To our knowledge, this paper is the first to use the novel R.E.S.P.T framework to analyze IPV risk using nationally representative data. In Kenya, a higher total R.E.S.P.T. score was associated with lower odds of both lifetime experience and past 12-month experience of IPV. Each 1-unit increase resulted in a 40% decrease in women’s risk of experiencing IPV. Individually, strategies related to relationship skills, services ensured, poverty reduced and transformed attitudes and beliefs were associated with lower odds of IPV. These results suggest that national policy and local programs should increase interventions in these areas in order to decrease the prevalence of IPV. Notably, E, as measured by land and property ownership, increased women’s risk of IPV. Further investigation of reasons for this finding is warranted.
Joint and women only decision-making has been shown to decrease odds of IPV in several studies (12, 17). Researchers using the continuous Peru DHS from 2005–2012 found that each additional joint decision was associated with 9 percent lower odds of moderate physical violence and 16 percent lower odds of severe physical violence. They also found that women-only decision making did not have a significant effect on IPV(15). We found that joint-decision making was more strongly protective against IPV than women-alone decision making. Women who were involved jointly in all 4 decisions had half the odds of experiencing IPV.
One study, in Mumbai, assigned points in a similar fashion to our R scale, but scored autonomous and joint decision making equally. Our study found that women with the highest score in decision-making had less than half the odds of experiencing lifetime IPV or IPV in the last 12 months. The Mumbai study found decision making was only significantly associated with IPV when considered along with justification of wife-beating; women who were both not involved in decision making and justified abuse were had more than double the risk of experiencing IPV than women who were involved in decision-making and did not justify wife-beating(17). We did not find a significant interaction between decision making and justified abuse. This discrepancy in findings may be a result of between-country cultural or contextual differences and/or to differences in scale construction.
We found that E was associated with an increased odds of experiencing IPV. If a woman jointly owned land and a home with her husband, she had 25% higher odds of experiencing IPV. This result was similar to results from some countries in the 28-country study investigating the relationship between ownership and IPV in the last 12 months. Women in 5 countries, Burkina Faso, Egypt, Jordan, Mali, and Nepal, were more likely to experience IPV if they owned assets, jointly or alone, than women not owning assets. Three other countries, The Democratic Republic of Congo, Pakistan, and Honduras had the opposite result. Additionally, studies in India,(21) Nicaragua and Tanzania(22) have reported women’s asset ownership to a be a protective factor for IPV. More research is needed to clearly define the relationship between asset ownership and IPV, and the contextual or cultural factors that account for the difference in findings across countries as it is important to understand how to advance women’s asset ownership and economic status without increasing risk of IPV. For every increase in wealth quintile women had less than half the odds of experiencing lifetime IPV or IPV in the last 12 months, similar to findings in prior studies in the 2014 KDHS(32) and in 46 LMICs(23).
This study adds to the growing body of work on barriers to care in relation to IPV. Women who had no perceived barriers had half the odds of experiencing lifetime IPV or IPV in the last 12 months. Studies in Bangladesh and Ethiopia found women who experienced IPV had lower odds of receiving care or delivering with a skilled clinician(27, 28). Studies in the US have reported conflicting results, with some studies finding that women who experience IPV were less likely to utilize care such as cancer screenings(33), while others found that women who experience IPV were more likely to use health care services(25, 26). More work is needed to understand the relationship between health care access/barriers to care and IPV experience.
Women who had a score of 1 on T, transformed attitudes regarding practices such as wife-beating, had 60% lower odds of experiencing IPV. Studies in Nigeria and India reported similar results(17, 30). In our study, the T strategy alone was associated with the lowest odds of IPV compared to any other strategy.
The DHS provides a unique opportunity to assess the utility of the R.E.S.P.E.C.T intervention strategy at a nationwide level. Many countries use the same or similar questions and enable cross-country comparisons. However, not every strategy has relevant questions in the DHS and thus the C and second E strategies could not be incorporated into this assessment. Also some strategies had a limited number of questions thus measurement of these strategies is likely incomplete. Furthermore, the Cronbach alphas for some strategies were low, suggesting the need for improved measurement of these strategies. Given the low Cronbach alpha for total score, analyzing strategies alone rather than together may be a better approach. Although using the DHS was an imperfect solution to evaluate the WHO RESPECT framework, it nonetheless provided valuable insight at a national level., Further development of question modules to improve measurement is warranted.
A limitation of the DHS is that it is cross-sectional and therefore causal inference cannot be established. However, repeated assessments across waves of the survey will provide evidence of trends over time. This study, as any study on IPV, included many sensitive questions, thus social desirability bias(34) is a concern. and may have resulted in under-reporting of IPV. The KDHS asked behaviorally specific questions to minimize under-reporting of IPV(35). Despite these limitations, this study is the first, to our knowledge, to assess the utility of the WHO’s novel framework, and provides a more comprehensive understanding of the joint role of multiple intervention strategies in reducing IPV.