1. Rollins School of Public Health, Emory University
Prevalence and District Level Differences in Patterns of IPV : Change Starts at Home Project
Cari Jo Clark
Rollins School of Public Health, Emory University
Binita Shrestha, Prabin Shrestha & Gemma Ferguson Equal Access International Jhumka Gupta George Mason University

2. IPV in Nepal IPV affects 1 in 3 women globally (WHO et al 2013)
32% of Nepal reproductive age women report lifetime emotional, physical, or sexual IPV (MOHP et al 2012)
Missing in Nepal and elsewhere is understanding of patterns of violent experiences
World Health Organization. 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. Ministry of Health and Population (MOHP) [Nepal], New ERA, ICF International Inc. Nepal Demographic and Health Survey Calverton, Maryland: Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International;2012.

3. Background
Latent Class Analysis has been used to examine patterns of violent experiences.
Are the constituent items different in type or magnitude?
Do the patterns have different covariates?
While not extensive, this research focused primarily on Western samples in which violence patterns may differ (MacMillan & Gartner 1999; Carbone-Lopez et al 2006; Watson & Parsons 2005; Ansara & Hindin 2009,2011; Spencer & Clark 2016).
Limited research has been conducted on samples from developing countries (Heise 2012).

4. MacMillan & Gartner 1999; Carbone-López et al 2006
Classes of IPV
Canada VAW Survey -1993
Classes
No violence (84%)
Interpersonal conflict (11%)
Pushing, slapping
Non systematic (3%)
Threats, low prob kicking, object thrown
Systematic (1%)
Kicking/hit, beating, choked
High probability
Risk factors
Different across classes
USA NVAW Survey-1995
Classes
No violence (77%)
Interpersonal conflict (11%)
Pushing, slapping
Physical aggression (8%)
Pushing, slapping, choked/beaten up
Systematic (3.5%)
Higher probability of all types, stalking
Health effects
Canada risk factors
Systematic: age, length of relationship, alcohol, witnessing violence in childhood, spouse education, spouse employment
Non systematic: witnessing violence in childhood, spouse education, spouse employment
Coercive control: Any of the following:
partner "is jealous and doesn't want you to talk to other men,"
"tries to limit your contact with family or friends,"
"insists on knowing who you are with and where you are at all times,"
"prevents you from knowing about or having access to the family income, even if you ask.“
Coercive control examined as a tactic used by unemployed men who have employed wives
MacMillan & Gartner 1999; Carbone-López et al 2006

5. Health Correlates of Latent Classes
Interpersonal Conflict
Physical Aggression
Systematic
Self Rated Health
1.95*
1.37
2.31*
Injury
1.85*
1.78*
3.29*
Miscarriage
1.55*
1.32*
2.04*
Depression
2.09*
1.82*
2.95*
MH Condition
2.27*
2.66*
3.77*
Daily alcohol consumption
1.23
0.68
2.83*
Drug use
2.78*
3.50*
1.98
Sedative use
2.16*
2.18*
2.65*
Health effects across classes, suggestion of higher impact among most severe systematic abuse class.
Carbone-López et al 2006

6. Classes of IPV: Emotional Aggression
Canadian General Social Survey-2004
Included emotional and economic abuse items
Classes
No violence (85%)
Jealousy/verbal (8%)
Physical aggression (3%)
Physical aggression/control/verbal (1%)
Severe vio/control/verbal (2%)
Control/verbal (1%)
Gradation across physical abuse classes
Frequency
Fear
Injury
Time off/bed ridden
Partners use of alcohol during episode
Depression, anxiety, low self esteem
Control featured in several classes
Severe forms of violence
1. tries (tried) to limit your contact with family or friends,
2. puts (put) you down or calls (called) you names to make you feel bad,
3. is (was) jealous and doesn’t (didn’t) want you to talk to other men/women,
4. demands (demanded) to know who you are (were) with and where you are (were) at all times,
5. harms (harmed), or threatens (threatened) to harm, someone close to you,
6. damages (damaged) or destroys (destroyed) your possessions or property,
7. prevents (prevented) you from knowing about or having access to the family income, even if you ask (asked).
Ansara & Hindin 2009; Ansara & Hindin 2011

7. Ireland National Survey of Domestic Violence
Classes of IPV
Ireland National Survey of Domestic Violence
3 classes of emotional abuse
76% no abuse
19% minor (embarrassed, called names)
0% severe impact
5% severe (embarrassed, called names, restricting $, isolation, threats of harm
58% severe impact
2 classes sexual violence
95.4% no abuse
4.6% severe
52.9% severe impact
3 classes of physical violence
87.6% no abuse
6.9% minor (Slapping / push or shove)
0% impact
6.5% severe (Higher prob of all forms of violence + being thrown/choked, smothered, suffocated)
93% severe impact
Different pattern of covariates
The criteria for severe impact, shown in the final column, are that:
• The incidents occurred ‘quite often’ or ‘very often’; and
• The incidents caused the respondent to be either ‘very frightened’ or ‘very distressed’; and
• The incidents had a ‘major’ impact on the respondent’s life.
Watson & Parsons 2005

8. Classes of IPV: LIMC
The mixed and systematic categories show the strongest relationship to health outcomes
suicidal thoughts in the last 4 weeks, lifetime suicide attempts, perceived poor health, usual activities in the last 4 weeks, unwanted pregnancy.
Gradient from emotional to physical/sexual dominant to mixed/systematic
Consistency in risk factors across classes.
Heise et al 2012

9. Research Questions
What are the patterns of IPV experiences and do they differ by district?
Do the patterns of IPV differ in their relationship to socio-demographics, depressive symptoms and fear?

10. Methods Cluster RCT Conditions 3 Districts Sample Analytic methods
Radio + community engagement
Radio alone
3 Districts
Nawalparasi
Chitwan
Kapilvastu
Sample
Women years
Clusters = 36 VDCs
N=1440 community sample
N=360 LDG sample
Analytic methods
Latent class analysis
Regression to examine potential differences in associated socio-demographic factors, fear and depressive symptoms

11. IPV Items: Frequency in Past 12 months
Emotional abuse
Insulted you or made you feel bad about yourself?
Belittled or humiliated you in front of other people?
Done things to scare or intimidate you on purpose for example by the way he looked at you, by yelling and smashing things?
Threatened to hurt you or someone you care about
Physical Violence
Slapped you or threw something at you that could hurt you?
Pushed you or shoved you?
Hit you with his fist or something else that could hurt you?
Kicked you, dragged you or beat you up?
Threatened to use or actually used a gun, knife or other weapon against you?
Sexual Violence
Physically forced you to have sexual intercourse when you did not want to?
Did you ever have sexual intercourse when you did not want because you were scared of what he might do?
Did he ever force you to do something sexual that you found degrading or humiliating?

12. Covariates Age Attended school: yes/no Employment: yes/no
Income from work /trade in past 12 months
Financial strain: Yes/no
Respondent or husband frequently stressed because of not having enough income
Afraid
Afraid of partner past 12 months
Depressive symptoms: PHQ8

13. Sample Characteristics
Indicator
Mean/Frequency
Age at marriage, mean (sd)
17.9 (3.3)
Attended school, % (#)
68.8 (1238)
Employed, % (#)
47.9 (861)
Financial Strain, % (#)
44.9 (806)
Afraid, % (#)
25.4 (458)
Depression, % (#)
2.6 (46)

14. Prevalence of IPV by Type, Item, & District
Nepal
(N=1800)
Nawalparasi (N=600)
Chitwan (N=600)
Kapilvastu (N=600)
Emotional
29%
30%
27%
Insulted
26%
25%
Belittled
13%
14%
11%
Scared
12%
16%
Threat 6% 9% 7% 4%
Physical
17%
Slapped
10%
Pushed
Hit 8%
Kicked
Weapon 3% 1%
Sexual
18%
15%
23%
Forced sex
Afraid sex
19%
Humiliating sex
Phys/sex 12 months
Nawalparasi: 25%
Chitwan: 22%
Kapilvastu: 30%
DHS ever: emot=16.4, phys=23.1, sex=14.3, phys/sex=28.2
DHS 12 months: emot=9.6, phys=10.4; sex=7.7
DHS terai ever phys: 30.5 (Change=25%), terai ever sex=18.0 (Change=22%), terai ever phys/sex=35% (Change 34%)

15. Number of Classes Nawalparasi Chitwan Kapilvastu 2 3 4 5 2 3 4 5 2 3 4LL
Param 23 35 47 59
AIC
3421.4
3253.5
3098.4
3046.8
BIC
3522.6
3407.4
3305.0
3306.2
ABIC
3449.6
3296.3
3155.8
3118.9
Entropy
0.95
0.93
0.96
LMR LRT
1422.3
191.9
179.1
75.5
(p-val)
0.00
0.02
0.01
0.08 2 3 4 5 23 35 47 59
2921.8
2693.2
2620.3
2583.8
3022.9
2847.1
2827.0
2843.2
2949.9
2736.0
2677.8
2655.9
0.98
0.92
0.95
1516.7
252.6
96.9
60.5
0.0 2 3 4 5 23 35 47 59
3525.4
3322.7
3213.0
3197.8
3626.5
3476.6
3419.7
3457.2
3553.5
3365.4
3270.5
3269.9
0.92
0.90
1198.1
226.7
133.7
39.2
0.0
0.2
Lo-Mendell-Rubin

16. Nawalparasi Systematic Sexual Mixed (less severe) None Insult 0.95
0.63
0.84
0.08
Belittle
0.78
0.30
0.55
0.02
Scare
0.86
0.21
0.52
Threat
0.11
0.31
0.01
Slap
0.96
0.23
0.41
Push
1.00
0.37
0.50
Kick
0.90
0.15
0.00
Hit
0.25
Fsex
0.70
0.79
0.03
Afsex
0.77
0.98
Othsex
0.67
0.61

17. Chitwan Systematic Sexual Mixed (less severe) None Insult 0.98 0.57
0.95
0.08
Belittle
0.86
0.24
0.54
0.00
Scare
0.94
0.15
0.35
0.01
Threat
0.64
Slap
0.91
0.23
Push
1.00
0.10
0.22
Kick
0.81
Hit
0.89
0.05
Fsex
0.87
0.14
0.03
Afsex
0.88
0.02
Othsex
0.40
0.66

18. Kapilvastu Systematic Sexual Mixed (Less Severe) None Insult 0.96 0.36
0.89
0.05
Belittle
0.71
0.16
0.27
0.01
Scare
0.86
0.20
0.50
0.02
Threat
0.39
0.06
0.00
Slap
0.92
0.13
0.31
Push
0.95
0.11
0.29
Kick
0.66
Hit
0.41
Fsex
0.75
0.19
Afsex
0.84
1.00
0.14
0.04
Othsex
0.53
0.65

19. Class Distribution # Proportion Systematic 123 7% Sexual 129 Mixed 178
10%
None
1370
76%

20. Risk and Protective Factors
Systematic
Sexual
Mixed
None
Age at marriage
0.93 (.87, .98)
0.98 (.93, 1.04)
0.96 (.91, 1.01)
ref
School
0.62 (.42, .92)
0.79 (.53, 1.17)
0.98 (.69, 1.40)
Work
1.17 (.80, 1.70)
2.26 (1.55, 3.30)
1.58 (1.15, 2.17)
Financial stress
3.49 (2.32, 5.24)
1.86 (1.29, 2.69)
3.14 (2.25, 4.39)

21. Risk and Protective Factors
Afraid
OR (CI)
Depression
Systematic
58.45 (32.72, )
16.99 (7.93, 34.41)
Sexual
10.43 (7.09, 15.35)
4.34 (1.58, 11.91)
Mixed
13.05 (9.23, 18.46)
2.84 (1.04, 7.78)
None
ref
Depression model adjusted for sociodemographics and experience of child maltreatment

22. Conclusions and Next Steps
Broad pattern of violence similar across 3 districts
Some nuanced differences
Similar pattern of sociodemographic covariates, although some differences in degree of association
All sub types associated with fear and depressive symptoms, although women experiencing systematic violence most impacted.
Unclear whether these classes are distinct sub types or indicators of a broader underlying phenomena.