to reduce violence against women. *Kathryn L Falb, Jeannie Annan, Jhumka Gupta International Rescue Committee, New York, NY 10168, USA (KLF, JA); Harvard T H Chan School of Public Health, Boston, MA, USA (KLF, JA); and George Mason University, Fairfax, VA, USA (JG) [email protected]
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We declare no competing interests. Copyright © Falb et al. Open access article published under the terms of CC BY-NC-ND. 1
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UN. Review and appraisal of the implementation of the Beijing Declaration and Platform for Action and the outcomes of the twenty-third special session of the General Assembly. 2014. http://www.un.org/ga/search/ view_doc.asp?symbol=E/CN.6/2015/3 (accessed Feb 25, 2015). WHO, London School of Hygiene & Tropical Medicine, South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization, 2013. Heise L, Kotsadam A. Cross-national and multilevel correlates of partner violence: an analysis of data from population-based surveys. Lancet Global Health 2015; 3: e332–40. Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet 2014; 385: 1555–65. Chandy L, Ledlie N, Penciakova V. The final countdown: prospects for ending extreme poverty by 2030. Washington DC: The Brookings Institution, 2013. World Bank. Harmonized list of fragile situations FY15. 2015. http://siteresources.worldbank.org/EXTLICUS/ Resources/511777-1269623894864/FY15FragileSituationList.pdf (accessed March 15, 2015). Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse 2011; 12: 127–34. Vyas S, Watts C. How does economic empowerment affect women’s risk of intimate partner violence in low and middle income countries? A systematic review of published evidence. J Int Dev 2009; 21: 577–602. Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006; 368: 1973–83. Gupta J, Falb KL, Lehmann H, et al. Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Cote d’Ivoire: a randomized controlled pilot study. BMC Int Health Hum Rights 2013; 13: 46.
www.thelancet.com/lancetgh Vol 3 June 2015
Achieving gender equality to reduce intimate partner violence against women This year marks 20 years since 189 countries signed the Beijing Declaration and Platform for Action and committed to prioritisation of women’s empowerment and gender equality. Yet a recently released UN analysis1 shows that violence against women persists at “alarmingly high levels”. Worldwide, one in three women reports sexual or physical violence from a male partner at some point in their lifetime, and such experiences have been linked with harmful effects on health, including maternal morbidity, poor mental health, and vulnerability to HIV/AIDS.2 The UN report also contends that progress towards gender equality has been slow.1 Effective and scalable interventions to reduce intimate partner violence remain scarce, and questions remain about what drives individual violence and why prevalence differs across settings and countries. Lori Heise and Andreas Kotsadam’s study in The Lancet Global Health, is thus very timely, and is a major advance in the understanding of worldwide intimate partner violence. This analysis of data from 44 countries suggests that gender inequality at the macro-level (ie, country-level) serves as a key driver in women’s individual risk of violence and provides insight into why prevalence of intimate partner violence varies across countries.3 Heise and Kotsadam make important contributions. Their study goes beyond individual-level factors (eg, age, education) for intimate partner violence and incorporates the importance of place in affecting intimate partner violence towards women. Gender inequality at the macro-level, including societal norms supporting male authority over women and discriminatory ownership rights, was associated with population levels of intimate partner violence across countries. These data offer support for policy-level interventions, such as the US International Violence Against Women Act, that aim to address these very macro-level factors. They also illuminate an important gap: although an emerging evidence base of effective programming exists to prevent or respond to intimate partner violence at the individual, family, or community levels,4 a large knowledge gap exists regarding the effect of macro-level interventions. The investigators also note that, at the macro-level, lower gross domestic product might be a marker for www.thelancet.com/lancetgh Vol 3 June 2015
women’s status in countries as opposed to a direct determinant of intimate partner violence.3 A crucial factor to consider in future work is how conflict and fragility might affect the association between women’s status (including intimate partner violence) and socioeconomic development. Gross domestic product will increasingly indicate state fragility because estimates suggest that two-thirds of the world’s poorest population will reside in a fragile state by 2030.5 Reflections on progress made since the Beijing conference note that conflict-affected countries had even slower, and in some cases, a reversal in progress of gender equality indicators.1 In the study by Heise and Kotsadam, less than a fifth of surveys were drawn from fragile situations.6 This low representation likely shows the absence of population-based data for intimate partner violence in such settings because intimate partner violence research in conflict-affected populations is in its nascent stage. The few existing studies,7 however, suggest a high prevalence. Thus, further understanding of the associations between poverty, gender equality, and intimate partner violence are needed in such settings. Previous research suggests that women’s economic empowerment has the potential to both amplify and diminish the risk of abuse.8 Heise and Kotsadam’s findings underline the need to examine how macro-level socioeconomic development and gender norms affect this association at the individual level. There is a need to expand the evidence base beyond the few promising interventions that have targeted both economic empowerment and traditional gender norms.9,10 Future research should aim to understand potential pathways of change and how programming effectiveness might vary across settings because interventions might be enhanced or hindered by macro-level indicators of gender equality. Other macro-level factors, such as rights of indigenous groups or those with disabilities, might also be important determinants of intimate partner violence because progress towards gender equality in marginalised groups has been particularly stagnant.1 Moving forward, intimate partner violence research must recognise that women and girls might
See Articles page e332
e302
Comment
simultaneously exist in other socially marginalised categories to more fully understand intimate partner violence determinants and intervention opportunities. Through analyses of data from surveys that used similar measures, methods, and ethical standards across 44 countries, Heise and Kotsadam have taken an important step towards an improved understanding of intimate partner violence and informing interventions. However, much work remains to be done. In view of the existing gaps in evidence,4 a need for significant investment to test interventions that address this crucial public health issue exists. We also know that evidence alone is insufficient. Within these efforts, intimate partner violence must be recognised as an urgent public health priority in and of itself, rather than merely as a contributing factor to other public health issues. Donors and governments must work alongside civil society and grassroots efforts to recommit to gender equality in both stable and fragile states to reduce violence against women. *Kathryn L Falb, Jeannie Annan, Jhumka Gupta International Rescue Committee, New York, NY 10168, USA (KLF, JA); Harvard T H Chan School of Public Health, Boston, MA, USA (KLF, JA); and George Mason University, Fairfax, VA, USA (JG) [email protected]
e303
We declare no competing interests. Copyright © Falb et al. Open access article published under the terms of CC BY-NC-ND. 1
2
3
4 5
6
7 8
9
10
UN. Review and appraisal of the implementation of the Beijing Declaration and Platform for Action and the outcomes of the twenty-third special session of the General Assembly. 2014. http://www.un.org/ga/search/ view_doc.asp?symbol=E/CN.6/2015/3 (accessed Feb 25, 2015). WHO, London School of Hygiene & Tropical Medicine, South African Medical Research Council. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization, 2013. Heise L, Kotsadam A. Cross-national and multilevel correlates of partner violence: an analysis of data from population-based surveys. Lancet Global Health 2015; 3: e332–40. Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet 2014; 385: 1555–65. Chandy L, Ledlie N, Penciakova V. The final countdown: prospects for ending extreme poverty by 2030. Washington DC: The Brookings Institution, 2013. World Bank. Harmonized list of fragile situations FY15. 2015. http://siteresources.worldbank.org/EXTLICUS/ Resources/511777-1269623894864/FY15FragileSituationList.pdf (accessed March 15, 2015). Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse 2011; 12: 127–34. Vyas S, Watts C. How does economic empowerment affect women’s risk of intimate partner violence in low and middle income countries? A systematic review of published evidence. J Int Dev 2009; 21: 577–602. Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet 2006; 368: 1973–83. Gupta J, Falb KL, Lehmann H, et al. Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Cote d’Ivoire: a randomized controlled pilot study. BMC Int Health Hum Rights 2013; 13: 46.
www.thelancet.com/lancetgh Vol 3 June 2015
