|Year : 2016 | Volume
| Issue : 1 | Page : 25-31
Prevalence and predictors of intimate partner violence in alcohol use disorder
Apala Aggarwal1, Suman Kumar Sinha2, Dinesh Kataria1, Hemant Kumar1
1 Department of Psychiatry and Drug De-addiction Centre, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
2 Consultant Psychiatrist, Waikato District Health Board, Hamilton, New Zealand
|Date of Web Publication||10-May-2016|
Department of Psychiatry, Drug De.addiction Centre, Lady Hardinge Medical College and Associated Hospitals, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Context: Intimate partner violence (IPV) is a major public health problem because of its detrimental effects on the physical and mental health of the victim. It is well-established that alcohol increases the occurrence and severity of violence between the partners. Aims: To find the prevalence and predictors of IPV in patients with alcohol use disorder (AUD). Settings and Design: This descriptive cross-sectional study was carried out at a De-addiction Centre of a Tertiary Government Hospital in New Delhi. Subjects and Methods: Thirty consecutive male patients were screened using International Classification of Diseases-10th Revision criteria for alcohol dependence syndrome. Their spouses were assessed using abusive behavior inventory for identifying physical, sexual, and emotional abuse. Statistical Analysis: Data were analyzed using descriptive statistics, multiple regression analysis, and Chi-square test. Results: Overall 6 months prevalence of IPV was 90%. Prevalence was 90% for physical and psychological abuse and 76.7% for sexual abuse. Physical abuse score ranged from 1 to 4.5 (mean 2.38, standard deviation [SD] 1.01). Psychological abuse score ranged from 1 to 4.71 (mean 2.64, SD 1.01). Sexual abuse score ranged from 1 to 4 (mean 2.11, SD 0.92). Total IPV score ranged from 1 to 4.4 (mean of 2.5, SD 0.94). Education of patient and spouse were significant predictors of overall abuse. While patient's education and family history of alcohol use significantly predicted physical abuse, spouse's education predicted psychological abuse. The incidence of abuse (any type) was also significantly associated with the joint family type. Conclusion: Study shows high IPV among spouses of AUD patients. There is a need to screen IPV in AUD patients so that adequate support could be provided to affected women.
Keywords: Abuse, alcohol, alcohol use disorder, intimate partner violence
|How to cite this article:|
Aggarwal A, Sinha SK, Kataria D, Kumar H. Prevalence and predictors of intimate partner violence in alcohol use disorder. J Mental Health Hum Behav 2016;21:25-31
|How to cite this URL:|
Aggarwal A, Sinha SK, Kataria D, Kumar H. Prevalence and predictors of intimate partner violence in alcohol use disorder. J Mental Health Hum Behav [serial online] 2016 [cited 2019 Dec 11];21:25-31. Available from: http://www.jmhhb.org/text.asp?2016/21/1/25/182101
| Introduction|| |
World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation.” Intimate partner violence (IPV) is defined as violence between two partners in a close relationship. IPV consists of violence in the following four domains.
- Physical abuse
- Sexual abuse
- Emotional abuse.
IPV is a major public health problem because of its adverse outcomes in terms of physical, mental and psychological health of the victims. The physical injuries include cuts, bruises, fractures, loss of vision, hearing, or sight. The sexual abuse may lead to unwanted pregnancies, abortions and sexually transmitted infections including HIV/AIDS.,, The psychological repercussions comprise of adjustment disorder, depression, posttraumatic stress disorder, eating disorders, drug abuse as a method of coping, and even suicide.,
The global presence of IPV and its health consequences have made it an important subject of study. Recent international estimates suggest that the prevalence of IPV falls between 21% and 47% in most countries of the world, with the highest prevalence of 71% in rural Ethiopia. While the South Asian countries report some of the highest rates of domestic violence in the world,,, lower rates are reported in the USA (1.5%), the UK (4%), and Canada (4%).
In India, about 40% of women have reported being physically abused by their husbands, at least once in their lifetime. According to the National Family Health Survey-3, conducted in 2005–2006, about 27.8% of married women experience physical violence and 7.7% experience sexual violence by their intimate partners.,
Strong evidence links alcohol use with IPV as alcohol retards a person's judgment and inhibits his social discretions. There is enough evidence suggesting that alcohol use increases the occurrence and severity of violence between the partners., It has been postulated that alcohol affects cognitive functioning and reduces self-control, which leaves a person incapable of negotiating a nonviolent resolution to conflicts with his partner. The risk of IPV is further increased due to family stressors such as financial constraints, child rearing issues, infidelity, which in turn are caused because of excessive alcohol intake. Many times, alcohol is used as an excuse for violent behavior due to societal belief that alcohol causes aggression. Furthermore, children who witness parental violence are more prone to develop harmful drinking patterns in their adult life.
In a model of marital aggression, certain proximal and distal factors are found to be directly associated with physical and psychological aggression. While distal factors are long-standing and include personality traits, gender roles, individual beliefs, and chronic drinking pattern, the proximal factors are transitory and include acute intoxication, immediate affective and cognitive state of the individual.
Further studies suggest that variables such as antisocial personality, marital dissatisfaction, family history of alcohol use, parental disharmony, duration, frequency, and severity of alcohol use  are also positively related with IPV.
One interesting study showed that IPV was related with the women's educational level. Growing evidence correlates neighborhood context with IPV suggesting that IPV is more common in women who live in areas with prominent poverty, unemployment, and neighborhood disadvantage.,,,
Another important predictor of IPV was found to be pregnancy in the partner. The prevalence of IPV during pregnancy was estimated between 18% and 28% by various national  and international  studies.
Although various studies have been performed internationally, there is a dearth of data from our country. Few studies from India so far have mostly involved special population groups such as pregnant women, women in slums  or were done in a different geographical area. One study from Northern India did focus on IPV in substance users, but it included both alcohol and opioid users and used different scales. Another study  found out that alcohol users indulged in IPV more frequently (odds ratio [OR] =2.20, 95% confidence interval [95% CI] =1.90–2.55, P = 0.001) as compared to general population.
While there are some data available on IPV in alcohol users from India, it remains patchy and incomplete. It is important to research this area so that we can formulate preventive measures for the psychological consequences in the victims, appropriate for our sociocultural background. Keeping these factors in mind, the current study was planned to find prevalence and predictors of IPV in patients with alcohol use disorder (AUD), attending a Tertiary Hospital De-addiction Centre.
| Subjects and Methods|| |
This study was carried out in the Department of Psychiatry and De-addiction Centre of a Tertiary Care Government Hospital in Northern India. The study was conducted in the year 2013 spanning over a period of 3 months and involved cross-sectional assessment of patients and their spouses. Ethical clearance was taken from the Ethical Committee. Thirty consecutive male patients with alcohol dependence and their spouses who met the inclusion criteria were enrolled in the study after taking written informed consent. Only male patients from the outpatient department were included in the study to make the sample homogenous.
- Adult males meeting the criteria of alcohol dependence syndrome (ADS) as per International Classification of Diseases-10th Revision Clinical Descriptions and Diagnostic Guidelines 
- Age of patient - 21–65 years
- Duration of ADS of at least 1 year or more
- Married for at least 1 year and cohabiting since then
- Availability of spouse for assessment
- Patient and spouse willing to participate in the study and willing to give written informed consent.
- Patients who were divorced or separated
- Patients and spouses with co-morbid axis I psychiatric illness.
Spouses were then interviewed separately and privately by a female psychiatry resident for physical, psychological, and sexual abuse in the last 6 months using abusive behavior inventory (ABI). ABI is a 30 item Likert scale assessing each item on a scale of 1–5 (1 = no abuse, 5 = very frequent abuse) with internal consistency between 0.79 and 0.92 and evidence of criterion, convergent, and discriminant validity. Spouses were also assessed for the presence of any psychiatric morbidity using Mini International Neuropsychiatric Interview. The sociodemographic information was collected using a brief semi-structured proforma. Kuppuswamy's socioeconomic status scale, modified for 2007 was used to assess socioeconomic status of the families. The tools were translated in vernacular by the interviewer for the subjects to understand and respond most appropriately. Organicity was ruled out by a detailed history and clinical examination.
Small Stata version 12 (StataCorp. 2011. Stata Statistical Software: Release 12. College Station, TX: StataCorp LP)was used for statistical analysis. Descriptive statistics were used to describe the data. Multiple regression model was used to analyze for predictor variables of total ABI score, and its physical, psychological, and sexual item subscale. Chi-square was used for categorical variables with more than two categories such as religion and family type. The level of statistical significance was kept at P < 0.05 for all the statistical tests.
| Results|| |
As shown in [Table 1], the majority of the study sample was Hindu. The most common family type was nuclear followed by joint family type. Most (93.3%) of the patients were employed, whereas only 26.67% of their spouses were employed. The majority of the patients belonged to the middle socioeconomic strata and had a long history of AUD. Family history of AUD was present in about three-quarter of the patients.
As shown in [Table 2] and [Table 3], the observed percentage of frequencies of all the abuse items on the abuse behavior inventory checklist were calculated along with the category-wise abuse items for the last 6 months.
|Table 2: Observed frequency of abusive behavior in past 6 months among partners of alcohol abusers|
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|Table 3: Observed frequency of abusive behavior in past 6 months as per category of abuse among partners of alcohol abusers|
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As shown in [Graph 1 [Additional file 1]], the overall 6 months prevalence of IPV was 90% which included the prevalence of 90% each for physical and psychological abuse and 76.7% for sexual abuse. This means 90% of spouses were victims of violence in at least one domain of the ABI. As shown in [Graph 2 [Additional file 2]], physical abuse score ranged from 1 (no abuse) to 4.5 (very frequent) with a mean of 2.38. Score for psychological abuse ranged from 1 to 4.7 with a mean of 2.64. Score for sexual abuse ranged from 1 to 4 with a mean of 2.11. Total IPV score ranged from 1 to 4.4 with a mean of 2.5.
Multiple regression analysis was performed for the outcome scores of ABI and its subscale for interval/ordinal variables. The following 14 variables were used to find an association with individual or total abuse.
- Age of patient
- Age of spouse
- Duration of marriage
- Education of patient
- Education of spouse
- Occupation of patient
- Occupation of spouse
- Family income
- Number of children
- Earning patient
- Earning spouse
- Birth order of patient
- Duration of alcohol use
- Family history of alcohol use.
As shown in [Table 4], the overall ABI score was predicted significantly by education level of patients as well as their spouses. The education level of patients was negatively associated (coefficient = −0.65, P < 0.05) whereas that of their spouses was positively associated (coefficient = 0.73, P = 0.035) with the total ABI score. The physical subscale of ABI was significantly associated with the education level of patients (coefficient = −0.71, P = 0.041) and the family history of SUD (coefficient = 1.21, P = 0.032). The psychological subscale of ABI was positively associated with the education level of patient's spouses (coefficient = 0.81, P = 0.03).
|Table 4: Multiple regression analysis for outcome abusive behavioral inventory scores (total/physical/psychological/sexual)|
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As shown in [Table 5], Chi-square test was used for categorical variables with more than two category levels, i.e., family type. The incidence of abuse was more in joint family type (observed = 177, expected = 156) than would be expected by chance alone while nuclear and extended family type had less incidence than expected. Chi-square test could not be used for religion as there were inadequate entries in each sub-category (1 Muslim, 2 Sikh, and 28 Hindu families).
| Discussion|| |
The study revealed multiple key findings.
First, the prevalence of overall abuse and abuse in individual domains was much higher (90%) than reported in the previous national  (63%) and international  (42%) studies carried out in this field. Although both these studies involved a hospital-based sample like our study, they had a bigger sample size which may have accounted for differences in prevalence. Furthermore, the national study  as mentioned above used a different scale with answers to each question as either yes or no. Such type of answering could have lowered the prevalence since less severe abuse could have been falsely answered as no by the partner. Furthermore, it is speculated that only those patients reported to the hospital in our study, who had a severe problem in terms of alcohol use and its behavioral consequences. The patients, who did not have severe problems with alcohol use, did not come to the hospital leading to a reporting bias.
Second, the reported physical (90%) and psychological abuse (90%) was higher than the reported sexual abuse (76.7%). This could be because of hesitation associated with discussing sexual behavior, especially in the Indian culture. Besides, most of the patients had a long-standing history of AUD, making them more prone to sexual dysfunction as a major side effect of chronic alcohol use and thus reducing sexual abuse of their spouses. A recent international study  did show that sexual abuse (23.1%) was lower than physical abuse (37.6%) although it was higher than emotional abuse (12.3%) in a clinic-based sample recruiting 1401 women. Lower prevalence of all types of abuse could be because of the lesser time frame (3 months) used in this study as compared to the time frame (6 months) in our study. This study  also highlighted that OR was higher for sexual abuse when the partner used alcohol as compared to nonalcohol using partners (OR = 6.1, 95% CI = 3.3–11.3). This finding could be because of the reason that this study  recruited female subjects attending family practice clinic and only a small percentage of perpetrators (20%) were using alcohol. Another study  showed that sexual abuse was high in alcohol users though it also sought to see the impact of other factors such as childhood abuse and sensation seeking which could have altered the findings.
Third, education level served as an important predictor of IPV in these couples. It was negatively associated with patient's education level and positively with spouse's education level. It meant that patients who were more educated were significantly less likely to indulge in IPV than those patients who were less educated. This could be attributed to more awareness of consequences of IPV and the related laws, which might have acted as deterrents. Education is also likely to have subdued the patriarchal bias traditionally present in the Indian culture. A recent Indian study  carried out on IPV in alcohol and opioid users had similar findings.
In addition, the finding that more educated spouses reported more IPV could be due to their ability to recognize and report IPV better than their less educated counterparts who may not have been more forthcoming believing many of the subtle items to be the norm rather than a form of abuse. Another probable explanation for this finding could be the bias of North Indian patriarchal society toward more educated spouse. A Western study found out that the highest chances of reported IPV was when the wife was more educated than the patient.
Furthermore, family history of AUD significantly predicted more IPV in these patients. This finding reflects the learning of maladaptive behavior from alcohol using parent or other members in the family by modeling and normalization of IPV as acceptable behavior. It could also link to the witnessing of parental discord or childhood violence due to alcohol use. As mentioned previously, studies do outline parental alcohol use or family history of alcohol use as a robust predictor of IPV in children, especially male, when they grow up.
Finally, incidence of abuse (any type) was more in joint family type than would be expected by chance alone while nuclear and extended family type had less incidence of abuse than expected. Although this finding is contrary to the existing literature, which reports higher incidence of abuse in the nuclear family, such a finding in our study could be because of reporting bias of the spouse in a joint family structure. The acceptance of abuse by more members in the family may make the abuse, more likely to be accepted and reported by the spouse.
Although our study added on the existing data, it also showed some differing results from the previous studies. We could not find any significant association between other demographic variables and IPV. It could be because of small sample size of the study. Moreover, since it was a hospital-based study, the results cannot be extrapolated for community-based prevalence. In addition, comparing with a control group could have given more accurate findings and validated our results in a better manner. Furthermore, we did not assess the personality of the patient, which could have significantly predicted the association between IPV and personality traits like impulsivity. A longitudinal, comparative, community-based, large sample-sized study with assessment of personality and cultural belief system would have been an ideal piece of work. However, due to the paucity of resources, such a study design could not be undertaken.
| Conclusion|| |
Limitations withstanding, our study did find a high prevalence of overall, physical, psychological, and sexual abuse in the spouses of alcohol users attending a Tertiary Care De-addiction Centre in North India. Association of IPV with family history of substance abuse and education of patients and their spouses throws light on the social area where preventive efforts need to be focused. As mental health professionals, it is our responsibility to ensure that the prevalence and predictors of IPV in patients with AUD are adequately researched and clearly put across to policy makers so that adequate support could be provided to affected women.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]