Prevalence and Predictors of Violence Against Women in Pakistan

Abstract

Violence against Pakistani women occurs at an alarming prevalence that reflects a significant risk to the health of women and families. Understanding violence against women in Pakistan comes with methodological and cultural complexities. Many of the studies examining prevalence and predictors of violence against women tend to utilize convenience samples contributing to the possibility of an inflated prevalence. Due to the patriarchal family structure and cultural context, domestic violence is normalized resulting in extremely low reporting rates. The present study utilizes a sample of ever-married Pakistani women collected across five provinces to shed light on the prevalence and predictors of women that experience domestic violence (emotional or physical abuse). Data were obtained from the 2012-2013 Pakistan Demographic and Health Survey including a large sample of Pakistani women from five provinces (Sindh, Punjab, Balochistan, Khyber Pakhtunkhwa, and Gilgit Baltistan). Binary Linear regressions were conducted to examine how intrinsic variables (age, education, region, urban/rural, type of marital relationship, and wealth) predicted experiencing emotional or physical abuse from one’s husband within the past year. Approximately, 20% of women endorsed experiencing physical violence and 28% endorsed experiencing emotional violence. Results found that educational level, wealth, and type of marital relationship were associated with a higher likelihood of experiencing some form of physical or emotional violence. Implications from this study support policy interventions aimed at education within the family, linking women with resources, and continued investment in the education of young women. Interventions would be best targeted in low wealth regions with a special emphasis on rural areas.

Keywords

domestic violence predicting domestic violence cultural contexts

Pakistani women live in a culture of silence (National Institute of Population Studies, 2013). Across investigations, only one third of women will report intimate partner violence to a family member (Shaikh, 2003). When combining high prevalence rates (Aftab & Khan, 2011) with a low likelihood of reporting, it is probable that Pakistani women will experience negative physical and emotional effects of abuse without adequate support or services. This dynamic characterizes domestic violence as a public health issue in Pakistan. Understanding which Pakistani women are most likely to experience abuse is an important first step in the eradication of violence. Yet, measurement of violence against women is an emerging field in Pakistan that is limited by region-specific sampling. The present study contributes to the literature by examining intrinsic predictors of intimate partner violence in a national sample of ever-married Pakistani women.

Intimate Partner Violence in Pakistan

Intimate partner violence is marked by violent behavior perpetrated by one’s spouse or partner through physical aggression, sexual aggression, or emotional abuse (National Institute of Population Studies, 2013). Manifestations of intimate partner violence appear different across cultures. It is essential that research critically examine how operational definitions of abusive behaviors vary within cultural contexts. Marriage in Pakistan reflects a patriarchal structure that emphasizes the subordination of women (Qadir, Farah, de Silva, & Khan, 2005). Adapting understandings of intimate partner violence to the Pakistani cultural context requires careful consideration on how patriarchal gendered structures influence perceived partner violence.

Research on gender roles within Pakistani culture provides insight into the intersection between culture and violence. Many Pakistani men consider it a husband’s duty to hit his wife (Fikree, Razzak, & Durocher, 2005). This perspective reflects a larger cultural structure in which men value being dominant, justifying violence to maintain superiority (Zakar, Zakar, & Kraemer, 2013). When placed within the context of a Pakistani community, intimate partner violence can function as a means to maintain a man’s respect by utilizing abusive behavior to demonstrate his wife’s subordination (Zakar et al., 2013). Using violence to achieve a clear hierarchy within a marriage is likely considered acceptable behavior that impacts the way in which Pakistani men conceptualize domestic violence.

Culturally specific perceptions of intimate partner violence are not unique to Pakistani men. Many Pakistani women consider physical abuse to be an expected response within an argument (Aslam, Zaheer, & Shafique, 2015). A recent investigation asked Pakistani women which behaviors they considered to be violence against women. Approximately half of the participants perceived physical abuse as violence against women, whereas, 8% identified verbal abuse and 28% categorized emotional abuse as violence against women (Madhani et al., 2017). Taken together, the cycle of intimate partner violence within Pakistan creates a situation in which intimate partner abuse occurs at a high rate, but identification and willingness to receive supportive services for affected women appears unlikely.

While there is evidence suggesting that Pakistani women may not identify violent domestic behaviors as intimate partner violence, population-based studies suggest concerning rates of abuse. Previous studies suggest that many (26%-80%) Pakistani women experience some form of emotional or verbal abuse from their husband (Aftab & Kahn, 2011; T. S. Ali & Bustamante-Gavino, 2007; Shaikh, 2003). Rates of emotional abuse appear to be in stark contrast to rates of physical abuse.

Rates of physical abuse are notably higher with 46% to 80% of women reporting some form of physical abuse (T. S. Ali & Bustamante-Gavino, 2007; Shaikh, 2003). Generalizability of these results may be interrupted by sampling issues. Many samples of Pakistani women in research tend to predominantly include low wealth populations (T. S. Ali & Bustamante-Gavino, 2007) and convenience samples (e.g., hospitals; Aftab & Kahn, 2011; Shaikh, 2003). Hospital samples, in particular, may be subject to bias. Women screened for intimate partner violence within a hospital may be in the hospital due to experiences of physical abuse. As such, rates collected from medical settings may be inflated (Shaikh, 2003). These limitations call for a need for a national sample addressing intimate partner violence for Pakistani women.

Impact of Intimate Partner Violence

Violence against Pakistani women not only occurs at a high rate but also includes extreme forms of violence. Physical violence within Pakistan has a wide range of manifestations from hitting and punching to acid throwing (Human Rights Commission of Pakistan, 2015). Violence can continue during pregnancy with a small proportion of Pakistani women reporting an increase in violence during pregnancy (Shaikh, 2003). Common injuries include sprains, sore muscles, scalp lacerations, and black eyes (Fikree & Bhatti, 1999). Thus, it is unsurprising that one third of physical abuse cases lead to serious medical injury and that intimate partner violence is associated with poor reproductive health (Human Rights Commission of Pakistan, 2015; Zakar, Zakar, & Abbas, 2016).

The impact of intimate partner violence goes beyond physical marks. Within samples of Pakistani women, experiencing intimate partner violence is associated with lower psychological well-being (Hassan & Malik, 2012; Zakar et al., 2016), increased risk for depression (Zahidie & Jamali, 2013), and increased suicidal ideation (T. S. Ali, Mogren, & Krantz, 2013). Risks associated with intimate partner violence not only impacts women but concurrently impacts the health of children. Within a literature review, Holt, Buckley, and Whelan (2008) concluded that exposure to intimate partner violence impacts children’s development contributing to disruptions in coping skills, social interactions, and behaviors. Furthermore, research in Pakistan suggests that women who witnessed intimate partner violence toward their mother related to an increased likelihood of experiencing intimate partner violence as an adult (Aslam et al., 2015).

Predictors of Intimate Partner Violence

To mitigate the negative impact that intimate partner violence has on women and children, researchers have started examining which subpopulations of women are most vulnerable to abuse. Researchers have primarily explored educational attainment, wealth, type of relationship with husband, and age. Results examining samples of Pakistani women are mixed. Educational experiences are highly valued by Pakistani women and previous studies suggest that increased exposure to education may serve as a protective factor against intimate partner violence (Aftab & Kahn, 2011).

However, depending on the economic context of the individual, increased educational attainment may be associated with more economic independence that may threaten a husband’s power within the relationship (T. S. Ali & Bustamante-Gavino, 2007). Indirectly, this dynamic may lend itself to increased abuse perpetrated by a husband to maintain the hierarchy within the marriage (Zakar et al., 2013). Beyond such dynamics, results remained mixed with some studies suggesting that lower educational attainment increases the likelihood of violence (Aftab & Kahn, 2011), and others find no relationship (Shaikh, 2003).

Similarly, wealth is a commonly explored variable for predicting intimate partner violence. Married Pakistani couples reported verbal and physical abuse associated with financial disputes (T. S. Ali & Bustamante-Gavino, 2007). Consistent with this finding, lower wealth has been a common predictor of lifetime abuse (T. S. Ali, Asad, Mogren, & Krantz, 2011; Zakar et al., 2016). This may place lower wealth women at a higher vulnerability suggesting that they are more likely to experience intimate partner violence and less likely to receive adequate and appropriate care. However, this finding has only been demonstrated in smaller scale studies within Pakistan and may not be generalizable.

Another common variable for predicting intimate partner violence is the type of family relationship to one’s husband. Marrying one’s first or second cousin is considered common within Pakistani culture (Shaikh, 2016). It is unclear how marrying one’s relative may impact vulnerability to intimate partner violence. Given that women may disclose abuse to a family member (Shaikh, 2003), marrying a first or second cousin may allow for the unique opportunity for a parent to intervene within the family system. Contrary to this expectation, Shaikh (2016) found that women married to a blood relative, specifically a cousin from the paternal side, experienced intimate partner violence at a higher proportion. However, these proportions did not consistently reach statistical significance suggesting that this finding needs to be further explored.

Finally, it is important to understand which age group of women is most likely to experience abuse. Younger women may be more susceptible to complications related to reproductive health and vulnerable to chronic health issues associated with early abuse. Few studies have examined age as a predictor of within Pakistani samples. One study found that older women appeared to be at a higher risk for lifetime experiences of abuse when compared with younger women (T. S. Ali et al., 2011). This is likely given that the older you are the more abuse you may experience. However, there do not appear to be any studies addressing age as a predictor of past year of abuse.

Present Study

From a public health perspective, identifying which Pakistani women are vulnerable to intimate partner violence is essential to guide the application of relevant programming. Majority of studies examining violence against women in Pakistan exclusively examine one region and utilize convenience samples obtained within clinical settings (P. A. Ali, Naylor, Croot, & O’Cathain, 2015). The present study accounts for this gap in the literature by conducting a secondary analysis of data obtained from a national survey across Pakistan. Specifically, this study aims to shed light on which socio-demographic variables (age, education level, wealth, region, relationship to husband) are associated with an increased likelihood of abuse within the past year.

Method

Study Design and Procedures

This study used nationally representative data from the 2012-2013 Pakistan Demographic and Health Survey (PDHS). PDHS represents the population of Pakistan including all urban and rural areas of the four provinces and Gigit Baltistan defined as such in the 1998 Population Census. PDHS excludes Azad Jammu and Kashmir, Federally Administered Tribal Areas (FATA), and restricted military and protected areas as developed by Pakistan Bureau of Statistics (PBS) in their urban area frame. The sample design consisted of a two-stage stratified clustered design with the household as primary sampling units. The first stage of sampling draw included 248 urban and 252 rural out of 26,543 enumeration blocks, updated through the economic census conducted in 2003. The second stage of sampling involved selecting households.

At each enumeration block, 28 households were selected by applying a systematic sampling technique with a random start. This resulted in 14,000 households being selected (6,944 in urban areas and 7,056 in rural areas). Two areas of Balochistan province (Punjgur and Dera Bugti) were dropped because of their deteriorating law and order situations. Interviews were conducted in a private setting. Only female interviewers gathered data from participants, and spouses were not present during the interview procedures. Detailed information on the sample design, methods, and survey rates for the 2012-2013 PDHS is available from Demographic and Health Survey (DHS) funded by the United States Agency for International Development (USAID). For the present study, data related to age, education, region, types of relationship, and wealth index were used as predictor variables to estimate the likelihood of experiencing intimate partner violence within the past year.

Participants

The sample included ever-married women aged 15 to 49 years (n = 3,685). Majority of participants were aged 30 to 39 years (n = 1,392, 37.8%) with 27.4% of the sample aged 40 to 49 years (n = 1,009), 18.8% of the sample aged 25 to 29 years (n = 691), 13% of the sample aged 20 to 24 years (n = 478), and 3.2% of the sample aged 15 to 19 years (n = 116). A large proportion of the sample (n = 2,050, 55.6%) reported no formal education, with a smaller proportion endorsing primary and middle school education (n = 764, 20.7%) or secondary school or higher (n = 872, 23.7%). There was a relatively even number of participants from rural (n = 1,953, 53%) and urban areas (n = 1,733, 47%). Participants were collected from the following regions: Punjab (n = 1,092, 29.6%), Sindh (n = 841, 22.8%), Balochistan (n = 479, 13%), Khyber Pakhtunkhwa (n = 684, 18.6%), Gilgit Baltistan (n = 333, 9.0%), and Islamabad (Islamabad Capital Territory [ICT]; n = 257, 7.0%). This represents a nationally representative sample of Pakistani women.

Measures

Age

The range of participant’s age was 15 to 49 years. Only women aged 15 to 49 years were included as that was the range addressed within the original study. Participant’s reported age in years was entered into the regression as a continuous variable. The mean age of the participants was 33.47 years (SD = 8.36 years).

Level of education

The highest level of education achieved was divided into three groups: no education, primary and middle school, and secondary or higher.

Regions

Categories of regions collected included Punjab, Sindh, Balochistan, Khyber Pakhtunkhwa, Gilgit Baltistan, and Islamabad (ICT).

Types of relationship

The type of relationship with one’s husband prior to marriage was divided into four categories: first cousin from father’s side, first cousin from mother’s side, second cousin in general, and other relationships.

Wealth index

The wealth index was constructed based on a previous study (Rutstein & Johnson, 2004). A principal component analysis was used to measure the overall wealth of household including all the sources of income including ownership of assets. Wealth estimations were divided into four categories based on quartiles estimates with lower quartiles being indicative of less wealth.

Intimate partner violence (Modified Conflict Tactics Scale)

A modified version of the Conflict Tactics Scale was utilized to derive estimates of physical, emotional, the combination of physical or emotional violence within the past year (Straus, 1990). An exploratory factor analysis with varimax rotations was conducted to verify the factor structure for the present sample (see factor loadings on Table 1). Results confirmed that shortened and modified version of conflict scales does represent one scale for physical and emotional violence (Table 1). Three outcome variables were used: (a) any violence related to the physical abuse, (b) any violence related to the emotional abuse, and (c) any violence related to the physical and emotional abuse. All three outcome variables were categorized into dichotomous variables: Yes (indicating any type of violence in the last 12 months) and No (no violence in the last 12 months).

Table 1.

Prevalence of Physical and Emotional Violence Within the Past 12 Months.

		Yes n (%)	No n (%)	Factor Loading^a
Physical violence in last 12 months	In last 12 months, does (did) your (last) husband ever:
	Push you, shake you, or throw something at you?	412 (11.2)	3,270 (88.8)	0.76
	Slap you?	631 (17.2)	3,042 (82.8)	0.71
	Twist your arm or pull your hair?	251 (6.8)	3,434 (93.2)	0.80
	Punch you with his fist or with something that could hurt you?	187 (5.1)	3,494 (94.9)	0.81
	Kick you, drag you, or beat you up?	122 (3.3)	3,559 (96.7)	0.74
	Try to choke you or burn you on purpose?	47 (1.3)	3,634 (98.7)	0.58
	Threaten or attack you with a knife, gun, or any other weapon?	46 (1.2)	3,639 (98.8)	0.44
Any type of physical violence		726 (19.8)	2,948 (80.2)
Emotional violence in last 12 months	In last 12 months, does (did) your (last) husband ever:
	Say or do something to humiliate you in front of others?	798(21.7)	2,882(78.3)	0.88
	Threaten to hurt or harm you or someone close to you?	127(3.5)	3,556(96.5)	0.61
	Insult you or make you feel bad about yourself?	870(23.6)	2,811(76.4)	0.87
Any type of emotional violence		1,029(28.0)	2,651(72.0)
Any type of domestic violence		Either physical or emotional in last 12 months
Any type of domestic violence		1,197(32.6)	2,476(67.4)

Note. Conflict Tactics Scale (Straus, 1990).

Eigen value from factor analysis = 3.52.

Planned Analysis

Descriptive statistics such as proportion, sample size, and chi-square were used to explain the survey results and the correlation between predictor variables and outcome variables. Three multivariate logistic regression models were used on each outcome variable (physical violence in the last 12 months, emotional violence in last 12 months, and physical or emotional violence in the last 12 months). Authors selected bivariate regression analysis to establish the simple relationship between independent and dependent variables. Age, education, region, urban/rural, types of relationship, and wealth index were used as predictors in all three models. Deviance statistics were used to validate each logistic model. The statistical package SAS 9.3 was used for all analyses.

Results

Prevalence of physical and emotional violence is displayed in Table 1. Approximately 20% of married women were physically abused in the last 12 months. The most common form of violence reported included slapping (17.2%), and pushing, shaking, or throwing (11.2%). Around 28% of married women reported experiencing emotional violence in the last 12 months. The most common forms of emotional violence included insulting or making them feel bad (23.6%) and humiliation in front of others (21.7%). Overall, 32.6% of women experienced some form of physical or emotional violence in the last 12 months.

Table 2 depicts the prevalence of physical and emotional violence organized by demographics. Across all age categories, around 25% to 30% of women reported experiencing some form of physical or emotional violence in the past year. Women aged 30 to 39 years exhibited the highest prevalence (37.8%) of experiencing either physical or emotional abuse. The highest rates of any form of physical or emotional abuse were in women without any formal education (37.2%). In terms of regional patterns, the Khyber Pakhtunkhwa (43.6%) and Balochistan (43.3%) regions had high rates of emotional or physical abuse. Experiencing emotional or physical violence appeared to be more common in rural (37.4%) than urban (27.0%) areas. Violence appeared to be more common (43.7%) for women who married a man who was not associated with their family. Finally, it appeared that experiencing any sort of physical or emotional violence appeared more common for women within lower quartiles of wealth (Q1, 38.3%; Q2, 37.1%).

Table 2.

Basic Demographic Information.

	Physical Violence	Emotional Violence	Physical or Emotional Violence	Sample Total
	n (%)	n (%)	n (%)	N (%)
Age (years)
15 to 19	25(21.6)	25(21.6)	30(25.9)	116(3.2)
20 to 24	99(20.8)	122(25.6)	145(30.4)	478(13.0)
25 to 29	145(21)	188(27.3)	221(32.1)	691(18.8)
30 to 39	286(20.6)	424(30.6)	489(35.3)	1,392(37.8)
40 to 49	169(16.9)	267(26.7)	307(30.7)	1,009(27.4)
Education
No education	476(23.3)	653(32)	759(37.2)	2,050(55.6)
Primary and middle	150(19.7)	214(28.2)	249(32.8)	764(20.7)
Secondary and higher	98(11.3)	159(18.3)	184(21.2)	872(23.7)
Region
Punjab	180(16.5)	354(32.5)	394(36.2)	1,092(29.6)
Sindh	116(13.8)	103(12.3)	153(18.2)	841(22.8)
Khyber Pakhtunkhwa	197(29)	261(38.4)	296(43.6)	684(18.6)
Balochistan	148(31.3)	181(38.3)	205(43.3)	479(13.0)
Gilgit Baltistan	23(6.9)	39(11.7)	44(13.3)	333(9.0)
Islamabad (ICT)	60(23.4)	88(34.4)	100(39.1)	257(7.0)
Place of residence
Urban	295(17.1)	398(23)	466(27)	1,733(47.0)
Rural	429(22.1)	628(32.4)	726(37.4)	1,953(53.0)
Types of relationship
First cousin on father’s side	177(18.3)	239(24.7)	283(29.3)	971(43.3)
First cousin on mother’s side	139(20)	190(27.4)	220(31.7)	697(31.1)
Second cousin	71(24)	86(29.1)	102(34.5)	298(13.3)
Other relationships	65(23.5)	111(40.1)	121(43.7)	277(12.4)
Wealth Index
Wealth Index: Q1	234(24.4)	318(33.2)	367(38.3)	964(26.2)
Wealth Index: Q2	206(23.4)	284(32.2)	327(37.1)	884(24.0)
Wealth Index: Q3	174(18.2)	256(26.8)	298(31.2)	962(26.1)
Wealth Index: Q4	110(12.6)	168(19.3)	200(23)	876(23.8)

Note. ICT = Islamabad Capital Territory.

Three multivariate logistic regressions were conducted to understand which factors led to a higher likelihood of experiencing emotional violence (Model 1), physical violence (Model 2), or any sort of physical or emotional violence (Model 3). Odd ratios are presented in Table 3. Across all three models, age did not predict a higher likelihood to experience any sort of physical violence. In all three models, educational status predicted an increased likelihood of experiencing any form of intimate partner violence. Women who have no education are approximately twice as likely to experience emotional abuse (odds ratio [OR] = 2.2, 95% confidence interval [CI] = [1.47, 3.26]), 1.8 times (95% CI = [1.30, 2.47]) more likely to face physical violence in last 12 months, and 1.8 times (95% CI = [1.30, 2.47]) more likely to experience either physical or emotional abuse compared with women who have completed some form of secondary or higher education. Women who had completed primary and middle school education were 1.8 times (95% CI = [1.20, 2.71]) more likely to experience physical violence, 1.6 times more likely to experience emotional violence (95% CI = [1.15, 2.32]), and 1.7 times more likely to experience either physical or emotional violence (95% CI = [1.20, 2.32]) as compared with women who had completed secondary education or higher.

Table 3.

Logistic Regression Model.

	Reported Odds Ratio and 95% Confidence Interval
	Physical Violence	Emotional Violence	Physical or Emotional
Age	1.0[0.97, 1.00]	1.0[0.98, 1.01]	1.0[0.98, 1.01]
No education vs. secondary/higher	2.2* [1.47, 3.26]	1.7* [1.19, 2.35]	1.8* [1.30, 2.47]
Primary and middle vs. secondary/higher	1.8* [1.20, 2.71]	1.6* [1.15, 2.32]	1.7* [1.20, 2.32]
Rural vs. urban	1.0[0.78, 1.30]	1.4* [1.11, 1.76]	1.3* [1.06, 1.64]
First cousin on father’s side vs. other relationships	0.7* [0.51, 0.99]	0.5* [0.35, 0.63]	0.5* [0.39, 0.68]
First cousin on mother’s side vs. other relationships	0.8[0.57, 1.12]	0.5* [0.40, 0.73]	0.6* [0.44, 0.78]
Second cousin vs. other relationships	1.1[0.73, 1.60]	0.6* [0.45, 0.91]	0.7[0.51, 1.01]
Q1 Wealth Index vs. Q4 Wealth Index	1.5* [1.00, 2.36]	1.6* [1.08, 2.32]	1.5* [1.02, 2.11]
Q2 Wealth Index vs. Q4 Wealth Index	1.6* [1.03, 2.35]	1.5* [1.04, 2.17]	1.4* [1.02, 2.03]
Q3 Wealth Index vs. Q4 Wealth Index	1.4[0.93, 1.98]	1.5* [1.06, 2.07]	1.4* [1.00, 1.87]

Significant at 5% level.

There was some evidence suggesting patterns of prevalence related to living environment and type of relationship to the husband. Living in a rural compared with an urban environment did not predict a statistically significant likelihood to experience physical violence (OR = 1.0, 95% CI = [0.78, 1.30]). However, living in a rural compared with an urban environment predicted a higher likelihood of experiencing emotional violence (OR = 1.4, 95% CI = [1.11, 1.76]) and experiencing either emotional or physical violence (OR = 1.3, 95% CI = [1.06, 1.64]). Being married to a first cousin (father’s side) as compared with other relationships was generally associated with a decreased likelihood of physical (OR = 0.7, 95% CI = [0.51, 0.99]), emotional (OR = 0.5, 95% CI = [0.35, 0.63]), and either emotional or physical violence (OR = 0.5, 95% CI = [0.39, 0.68]).

A similar pattern emerged for marrying a first cousin on the mother’s side. Marrying a first cousin was associated with a decreased likelihood of emotional violence (OR = 0.5, 95% CI = [0.40, 0.73]) and either physical or emotional violence (OR = 0.6, 95% CI = [0.44, 0.78]) as compared with other relationships. This pattern was only seen for marrying a second cousin as compared with nonfamily relationships as decreasing likelihood of emotional violence (OR = 0.6, 95% CI = [0.45, 0.91]) as compared with other relationships.

Generally being below the highest quartile of wealth (Q4) was associated with a decreased likelihood of experiencing physical or emotional violence. Across all three models being in the lowest quartile of wealth (Q1) as compared with the highest (Q4) was associated with increased likelihood of physical (OR = 1.5, 95% CI = [1.00, 2.36]), emotional (OR = 1.6, 95% CI = [1.08, 2.32]), and either emotional or physical violence (OR = 1.5, 95% CI = [1.02, 2.11]). Being in the second lowest quartile (Q2) compared with the highest (Q4) was associated with increased likelihood of experiencing physical (OR = 1.6, 95% CI = [1.03, 2.35]), emotional (OR = 1.5, 95% CI = [1.04, 2.17]), and either emotional or physical violence (OR = 1.4, 95% CI = [1.2, 2.03]). A similar pattern emerged for being in the third lowest quartile in wealth (Q3) compared with the highest (Q4) for experiencing emotional (OR = 1.5, 95% CI = [1.06, 2.07]) and either emotional or physical (OR = 1.4, 95% CI = [1.02, 2.11]).

Discussion

The present study examined experiences of physical and emotional abuse within the past year in a nationally representative sample of Pakistani women. We found that approximately 20% of women encountered some form of physical abuse within the past 12 months, and 28% experienced some form of emotional abuse within the past 12 months. Overall, approximately 32.6% of women experienced some form of intimate partner violence. Compared with other investigations, the rates found in the present sample were lower. Some of these differences may be accounted for by the time frame. Because our study examined emotional or physical violence within the past year, prevalence rates appeared somewhat lower than previous studies that examined lifetime experiences of abuse.

An important conclusion from this study is to provide guidance for where prevention and services for survivors of intimate partner violence are most pertinent. Based on the present study, it appears that lower wealth is associated with susceptibility to emotional abuse. This is consistent with previous literature: most specifically literature suggesting that lower wealth is associated with an increased likelihood of violence with Pakistani men (Fikree et al., 2005) and reports that abuse is a common reaction to financial disputes (T. S. Ali & Bustamante-Gavino, 2007).

Programming addressing means to navigate financial disputes, such as microloans, may be warranted. Microloans are small, interest-free loans provided to women to increase empowerment. Investigations of microloan programs in both Akhuwat and Gujarat suggested that microloans contribute to an increase in perceived empowerment for Pakistani women (Khan, Sajid, & Rehman, 2011; Rehman, Moazzam, & Ansari, 2015). Neither study incorporated the role of microloans in creating empowerment within the context of intimate partner violence.

Future studies may work to investigate how microloans function to empower Pakistani women experiencing emotional and physical violence. Based on the patriarchal family structure and a possibility that violence may function for Pakistani men to maintain status in low wealth communities (Zakar et al., 2013), it is possible that increased economic mobility for women may be perceived as threatening. It is unclear whether or not such interventions would be helpful within the context of microloans. More research is needed within this particular area.

Despite consistent evidence suggesting an increased likelihood of emotional violence within lower wealth quartiles, we did not find a higher likelihood of experiencing physical violence when comparing the two lowest wealth quartiles. This means that being in the fourth as compared with the third quartile did not predict an increased likelihood of experiencing physical violence. In general, lower wealth was affiliated with a higher likelihood of domestic violence for all comparisons except for the lowest two quartiles of wealth. It is possible that there may be an overall relationship between lower wealth being associated with increased probability of physical violence and that a binary variable does not adequately capture the overall relationship. In addition, it may be that the impact on daily life between the third and fourth quartiles may not be significant enough to contribute to differences in likelihood of abuse. Possible mechanisms such as examining number of arguments regarding financial stress between individuals in the lowest quartiles of wealth may be a subject of future investigation.

In regard to education, our results suggest that education continues to be a protective factor. This is consistent with some of the previous literature (Atfab & Kahn, 2011; Zakar et al., 2016), but not in other studies (Shaikh, 2003). These contrary findings may be due to the power differential that can occur depending on the husband’s level of educational attainment, meaning that if a wife’s educational attainment surpasses her husbands, the marital hierarchy may be threatened. To support the possibility of interventions integrating sensitivity to the martial hierarchy, future research is needed. More studies may need to investigate the relationship between Pakistani men’s perceptions of education and adherence to a hierarchical notion of marriage play in prohibiting and inhibiting forms of violence.

T. S. Ali et al. (2011) found that older women were more likely to experience intimate partner violence within their lifetime. Our study contributed to the literature by examining the past year of physical and emotional violence. We found no association between age and likelihood of violence within the past year. This difference is likely accounted for by the span of time, meaning that older women have a longer period of years to experience violence as compared with younger women.

Our study also found that being married to a first cousin on either the father’s or mother’s side was associated with a decreased likelihood of abuse when compared with another relationship. This is contrary to findings suggesting that being women married to a paternal cousin reported the highest prevalence of physical abuse (Shaikh, 2016). Examining the relationship with the husband is an emerging variable that needs a future investigation to clarify its role within the perpetration of or protection from domestic abuse.

Regardless, there is an important policy implication that follows from this finding. Because the relationship of the husband matters, it may be important to provide preventive education and programming to mothers of Pakistani women and daughters prior to marriage. This would allow for an intervention that honors the cultural practice of keeping discussions within the family, while also activating a potential protective factor.

Although the present study provides a wide and generalizable context to understand violence, it is not without limitations. Our sample included ever-married women age from 15 to 49 years. Abuse can occur across the lifespan, so an important portion of women may have been overlooked within our analysis. The measures of intimate partner violence only included emotional and physical violence and did not include sexual violence or common forms of violence within Pakistan (e.g., acid burning). The measures of intimate partner violence within the present study described behavior that could be understood as intimate partner violence. Cultural norms regarding patriarchal marriage structures may inhibit the extent to which Pakistani women would label reported behavioral intimate partner violence as such. More research is needed on this possible discrepancy.

There could have also been more variables included to further clarify the impact of the husband’s status. Many studies have found variables related to the husband’s demographic characteristics (e.g., being an unskilled worker, level of education) as relevant predictors that were not included in the present investigation. Despite these limitations, this study serves an important function in identifying a general assessment of what violence against women looks like across Pakistan. Most importantly, the present study offers guidance on which population of women may be most vulnerable to abuse.

Footnotes

Authors’ Note

Kathryn LaBore is also affiliated with Rocky Mountain MIRECC, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA and the University of Utah, Salt Lake City, UT, USA. Rashid Ahmed is also affiliated with University of Manitoba, Winnipeg, Canada.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by College of Nursing and Professional Developmental (CNPD) Internal Research Funds, University of North Dakota, Grand Forks, ND, USA. Writing of this manuscript was partly supported by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs.

Author Biographies

Kathryn LaBore graduated with a PhD in counseling psychology at the University of North Dakota located in Grand Forks, ND. For the past 10 years, she has devoted her time to the preventing, counseling, and researching sexual assault. She currently works as a MIRECC postdoctoral research fellow at the VISN 19 Salt Lake City Department of Veterans Health.

Tooba Ahmed graduated with bachelor of arts in economics and statistics from University of Karachi. She is working as a research assistant with Department of Community Health Sciences (CHS), Max Rady College of Medicine, University of Manitoba. She has been mentor and funded by Dr. Evelyn Forget, Professor at University of Manitoba.

Rizwan-ur-Rashid completed his master of computer science degree from Department of Computer Science & Information Technology, NED University of Engineering & Technology, Karachi, Pakistan. He is working as a Director of Research and Development in Bhitai Dental Medical College.

Rashid Ahmed is an associate dean of research and associate professor in the College of Nursing at the University of North Dakota. His background is in epidemiology and biostatistics and has experience in the development of statistical methods for the design of community-based interventions and the analysis of longitudinal health data.

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