The Open Public Health Journal




ISSN: 1874-9445 ― Volume 12, 2019
SYSTEMATIC REVIEW

Doctoral Theses as a Source of Knowledge Production for IPV Prevention: A Literature Review of Doctoral Theses at a Swedish University



Okenwa-Emegwa Leah1, 2, *
1 Department of Medicine and Public Health, The Swedish Red Cross University College, Stockholm, Sweden
2 Department of Occupational and Public Health Sciences, Faculty of Health and Occupational Sciences, University of Gävle, Gävle, Sweden

Abstract

Background:

Intimate Partner Violence (IPV) is a pervasive form of Violence Against Women (VAW). IPV has been acknowledged as a human rights violation and a public health problem. Years of research and advocacy have led to a better understanding of the problem including the development of the ecological model for explaining IPV. Although diverse international policies and global advances in women’s rights have contributed to addressing IPV, the problem still persists. IPV is associated with adverse health outcomes, therefore, its prevention is an important aspect of population health promotion.

Objective:

Considering that doctoral research and theses form an integral aspect of knowledge production, the present study aims to provide a review of doctoral theses on IPV at a Swedish university in order to identify areas of unmet need for future IPV prevention studies.

Methods:

A search was conducted to identify IPV related thesis stored in the Karolinska Institutet (KI), which is a database where all publications produced at KI are stored. A total of thirteen PhD theses (the earliest published in 2004 and the latest in 2017) met the inclusion criteria and were reviewed.

Results:

Through their wide range of contexts and contents, these theses provide a global insight into IPV. Findings show that prevalence estimates and risk factors at the individual and relationship levels are well researched. Potential areas of unmet needs include the under-researched nature of risk factors and interventions at the community and societal level as well as underlying issues preventing the healthcare sector from actively playing its role in addressing IPV.

Conclusion:

Capacity building for the health sector and addressing community and societal level risk factors of IPV are modifiable factors to address IPV and improve population health.

Keywords: Intimate partner violence, Prevention, Health promotion, Gender inequality, Attitudes, Disclosure.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 145
Last Page: 154
Publisher Id: TOPHJ-12-145
DOI: 10.2174/1874944501912010145

Article History:

Received Date: 04/01/2019
Revision Received Date: 12/03/2019
Acceptance Date: 21/03/2019
Electronic publication date: 25/04/2019
Collection year: 2019

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© 2019 Okenwa-Emegwa Leah

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the The Swedish Red Cross University College, P.O. 1059, SE-141 21 Huddinge, Sweden; Tel: +46(0)8-587 516 79; E-mail: leok@rkh.se




1. INTRODUCTION

There is an increasing global effort to address Intimate Partner Violence (IPV) which is one of the most pervasive forms of Violence Against Women (VAW). IPV is described as any behaviour (including controlling behaviours), within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship [1World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence 2013., 2World Health Organisation. Understanding and addressing violence against women 2012. [cited 2018 3 march]. Available from: http://apps.who.int/iris/bitstream/handle/10665/77433/WHO_RHR_12.35_eng.pdf;jsessionid=EB09982574411D024C5B8E53EF3FF4C6?sequence=1]. The global life-time prevalence of IPV among ever partnered women is about 30% [3World Health Organisation. Intimate partner violence Situation and trends [cited 2018 20 August]. Available from: http:// www.who.int/gho/women_and_health/violence/intimate_partner/en/]. IPV is associated with adverse health outcomes such as injury, physical and mental health problems and a range of diseases [4Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002; 360(9339): 1083-8.[http://dx.doi.org/10.1016/S0140-6736(02)11133-0] [PMID: 1238 4003] ]. Research and advocacy through the years have contributed to knowledge production [5Heise L. What works to prevent partner violence? An evidence overview 2011.]. Diverse international declarations and policies continue to contribute to advances in women’s rights globally [6Johnson MP. Gender and types of intimate partner violence: A response to an anti-feminist literature review. Aggress Violent Behav 2011; 16(4): 289-96.[http://dx.doi.org/10.1016/j.avb.2011.04.006] -10UN Women. 2018. Turning promises into action: Gender equality in the 2030 Agenda for Sustainable Development United States: United Nations Women; 2018 [updated 2018; cited 2018 14 September]. Available from: http://www.aidsdatahub.org/sites/default/files/ publication/UNWOMEN_Turning_Promises_into_Actions_2018_Summary.pdf], yet the problem persists. Currently, elimination of all forms of VAW including IPV is part of the Sustainable Development Goals, SDGs [11The United Nations. 2015. Sustainable development goals: 17 to transform our world: The United nations; 2015 [cited 2018 28 June]. Available from: https://www.un.org/sustainabledevelopment/] and is considered central to achieving the SDGs [10UN Women. 2018. Turning promises into action: Gender equality in the 2030 Agenda for Sustainable Development United States: United Nations Women; 2018 [updated 2018; cited 2018 14 September]. Available from: http://www.aidsdatahub.org/sites/default/files/ publication/UNWOMEN_Turning_Promises_into_Actions_2018_Summary.pdf].

Understanding the determinants of IPV is the bedrock of prevention. The ecological model for explaining IPV presents factors associated with IPV at four distinct levels, i.e. individual, relationship, community and societal levels [12Heise LL. Violence against women: An integrated, ecological framework. Violence against women 1998; 4(3): 262-90.-14Centers for Disease Control and Prevention. The Social-Ecological Model: A Framework for Prevention 2018. [cited 2018 21 Dec]. Available from: https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html.]. The ecological model provides an important framework for understanding interactions between different factors that can result in IPV as well as specific points in the model at which prevention strategies can be introduced. While primary prevention focuses on measures to stop the prevalence of IPV [15UN Women. Focusing on prevention to stop the violence 2018. [cited 2018 11 Dec]. Available from: http://www.unwomen.org/en/ what-we-do/ending-violence-against-women/prevention], the focus of secondary and tertiary prevention is to identify cases and manage the health outcomes of IPV, respectively. Continuous knowledge production to identify determinants in different population groups is thus an essential aspect of prevention.

Doctoral (PhD) research constitutes an important source of knowledge production in every discipline [16Walsh E, Anders K, Hancock S. Understanding, attitude and environment: The essentials for developing creativity in STEM researchers. Int J Res Dev 2013; 4(1): 19-38.[http://dx.doi.org/10.1108/IJRD-09-2012-0028] , 17European University Association. Bologna Seminar on “Doctoral Programmes for the European Knowledge Society” CONCLUSIONS AND RECOMMENDATIONS 2010 [cited 2018 22 Dec]. Available from: https://eua.eu/downloads/publications/salzburg%20 recommendations%202005.pdf.]. Doctoral theses are often executed within knowledge environments characterised by creativity, application and flexibility [16Walsh E, Anders K, Hancock S. Understanding, attitude and environment: The essentials for developing creativity in STEM researchers. Int J Res Dev 2013; 4(1): 19-38.[http://dx.doi.org/10.1108/IJRD-09-2012-0028] , 17European University Association. Bologna Seminar on “Doctoral Programmes for the European Knowledge Society” CONCLUSIONS AND RECOMMENDATIONS 2010 [cited 2018 22 Dec]. Available from: https://eua.eu/downloads/publications/salzburg%20 recommendations%202005.pdf.]. They are designed to be original and closely aligned with current global needs [18Marginson S, Wende Mvd. Globalisation and higher education 2007.]. The elimination of all forms of VAW including IPV and generation of evidence have been major global goals in recent times [13World Health Organization. Preventing intimate partner and sexual violence against women: taking action and generating evidence 2010. Available from: http://apps.who.int/iris/bitstream/handle/10665/44350/9789241?sequence=1, 15UN Women. Focusing on prevention to stop the violence 2018. [cited 2018 11 Dec]. Available from: http://www.unwomen.org/en/ what-we-do/ending-violence-against-women/prevention]. While acknowledging the importance of scientific utility for a doctoral thesis, Lafont (2014) highlights the importance of social utility of doctoral theses to account for societal issues and aid decision-makers [19Lafont P. Knowledge producing of the doctoral thesis: Between scientific utility and social usage. Procedia Soc Behav Sci 2014; 116: 570-7.].

This paper is intended to provide a review of IPV related thesis at a Swedish university and to ïdentify likely areas of unmet need for IPV intervention.

1.1. Context

Karolinska Institutet (KI), is a leading medical university [20Karolinska Institutet. 2018. About Karolinska Institutet - a medical university 2018 [cited 2018 9 July]. Available from: https://ki.se/en/about/startpage]. Research at the department of public health sciences focuses on identifying public health problems and designing population-level interventions [21Haglund BJ. Avhandlingar vid Institutionen för Folkhälsovetenskap, Karolinska Institutet åren 2008, 2009 och 2010. Socialmed Tidskr 2011; 88(1): 80-6.]. PhD theses at the department provide a global perspective since almost two-thirds of them are based on non-Swedish populations [21Haglund BJ. Avhandlingar vid Institutionen för Folkhälsovetenskap, Karolinska Institutet åren 2008, 2009 och 2010. Socialmed Tidskr 2011; 88(1): 80-6.].

2. MATERIALS AND METHODS

KI has had an open access policy since 2011, and therefore, maintains a database known as the KI open archive. The foregoing is an electronic archive where all publications produced at KI are stored. The thesis section of the database was searched between April and May 2018; the search was not limited by the publication year. A singular search term ”Violence” was first applied and resulted in 325 hits. It is important to note that theses written in Swedish also had an abstract in the English Language. The 325 hits were then individually examined to identify those dealing with VAW. This screening further resulted in a total of 23 theses. In the final step, IPV was used as the inclusion criteria yielding a total of 14 PhD theses. Only thirteen theses were included in the current study due to the exclusion of one thesis which focused on only perpetrators (Fig. 1).

Fig. (1)
Flow chart showing selection article process.


3. RESULTS

A total of thirteen theses met the set inclusion criteria, the earliest was published in 2004 and the latest published in 2017. The theses covered twenty-four different countries, a majority of them were low and middle-income countries (Table 1). The theses explored prevalence estimates and determinants (including IPV in pregnancy), diverse health-related outcomes, attitudes, disclosure and help-seeking behaviour (Table 2). Only two theses in total had intervention components i.e. one with the intervention to improve screening skills among nurses [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015.], and another which conducted a mapping of possible aspects to include in a planned intervention [23Hamzeh B. Intimate partner violence against women: Foundation for prevention and for an educational programme for new couples in an Iranian city: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2009.]. Findings of this review are presented in two broad categories i.e. background information in the theses and the result findings.

Table 1
Showing a summary of PhD thesis included in the review.


3.1. Background Information

3.1.1. Definitions and Typologies of IPV

Various definitions were adopted by authors, some definitions almost exhaustively describe what constitutes IPV and who the potential victims are, examples included definitions by the World Health Organisation, WHO and Center for Disease Control, CDC [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.-26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.]. The Center for Disease Control (CDC), defines IPV as any ”physical, sexual, or psychological harm by a current or former partner or a spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy. IPV can vary in frequency and severity. It occurs on a continuum, ranging from one hit that may or may not impact the victim to chronic, severe battering” [27Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: Uniform definitions and recommended data elements. Version 1.0. 1999]. Various terms were used to describe IPV e.g. domestic violence, men’s violence against women and sometimes VAW. Some authors [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008.] discussed this tendency to use terms interchangeably and made attempts to clarify each term. The United Nations’ (UN) definition of VAW was commonly referred [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015.-24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008.].

3.1.2. International Documents Cited

Global health policies and strategies are instrumental in shaping health promotion strategies at national and local level. Some authors [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008.-30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.] approached IPV from human and women’s rights perspectives. More commonly cited were UN’s convention on the elimination of all discrimination and violence against women (CEDAW) and UN’s 1993 Declaration on the Elimination of Violence against Women.

Table 2
Showing list of outcome variables in the studies.


3.1.3. Theses Methodologies

3.1.3.1. Design, Study Context, Setting and Participants

A total of five theses [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 23Hamzeh B. Intimate partner violence against women: Foundation for prevention and for an educational programme for new couples in an Iranian city: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2009., 25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.] used mixed methods incorporating qualitative (i.e. deep interviews and focus group discussions, FGD) and quantitative approaches. About six theses [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012., 30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.-34Rubertsson C. Depression and partner violence before and after childbirth: Institutionen Neurobiologi, vårdvetenskap och samhälle /Neurobiology 2004.] were quantitative of mainly cross-sectional design; Kaye (2006) combined cross-sectional, case control, and prospective cohort [25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006.]. Quantitative data source was either through a larger research project [34Rubertsson C. Depression and partner violence before and after childbirth: Institutionen Neurobiologi, vårdvetenskap och samhälle /Neurobiology 2004.], active data collection [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 23Hamzeh B. Intimate partner violence against women: Foundation for prevention and for an educational programme for new couples in an Iranian city: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2009., 25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006., 26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008.-30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010., 33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.], registers [32Caman S. Intimate partner homicide rates and characteristics. 2017., 35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.] or a combination of active data collection and registers/database (24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008., 33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.). Three Swedish registers were used i.e. National Public Health Survey conducted between 2004 and 2009 [33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.], national homicide dataset and the Forensic Homicide Database [32Caman S. Intimate partner homicide rates and characteristics. 2017.]. Demographic and Health Surveys (DHS) is an international database for monitoring demographic and health situations in developing countries, DHS was used by three authors [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008., 35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. The populations included in the theses are presented in Table 1. Some studies were conducted in clinical settings [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.-26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012., 30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.], others were household surveys or a combination of both (Table 1). Many of the theses based on DHS data focused on women of reproductive age (i.e. 15-49 years) while others chose a wider age range i.e. 16 – 84 years [33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.].

3.1.3.2. Instruments Used in the Quantitative Studies

Operationalisation of IPV was majorly based on the Conflict Tactic Scales (CTS and CTS2) [36Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2) development and preliminary psychometric data. J Fam Issues 1996; 17(3): 283-316.[http://dx.doi.org/10.1177/019251396017003001] , 37Strauss M. Measuring intrafamily conflict and violence: The Conflict Tactic Scales. 1990; 8145] which are well established self-report measure of IPV [36Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2) development and preliminary psychometric data. J Fam Issues 1996; 17(3): 283-316.[http://dx.doi.org/10.1177/019251396017003001] , 38Straus MA. Dominance and symmetry in partner violence by male and female university students in 32 nations. Child Youth Serv Rev 2008; 30(3): 252-75.[http://dx.doi.org/10.1016/j.childyouth.2007.10.004] ]. Some theses authors adapted and used the WHO questionnaires for some or all aspects of their studies [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. CTS was used to measure chronicity and severity of IPV [25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006., 26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.]. Other IPV related instruments used were Controlling Behaviors Scale-Revised (CBS-R) [26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012., 39Graham-Kevan N, Archer J. Intimate terrorism and common couple violence. A test of Johnson’s predictions in four British samples. J Interpers Violence 2003; 18(11): 1247-70.[http://dx.doi.org/10.1177/0886260503256656] [PMID: 19774764] , 40Graham-Kevan N, Archer J. Investigating three explanations of women’s relationship aggression. Psychol Women Q 2005; 29(3): 270-7.[http://dx.doi.org/10.1111/j.1471-6402.2005.00221.x] ]; attitudes towards IPV [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]; Decision Making In Abuse Relationships Interview, DIARI [33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.]; Domestic Violence Healthcare Provider Survey scales and Violence against Women Health Care Provider Survey [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.].

3.2. Theses Findings

3.2.1. Prevalence and Determinants of IPV

Lifetime prevalence ranged from 30.9% to 57.6% (29, 30), past year prevalence was between 8.3% in Vietnam to 56.3% in Pakistan [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.]. Psychological IPV appeared to be the most common of IPV. In one study, 69% of the women reported having perpetrated IPV in the past year [26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.]. Women’s use of controlling behaviors over partners predisposed them to psychological and sexual IPV [26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.], while partners’ use of controlling behaviors was positively associated with physical IPV and injury but negatively associated with psychological IPV [26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.].

Determinants of IPV include woman’s or partner’s low education, illiteracy [28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.]; large family size [29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]; being foreign-born, lack of social support, psychological distress, hazardous drinking and financial problems [33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.], having children [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.], controlling behaviors, being a perpetrator and history of abuse in childhood [26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012.], low education, polygamy, having witnessed IPV between parents, low household income, low occupational status [28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.] etc. Others include religion, suspected husband’s infidelity, dowry issues, alcohol problems [31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.], large age difference between partners, polygamy [31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.], lack of access to information, women’s lack of autonomy in decision making, [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.], and being in the age group 15-24yrs [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.].

Whereas financial problems such as difficulty managing monthly expenditure and contribution to household expenses were risk factors in studies in Nigeria and Sweden, financial strain was a protective factor for IPV in Mozambique [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012., 33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.]. In Kenya, high educational level was a protective factor for IPV, however high educational level combined with being employed and high occupational status were risk factors for IPV. Risk factors for IPV in pregnancy were adolescent pregnancy, abuse in childhood and first pregnancy. The study from Iran [23Hamzeh B. Intimate partner violence against women: Foundation for prevention and for an educational programme for new couples in an Iranian city: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2009.] showed gender differences regarding what men and women considered causes and triggers of IPV. While 90% of women ranked the three top causes of IPV as partner’s addiction, mental disorder, husband’s unemployment, 70-75% men ranked it as not obeying husband, unpleasant comment in the presence of other people and wearing unsuitable clothes.

3.3. Associated Consequences of IPV

IPV was significantly associated with adverse reproductive health outcomes such as miscarriages, stillbirths, having many children and increased used of modern forms of contraception [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.], induced abortions [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006.], depressive mood during pregnancy [34Rubertsson C. Depression and partner violence before and after childbirth: Institutionen Neurobiologi, vårdvetenskap och samhälle /Neurobiology 2004.], antepartum hospitalisations [25Kaye DK. Domestic violence during pregnancy in Uganda: The social context, biomedical consequences and relationship with induced abortion. 2006.], suicide, suicidal thoughts and homicide [28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.]. One study showed that female perpetrated intimate partner homicides are few and have remained relatively unchanged during the period studied [32Caman S. Intimate partner homicide rates and characteristics. 2017.]. Female perpetrators of intimate partner homicide are likely to have a history of substance abuse or prior victimization by the male victim [32Caman S. Intimate partner homicide rates and characteristics. 2017.]. Mental health outcomes include depression and worthlessness even in cases where women were perpetrators [26Zacarias AE. Women as victims and perpetrators of intimate partner violence (IPV) in Maputo City, Mozambique: Occurrence, nature and effects: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2012., 28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. Other outcomes associated with IPV were chronic pains [28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008.] and economic burden especially on families due to injury, death, deprivation etc. [31Dalal K. Causes and consequences of violence against child labour and women in developing countries: Institutionen för folkhälsovetenskap/ Department of Public Health Sciences; 2008.].

3.4. Attitudes, Disclosure and Help-Seeking

3.4.1. Attitudes

More women than men justified IPV [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]; the determinants of justifying IPV include living in disadvantaged communities, husbands having higher education, polygamy, lack of autonomy in decision making and being young [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. Living in urban areas, certain ethnicity and a rich wealth index were factors associated with the non-justification of IPV [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. The likelihood of justifying abuse was lower among women with frequent access to newspapers compared to access to radio and television [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. Protection of family honour was central to why women tolerated IPV, however, having an educated extended family and being younger reduced tolerant attitudes [29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. This finding is in contrast to one of the studies from Nigeria where tolerant attitudes to IPV were more among younger woman [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. In Vietnam, witnessing IPV during childhood was associated with justifying IPV [28Vung ND. Intimate partner violence against women in rural Vietnam: Prevalance, risk factors, health effects and suggestions for interventions: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2008.]

3.4.2. Disclosure and Help-seeking

Five studies [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.-35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.] examined disclosure and help-seeking. About 54% of women were not willing to disclose abuse, only 1% of those willing to disclose will report to the police while the majority preferred to disclose to friends, relatives or religious leaders [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. Ali (2011), approached disclosure as a coping strategy and found that only 177 of the 646 women subjected to IPV actually disclosed abuse [29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. A majority disclosed to their parents, friends and in-laws, however, only 1.5% sought formal help e.g. from healthcare services, judiciary or religious leaders [29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. Whereas one thesis [35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.] found that tolerant attitudes to IPV were significantly associated with disclosing IPV, another study [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.] found that women with tolerant attitudes did not differ from those with non-tolerant attitudes in their willingness to disclose.

In one study from Sweden, only about 5% of women exposed to IPV after childbirth reported to the police [34Rubertsson C. Depression and partner violence before and after childbirth: Institutionen Neurobiologi, vårdvetenskap och samhälle /Neurobiology 2004.]. Compared to non-help seeking women, women who seek help for IPV were likely to be younger, less educated and still in a relationship and have children together with the perpetrator; they also had more psychological and psychosocial impairments [33Dufort M. Individual needs and psychosocial health among victims of intimate partner violence: Inst för klinisk neurovetenskap/Dept of Clinical Neuroscience; 2015.].

3.5. Health Sector Response

Two theses [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.], examined IPV screening practices among health care providers (HCPs) and found that victim blaming [30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.] and preconceived notions about victims were common [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015.]. HCPs (comprising doctors, midwives, nurses and social workers) scored low on readiness to screen [30John IA. Screening for intimate partner violence in healthcare in Kano, Nigeria: Barriers and challenges for healthcare professionals: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2010.]. Social workers had higher self-efficacy and a network to screen and refer victims of IPV. Other factors associated with increased likelihood of screening for IPV were being male, victim blaming and increased self-efficacy. Screening for IPV was associated with women’s satisfaction with nursing care. Sundborg’s thesis [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015.] investigated Swedish nurses knowledge and readiness to inquire about IPV. Nurses lacked knowledge and skills for IPV screening, nurses who inquired about IPV had most likely acquired knowledge on their own. Furthermore, nurses commonly referred abused women to doctors.

3.6. Interventions

One thesis from Iran [23Hamzeh B. Intimate partner violence against women: Foundation for prevention and for an educational programme for new couples in an Iranian city: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2009.] found that a majority of the participants believed that education based prevention is a good approach. Suggestions of important components of such education include improving knowledge of women’s rights according to Islamic laws, knowledge about women’s rights, sexual education, consequences of VAW and coping strategies with legal action as the last alternative. Participants’ suggestions for intervention revealed gender differences. Another thesis [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015.] developed an education-based intervention to equip nursing staff with the necessary knowledge and readiness for identifying victims of violence and offer them adequate care. Post-test after one year showed significant improvements in knowledge and readiness to screen among participants. Part of this thesis was developing and testing a Swedish version of the Violence Against Women Health Care Provider Survey.

4. DISCUSSION

Using doctoral research theses produced at a Swedish university, this study sought to review the contribution of doctoral studies to knowledge production for IPV and IPV prevention. Another goal of this review was to identify areas of unmet need for IPV intervention studies. Only two of the theses had elements of intervention [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 23Hamzeh B. Intimate partner violence against women: Foundation for prevention and for an educational programme for new couples in an Iranian city: Institutionen för folkhälsovetenskap/Department of Public Health Sciences; 2009.] further confirming the current concern about the dearth of IPV intervention studies [13World Health Organization. Preventing intimate partner and sexual violence against women: taking action and generating evidence 2010. Available from: http://apps.who.int/iris/bitstream/handle/10665/44350/9789241?sequence=1, 15UN Women. Focusing on prevention to stop the violence 2018. [cited 2018 11 Dec]. Available from: http://www.unwomen.org/en/ what-we-do/ending-violence-against-women/prevention]. The only thesis which conducted an actual intervention did so within the healthcare setting and is from Sweden, a high-income country [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015.]. According to the WHO (2010), the need to refine and adapt the few available evidence-based interventions emanating from high-income countries for use in low-resource settings is a challenge [13World Health Organization. Preventing intimate partner and sexual violence against women: taking action and generating evidence 2010. Available from: http://apps.who.int/iris/bitstream/handle/10665/44350/9789241?sequence=1]. The existence of very little intervention studies especially from low-resource settings is an area of unmet need for IPV prevention.

The wide range of countries covered and the diverse nationally representative data materials in this review provide a range of important findings for future practice. Despite the potential problem of underreporting, the prevalence estimates, determinants and associated consequences of IPV found in these theses provide relevant information for planning interventions in different population groups. Moreover, the observation of the inverted U phenomenon (i.e. varying directions of association observed in different contexts for certain demographic and socioeconomic factors), provides a much-needed input for designing appropriate context-specific interventions. Using the widely accepted ecological model as a point of departure [12Heise LL. Violence against women: An integrated, ecological framework. Violence against women 1998; 4(3): 262-90., 13World Health Organization. Preventing intimate partner and sexual violence against women: taking action and generating evidence 2010. Available from: http://apps.who.int/iris/bitstream/handle/10665/44350/9789241?sequence=1], it appears that factors at the proximal end of the model (i.e. individual and relationship levels) are more well-researched than factors at the distal end (community and societal levels). This tendency probably explains why many of the evidence-based interventions and those for which evidence is emerging, are majorly based on addressing factors at the individual and relationship levels [13World Health Organization. Preventing intimate partner and sexual violence against women: taking action and generating evidence 2010. Available from: http://apps.who.int/iris/bitstream/handle/10665/44350/9789241?sequence=1]. While these are crucial aspects for prevention, the need for a holistic approach which takes community and societal level factors into consideration can not be overemphasised.

A relevant example for the foregoing is the finding that tolerant attitudes to and justification of IPV are common in many patriarchal, low-income contexts as well as in disadvantaged communities [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 29Ali TS. Living with violence in the home: Exposure and experiences among married women, residing in urban Karachi, Pakistan: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 35Uthman AO. Attitudes towards and exposure to intimate partner violence against women in sub-Saharan Africa: Contextual effects, neighbourhood variations and individual risk factors: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011.]. IPV and justification of IPV are rooted in social norms which reinforce gender inequality and perpetuate IPV [6Johnson MP. Gender and types of intimate partner violence: A response to an anti-feminist literature review. Aggress Violent Behav 2011; 16(4): 289-96.[http://dx.doi.org/10.1016/j.avb.2011.04.006] , 7World Health Organization. Gender, women and primary health care renewal: A discussion paper 2010., 10UN Women. 2018. Turning promises into action: Gender equality in the 2030 Agenda for Sustainable Development United States: United Nations Women; 2018 [updated 2018; cited 2018 14 September]. Available from: http://www.aidsdatahub.org/sites/default/files/ publication/UNWOMEN_Turning_Promises_into_Actions_2018_Summary.pdf]. Despite evidence that tolerant attitudes are known predictors of IPV victimization and perpetration, many interventions have only targeted women through economic empowerment and equipping them with skills related to gender equality [41World Health Organisation. Violence against women: Key facts 2017 [cited 2018 11 Dec]. Available from: https://www.who.int/news-room /fact-sheets/detail/violence-against-women]. Interventions to address harmful norms and values must target the wider society in order to alter beliefs and practices which perpetuate IPV. Furthermore, the finding that women who frequently watched television were more likely to have tolerant attitudes to IPV compared to those who read newspapers frequently [24Okenwa L. Intimate Partner Violence Among Women of Reproductive Age in Nigeria: Magnitude, Nature and Consequences For Reproductive Health: Inst för folkhälsovetenskap/Dept of Public Health Sciences; 2011., 42Okenwa-Emegwa L, Lawoko S, Jansson B. Attitudes toward physical intimate partner violence against women in Nigeria. SAGE Open 2016; 6(4): 2158244016667993.[http://dx.doi.org/10.1177/2158244016667993] ], may have implications for the use of access to information as a measure of women’s empowerment in research. Indeed, concerns regarding contents that seem to promote gender inequality in African movies and television programmes have previously been raised [42Okenwa-Emegwa L, Lawoko S, Jansson B. Attitudes toward physical intimate partner violence against women in Nigeria. SAGE Open 2016; 6(4): 2158244016667993.[http://dx.doi.org/10.1177/2158244016667993] , 43Adewoye OA, Odesanya AL, Abubakar AA, Jimoh OO. Rise of the’homo erotica’? Portrayal of women and gender role stereotyping in movies: Analysis of two Nigerian movies. Developing Country Studies 2014; 4(4): 103-10.]. Access to tv and radio as parameters for women’s empowerment may have to be specified in terms of what content has been accessed.

While primary prevention is important for preventing the occurrence of IPV, secondary and tertiary prevention helps to identify and manage cases, disclosure is therefore important. The finding that women are more willing to disclose IPV (or the fear of it) to informal resources such as family, friends or religious leaders, than to formal sources, e.g. police, healthcare is an important one. Informal resources provide social support and collaborate effectively with formal resources (e.g. counselors, doctors, law enforcement etc.) in providing safety and help to victims. Future research may aim at providing evidence for best practices regarding how to effectively engage informal resources. Women’s willingness to disclose is the bedrock of screening practices commonly found in healthcare settings. The health care sector has long been identified as an important arena for addressing IPV. While existing guidelines and standard routines in the sector may serve as good frameworks for responding to IPV, findings from this review further confirm that they do not provide the fundamental knowledge and competence for identifying IPV and responding accordingly [22Sundborg E. Om man inte frågar får man inget veta: Inst för neurobiologi, vårdvetenskap och samhälle/Dept of Neurobiology 2015., 44Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement. Ann Intern Med 2013; 158(6): 478-86.[http://dx.doi.org/10.7326/0003-4819-158-6-201303190-00588] [PMID: 23338828] ]. More studies on capacity building strategies for the general public health workforce (including healthcare) will help generate evidence for IPV prevention [45Okenwa-Emgwa L, von Strauss EJPhr. Higher education as a platform for capacity building to address violence against women and promote gender equality: The Swedish example. 2018; 39(1): 31.].

4.1. Strengths and Weakness

The national representative data used in most of the theses, the methodological rigor of databases used (e.g. DHS) and the various methodologies employed in the studies etc., all contribute to the strength of this review. Some weaknesses are however worthy of note. Firstly is that this review is based on doctoral theses from one university in Sweden and does not cover other contexts. Secondly, some of the theses are based on populations recruited within clinical settings. Although clinical populations provide quick access to participants, it is often criticised due to the risk of overrepresentation of IPV victims.

CONCLUSION

IPV research and advocacy have come a long way, however, the dearth of IPV intervention studies is an area of unmet need. Also, unlike factors at community and societal level, many of the determinants of IPV at individual and relationship level are well research and have provided vital information for interventions. The need to address community and societal levels factors that perpetuate IPV, e.g. attitudes towards IPV, can however not be overemphasised. Addressing community and societal level factors is important in order to have a holistic approach to IPV prevention. More studies on capacity building for the public health workforce (including the healthcare sector) will contribute to generating much-needed evidence for effective response to IPV. Doctoral theses research provide vast opportunities for knowledge production in addressing IPV and VAW in general.

AUTHORS' CONTRIBUTIONS

Dr. Emegwa-Okenwa Leah, PhD is the only author of this manuscript

SIGNIFICANCE FOR PUBLIC HEALTH

The findings from this review raise awareness for the need for more intervention studies on intimate partner violence in order to generate more evidence. Capacity building for public health workforce and addressing community and societal level determinants of IPV are discussed here as modifiable factors to address IPV and improve population health.

CONSENT FOR PUBLICATION

Not applicable.

STANDARDS OF REPORTING

PRISMA guidelines and methodology were followed.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The author wishes to thank Professor Bjarne Jansson, Department of Public Health Sciences, Karolinska Institutet, for the invitation to do this overview.

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