Abstract
Intimate Partner Violence (IPV) constitutes a significant public health crisis worldwide, with profound social and economic implications. This cross-sectional study explores the linkage between childhood adversities and IPV among married women in urban Bangladesh. From January to December 2018, the research involved 230 female participants from 3 urban sub-districts of Dhaka city. Utilizing the Adverse Childhood Experiences (ACE) questionnaire alongside an IPV questionnaire from the modified version of the Abuse Assessment Screen, this study examined the prevalence and severity of physical, sexual, and psychological abuse. Multiple linear regression analysis was employed to identify predictors of IPV. Findings reveal a strikingly high prevalence of IPV, with 91.7% of participants reporting experiences of some form of IPV. The frequency of IPV varied, with substantial portions experiencing multiple forms of abuse. The regression analysis indicated that higher ACE scores (B = 0.24, P < .05), inability to pay utility bills (B = 0.41, P < .05), and smoking at home (B = 0.53, P < .05) significantly contributed to increased IPV scores. The study underscores the profound impact of childhood adversities on the likelihood of experiencing IPV in adulthood, advocating for comprehensive public health strategies that address the prevention of violence across the lifespan. It emphasizes the need for targeted interventions that not only address the immediate factors contributing to IPV but also the broader socioeconomic issues that underpin such behaviors.
Keywords
Highlights
●91.7% of married women experienced some form of IPV in married life.
●Higher ACE scores were significantly linked to increased IPV risk in adulthood.
●Economic instability was also associated with higher IPV scores.
Introduction
Background and Global Context
In recent decades, there has been a significant increase in global awareness of violence against women, with intimate partner violence (IPV) being identified as the most prevalent, thus necessitating public intervention. 1 IPV is recognized globally as a major public health concern with profound social and economic impacts, 2 affecting individuals across all socio-economic, religious, and cultural backgrounds. According to World Health Organization, 3 IPV encompasses physical, psychological, or sexual harm inflicted by a partner, including physical violence, sexual coercion, mental abuse, and economic deprivation.
Global and Regional Burden of IPV
Studies indicate that approximately 35% of women worldwide may experience IPV or non-partner sexual violence in their lifetime, with 1 in 3 women facing IPV.4,5 According to a WHO report, the highest rates of IPV are found in Southeast Asia (37.7%), followed by the Eastern Mediterranean (37%) and Africa (36.6%). 6 A study highlighted the lowest rates of IPV in Japan and the highest rates in Ethiopia, Peru, and Bangladesh, with a scoping review in Bangladesh reporting that 15.5% to 48% of women experience IPV.7,8 Several recent studies indicate a high rate of IPV in Bangladesh, with women as the primary victims 9 ranking the country fourth globally. 10
Risk Factors for IPV
Diverse risk factors for IPV include low education, substance use, stress, communication issues, unequal power dynamics in relationships, male partners’ unemployment, gender inequitable norms, and attitudes that marginalize women. 11 Economic instability, such as food and housing insecurity, has also been linked to higher IPV risks, as evidenced by a study linking financial hardship to higher IPV prevalence among women in the United States of America (USA). 12
In Bangladesh, a study conducted during the COVID-19 pandemic found that women in arranged marriages, living in rural areas, unemployed, or experiencing significant family income reduction were at a higher risk of experiencing IPV, 9 while another study on adolescent married women identified additional risk factors, including younger age at marriage, a higher number of miscarriages, lower education, a larger age gap with the spouse, lower spousal income, poor marital adjustment, and lower subjective happiness. 13
Besides these findings, behavioral factors such as tobacco smoking have also been found to be associated with a higher likelihood of experiencing or perpetrating IPV in some studies.14,15
Some studies have revealed an association between early exposure to increased adverse childhood experiences (ACEs), such as abuse, and a higher risk of IPV in adulthood.11,16 In a study, a significant indirect association between female ACEs and both male-to-female and female-to-male partner violence, mediated by depression was found. 17 In an empirical study among married couples from 50 medium-to-large California cities, a strong connection was found between women who experienced ACEs and their likelihood of becoming victims of IPV. 18 Moreover, a recent meta-analysis of IPV and ACE depicts that individuals who experience ACEs, such as abuse or household dysfunction, are prone to become victims or perpetrators of IPV in adulthood. 19
In Bangladesh, previous studies have reported a high rate of ACEs and a high prevalence of child maltreatment. 20 suggesting a potential link to the country’s elevated IPV rates. However, to our knowledge, no study has explicitly established this connection in Bangladesh.
Theoretical Frameworks and Their Mechanisms
Various theoretical frameworks explain the link between ACEs and IPV. Social learning (SL) theory suggests that violence is transmitted across generations, as children learn behaviors by experiencing and observing parental interactions. 21 This theory explains that those who witness or experience violence in childhood may later mimic or tolerate similar behaviors in adult relationships. 22
An empirical study using data from the 2016 South Africa and Uganda Demographic and Health Surveys found that women exposed to maternal abuse by a male partner in childhood were more likely to perceive such behavior as acceptable and normal in their intimate relationships. This perception can contribute to the continuation of violence in later life.23,24
The Intergenerational Transmission of Violence (IG) theory, based on social learning theory, suggests that children adopt violent behaviors from their parents, increasing the acceptability of aggression in intimate relationships and perpetuating aggressive behavior across generations. 25 A study of 816 Thai married women found that childhood exposure to family violence exacerbates women’s societal and family disadvantages, increasing their likelihood of psychological and physical victimization in adulthood. 26 Numerous studies also link ACEs to IPV, using various metrics to assess childhood abuse and violence in adult partnerships.27 -29
Attachment theory explains that childhood bonds with caregivers shape future relationships. Bowlby 30 explained this as an “internal framework” influencing expectations in adulthood. Hazan and Shaver 31 and Bartholomew and Horowitz 32 expanded on this, showing that early attachments impact romantic relationships. Those who experience childhood abuse may subconsciously choose a partner who has control or manipulation power in the relationship. 33
Empirical studies have shown that a notable proportion of children in Bangladesh are subjected to maltreatment. 34 Furthermore, a wide range in the prevalence of various types of ACEs, spanning from 14% to 90% has been reported. 20 These alarming rates of child maltreatment and ACEs may be attributed to the elevated prevalence of IPV within the country. Although the evidence is persuasive, longitudinal studies are required to assess the distinct effects of these risk factors on IPV in Bangladesh context. While the association between ACEs and IPV has been well-documented in high-income countries, there is limited evidence from Bangladesh, where socio-cultural norms and economic challenges may amplify these risks.
Identifying the significant risk factors for IPV perpetration will enable the allocation of limited prevention resources to the most effective intervention targets. Therefore, this study aims to determine the prevalence of IPV and investigate the associated risks, including adverse childhood experiences.
Methods
Study Setting and Population
This study included data from 230 women living with their husbands and having at least 1 apparently healthy child, recruited between January and December 2018 from 3 adjacent urban sub-districts (Thanas) in Dhaka, the capital of Bangladesh, namely Kadamtali, Jatrabari, and Demra. Participants from a previous study were included to investigate the association between IPV and ACE. 20 The sample size was found to be significant to detect a association between IPV and ACE with an effect size (h = 0.3), a 5% significance level, and 80% power. 35 In the previous study, this group served as a neighborhood control while the case group consisted of mothers of children with physician-diagnosed Neuro-developmental Disorders (NDD). Each case was matched to the controls based on characteristics such as age, sex, or socioeconomic status to reduce bias. Mothers with children under 3 years of age were excluded. Data were collected through face-to-face interviews using a pre-designed semi-structured questionnaire. Participants were contacted by the phone and interviews were conducted in a secluded place of their choice. Informed written consent was obtained from all respondents before the interviews. The detailed methodology of the study procedure, sampling, sample size, and data collection technique is described in that article.
Data Collection Tool
Adverse Childhood Experience (ACE) Questionnaire
The Adverse Childhood Experiences (ACE) questionnaire, a widely recognized instrument for assessing childhood adversity before the age of 18, was utilized in this study. 36 The ACE questionnaire was used in this study because of its well-established reliability and validity in assessing a range of childhood adversities, which are relevant to the objectives of this study. The ACE questionnaire has been widely used in both global and local contexts for child-related trauma assessment and its future impacts on health and wellbeing. 37 In particular, the ACE measure has been previously employed in studies in Bangladesh and other South Asian countries to explore the impact of childhood adversity on adult health outcomes. 20 It encompasses 10 different types of ACEs, including different types of abuses, neglect, and household challenges. This questionnaire includes 3 types of abuse such as physical, emotional and sexual. For example, the emotional abuse-related question is “A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt.” The response for each question is “Yes” or “No.” For each positive response to the questionnaire’s items is assigned a score of 1, resulting in total scores that range from 0 to 10. Although the ACE score captures the diversity of ACEs experienced rather than their frequency or severity, it is categorized into 2 groups based on experiencing adversities for analysis: 0 to 3 (experiencing up to 3 adversities) and 4+ (experiencing 4-10 adversities). The scoring and categorization methods employed by this tool are consistent with those utilized in previous research.38,39 The tool’s internal consistency was confirmed with a Cronbach alpha score of .56 in this study.
Intimate Partner Violence (IPV)
After reviewing the literature, a questionnaire for IPV with 4 questions was developed from the modified version of the Abuse Assessment Screen. 40 It included questions on physical (1 question), sexual (1 question), and psychological abuse (2 questions) by a husband. The participants gave a history of being abused by their partners after their marriage. Each question focuses on a specific type of abuse and is designed to identify whether abuse has occurred. For example, to determine the physical abuse by the husband, the woman was asked “Have you ever been hit, slapped, kicked or otherwise physically hurt by your spouse/significant other?.” A positive answer scored 1 point, with a total score range of 0 to 4. 1 indicates a victim of 1 type of abuse, while 4 represents a victim of all 4 types of abuse. The internal consistency of this tool was confirmed with a Cronbach alpha score of .707 in this study.
Validation of the Tools
Both the ACE and IPV questionnaire was translated into Bengali and adapted to ensure its validity within the local context. Several types of validity were considered during this process. Translational validity was established through a rigorous translation and back-translation process, 41 ensuring that the meaning of the original instrument was accurately preserved in the Bengali version. Two translators independently translated the original English tool into Bengali, and 1 researcher compiled them in a single document. Subsequently, another individual with a graduate degree in English literature translated the tool back into English. A separate reviewer then compared the original tools with the back-translated versions to identify inconsistencies. Finally, the entire research team convened to address the inconsistencies and prepare a standardized Bengali version of the tool. We follow the similar procedure to confirm translational validity for both ACE and IPV questionnaire.
Cultural validity was ensured through careful adaptation of the questionnaire to reflect culturally appropriate understandings of adversity and violence, confirmed through discussions with local participants.
Socio-demographic Variables
Besides, information about participants’ age, education level, occupational status, age at marriage, present history of diabetes mellitus and hypertension, type of family-nuclear and extended, spouse occupation, number of children, family history of congenital anomaly, and household assets such as table, chair, watch, computer, electricity supply, refrigerator, television, radio, mobile phone, bicycle, and air conditioner were collected. Finally, the questionnaire was finalized through pretesting.
Data Collection Procedure
Data collectors received extensive training to ensure they could approach sensitive topics, such as childhood adversities and IPV, with care and professionalism. The training covered the importance of confidentiality, informed consent, and techniques for minimizing distress while discussing difficult experiences. Prior to data collection, all interviewers underwent a comprehensive 3-day hands-on training session. A pilot test was conducted with a small sample to refine the survey tool, and feedback from this test was used to improve the data collection process further.
Data was collected through structured face-to-face interviews using a Bengali-translated version of the ACE questionnaire and an IPV questionnaire specifically developed for this study. The interviews were conducted in private settings, such as participants’ homes, ensuring that the responses were confidential and that the participants felt safe and comfortable discussing sensitive issues. Before beginning each interview, the interviewer explained the purpose of the study and obtained informed consent from the participant. They emphasized the voluntary nature of participation and the right to withdraw at any time. Interviewers followed a standardized script to ensure consistency across interviews and reduce potential biases in how questions were asked.
All responses were recorded in real-time using paper forms, and these forms were later digitized for analysis. Data was encrypted and stored securely, accessible only to authorized research personnel to ensure the privacy and confidentiality of the participants. In cases where participants exhibited signs of distress during the interviews, interviewers were trained to provide immediate emotional support and, when necessary, refer them to local services offering psychological counseling and legal assistance. The collected data were double-checked for completeness and accuracy, with regular monitoring by field supervisors to ensure the quality of data collection throughout the study.
Statistical Analysis
A multiple linear regression analysis was used to determine factors that affect the dependent variable and how much each factor individually contributes to its variation. The regression model explains approximately 23.2% of the variance in IPV scores (Adjusted R-squared = .232). The statistical significance of the model indicates that the predictors exert substantial effects on IPV scores together. The normality of the data was evaluated using the Shapiro-Wilk test, and the results were not statistically significant, indicating that the data followed a normal distribution. No transformations were applied to the data. No missing data was present.
The ANOVA results confirm the model’s overall significance, with a Regression Sum of Squares of 66.700, a Mean Square of 6.670, and an F-statistic of 7.931, all indicating that the model significantly predicts IPV scores (P < .001). The Normal P–P Plot shows that the regression model’s residuals align well with the expected normal distribution, indicating that the model’s assumptions of normality and linearity are met, with no significant outliers observed. This implies a good model fit for the IPV score analysis.
Ethical Consideration
Ethical permission for the study was obtained from the Institutional Review Board of Institutional Review Board of BSMMU, Dhaka (memo no. 2018/10603) on September 01, 2018.
Consent to Participate
Written informed consent was obtained from the participants before data collection. All physical data, transcripts, and documents were encoded and stored in locked cabinets to protect participants’ privacy. Only research staff had access to the data. The information gathered was used solely for research purposes. The survey included sensitive inquiries about IPV and ACE, delving into participants’ personal histories of childhood and marital experiences, which could have triggered distressing memories. To address this, expert researchers thoroughly trained all data collectors to provide counseling should emotional distress arise. We used the STROBE cross-sectional checklist when writing our report. 42
Results
Demographic Characteristics
Out of 230 participants, 94 (40.9%) are under 30 years old, while 136 (59.1%) are over 30 years old. Table 1 shows that the mean age of participants is 29.9 years, with most (66.1%) married before the age of 18. Half of the participants and their spouses had an education level up to primary school, while the remainder attained secondary education or higher. Nuclear families predominated (79.1%), and the majority were homemakers (89.1%) with employed spouses (94.8%). Socio-economic status was distributed almost equally across lower (37.8%), middle (38.7%), and upper (23.5%) classes.
Socio-Demographic Characteristics of the Participants (n = 230).
Note. SD = standard deviation; ACE = adverse childhood experience.
ACEs and Smoking History
Notably, 26.5% of participants reported an ACE score of 4 or higher indicating exposure to 4 or more adverse experiences during childhood. These adversities included various forms of abuse (physical, emotional, or sexual) and neglect. In addition, 23.9% experienced smoking in the household (Table 1).
Prevalence and Intensity of IPV
Among the participants, 91.7% experienced IPV overall, with 33.9% experiencing at least 2 forms of IPV. Fear from a spouse (87.4%) and psychological abuse (63.9%) were the most prevalent forms while a smaller percentage of participants reported instances of physical abuse (22.2%). Details are reported in Table 2.
Overview of Intimate Partner Violence (IPV; n = 230).
Note. IPV = intimate partner violence; CI = confidence interval.
Regression analysis in Table 3 revealed that increased smoking at home (B = 0.53, P < .05), increased ACE score (B = 0.24, P < .05), and failure to pay utility bills (B = 0.41, P = .05) were significant positive predictors of IPV. Conversely, the use of smokeless tobacco (B = −0.36, P = .05) was significantly negatively associated with IPV. A history of diabetes mellitus did not significantly influence IPV scores. Family structure appeared to play a role in IPV, with individuals from extended families exhibiting higher IPV scores compared to those from nuclear families. However, this result was only marginally significant (B = 0.28, P = .08). Age at marriage showed a slight but non-significant decrease in IPV scores, with each additional year in age at marriage associated with a decrease in IPV (B = −0.01, P = .22). Educational factors, both of the individual and the spouse, indicated a trend toward lower IPV scores with higher education levels, although these effects were not statistically significant (Table 3).
Association Between Socio-Demographic Characteristics and Intimate Partner Violence (IPV; n = 230).
Note. DM = diabetes mellitus; B = unstandardized coefficients; β = standardized coefficients; SE = standard error; ACE = adverse childhood experience; Ref = reference.
P value ≤ .05.
Discussion
This study documented the relationship between childhood adversities and IPV among the urban population in Bangladesh. The findings highlight a distressingly high prevalence of IPV among women in urban Bangladesh. According to the 2015 Violence Against Women (VAW) Survey, 72.6% of women who have ever been married reported experiencing at least 1 form of violence from their husbands in Bangladesh, which aligns with our research. 43 In a study conducted in Australia as part of the Australian Longitudinal Study on Women’s Health (ALSWH), a national health survey reported a lifetime prevalence rate of IPV at 21.6%. 44 This rate is lower compared to the findings of our study. Furthermore, in Western Europe, 22% of women have experienced IPV, which is also substantially lower than the rates observed in Bangladesh. 45
One of the plausible causes of the increasing rate of IPV in Bangladesh is child marriage. In our study, we found that around 66% of women married before 18 years, and among them, approximately 35% gave birth before they attained 18 years. Although, globally, the percentage of marriages before the age of 18 years among women has been gradually decreasing during the past decade, child marriage remains widespread in Southeast Asia, where around 1 in 4 young women were first married or in union before 18 years. 46 Child marriage is regarded as a significant indicator of gender-based inequality and is frequently supported by the unequal gender norms that are common in low and middle-income countries (LMICs) like Bangladesh. 47 Our study reveals a notable mean age gap of approximately 8 years between male and female partners in Bangladesh, reflecting traditional norms where men marry younger women. This spousal age difference gives the male partner authority to foster a power imbalance in the relationship. To normalize and justify male dominance and control over women in this patriarchal society, they exhibit physical violence. In developed countries where stronger legal frameworks and support systems create greater societal awareness and condemnation of such violence against women, in LMIC like Bangladesh, traditional gender roles and societal norms may perpetuate the acceptance of IPV, and limited access to support services can exacerbate the issue.
Our study findings also supported the SL, IG and attachment theories where we found that an increased ACE score (B = 0.24, P < .05) is strongly associated with increased IPV in adult life. These theories depict that children who have seen IPV among their parents may come to view violence as a normal or acceptable method for handling conflicts or interactions within a relationship and tends to form relation with the abusive partner in later life. This perception increases their likelihood of becoming victims of violence in their adult relationships. An increased ACE score was found to be a significant predictor with a positive association with IPV, echoing numerous studies that have documented the long-lasting effects of early adversities on later violence16,20,48 also found that ACE is linked to a higher risk of IPV; as the number of violent childhood experiences increased, the risk of IPV also increased. Childhood exposure to abuse and domestic violence may result in revictimization and the perpetuation of the cycle of abuse. Based on the social learning model, experiencing childhood abuse and observing domestic violence can influence interactions with antisocial partners and increase exposure to violence throughout a person’s life. 21
Economic factors played a significant role in the prevalence of IPV. The inability to pay utility bills, a marker of economic instability, was associated with higher IPV scores. This finding aligns with existing literature suggesting that financial stress can exacerbate household tensions and contribute to violence. 2 Moreover, environmental factors such as increased smoking in the household were also significant predictors, potentially indicative of broader behavioral patterns associated with risk-taking and aggression. 49
Implications
Understanding cultural and societal differences is significant for developing effective interventions tailored to the specific contexts of IPV. Our study’s implications extend to policy and intervention strategies. Community-based interventions should prioritize preventing ACEs through programs that educate parents on the long-term effects of childhood trauma and promote positive, non-violent parenting practices. This approach can help disrupt the intergenerational cycle of violence. Addressing economic instability could reduce stress-related violence. New employment opportunities should be created, and women should be economically empowered by providing appropriate training and microfinance programs. Moreover, the high prevalence of IPV despite relatively high educational attainment among the participants suggests that education alone may not be protective against IPV. Academic content should be enhanced with resources that address equality and gender norms to mitigate this. Finally, in addition to the rigorous enforcement of protective laws, strong support networks for IPV survivors should be strengthened. These networks should include readily accessible psychological treatment, legal assistance, and safe shelters. These measures, tailored to the socio-cultural context of urban Bangladesh, provide a practical framework for reducing IPV and creating a safer, more equitable society.
Strengths and Limitations
Strengths of the study include its comprehensive assessment of IPV using validated measures and its focus on the urban population of Bangladesh, which is often underrepresented in research on IPV. Additionally, the study utilized multiple regression analysis to identify predictors of IPV, providing valuable insights into the complex interplay of risk factors.
However, several limitations should be acknowledged. The study’s cross-sectional design precludes causal inference, and the reliance on self-report measures may introduce bias, particularly given the topic’s sensitive nature. Additionally, the sample was limited to female participants, potentially overlooking the experiences of male victims of IPV. Future research should consider a longitudinal approach and include a broader demographic sample to enhance the generalizability and depth of findings.
Conclusion
The study highlights the pervasive nature of IPV in urban Bangladesh and underscores the urgent need for comprehensive public health interventions. By addressing the root causes and contributing factors of IPV, including childhood adversities and socio-economic determinants, policymakers, and stakeholders can work toward creating a safer and more equitable society for women. Future research should continue to explore the effectiveness of specific interventions and strategies in addressing IPV within local contexts and across diverse populations.
Supplemental Material
sj-docx-1-inq-10.1177_00469580251332057 – Supplemental material for Association Between Childhood Adversities and Intimate Partner Violence in Women During Adulthood: Insights from Urban Bangladesh–A Cross Sectional Study
Supplemental material, sj-docx-1-inq-10.1177_00469580251332057 for Association Between Childhood Adversities and Intimate Partner Violence in Women During Adulthood: Insights from Urban Bangladesh–A Cross Sectional Study by Anika Tasnim, Khandakar Fatema, Sharmin Islam and Md Atiqul Haque in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Supplemental Material
sj-docx-2-inq-10.1177_00469580251332057 – Supplemental material for Association Between Childhood Adversities and Intimate Partner Violence in Women During Adulthood: Insights from Urban Bangladesh–A Cross Sectional Study
Supplemental material, sj-docx-2-inq-10.1177_00469580251332057 for Association Between Childhood Adversities and Intimate Partner Violence in Women During Adulthood: Insights from Urban Bangladesh–A Cross Sectional Study by Anika Tasnim, Khandakar Fatema, Sharmin Islam and Md Atiqul Haque in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Supplemental Material
sj-pdf-3-inq-10.1177_00469580251332057 – Supplemental material for Association Between Childhood Adversities and Intimate Partner Violence in Women During Adulthood: Insights from Urban Bangladesh–A Cross Sectional Study
Supplemental material, sj-pdf-3-inq-10.1177_00469580251332057 for Association Between Childhood Adversities and Intimate Partner Violence in Women During Adulthood: Insights from Urban Bangladesh–A Cross Sectional Study by Anika Tasnim, Khandakar Fatema, Sharmin Islam and Md Atiqul Haque in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
References
Supplementary Material
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