Gender-based violence (GBV) is a gross violation of human rights and a global public health problem. Many forms of GBV exist, of which the most common form is domestic abuse, which is defined in the UK as “any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality”. Other forms include physical abuse, sexual abuse, psychological abuse, coercive control, financial abuse, stalking, child marriage, female genital mutilation (FGM), and elder abuse.
Exposure to violence and abuse is associated with substantial morbidity and mortality, through impacts on physical, mental, sexual and reproductive health. The literature reports associations with chronic pain, cardiovascular disease, arthritis, somatoform disorders, mental health disorders, gynaecological disorders and adverse pregnancy outcomes. Previous studies using the 'The Health Improvement Network’ (THIN) database have also reported associations between domestic abuse exposure and chronic pain syndromes, cardiovascular disease, and depression.
However, discrepancies in the definition and measurement of GBV subtypes mean that there are critical gaps in our understanding of its nature, incidence & prevalence, and consequences across the population. Therefore, we aim to explore using linked datasets (hospital and GP data) on a broader scale, a closer representation of the true extent of burden on GBV in the UK. Understanding this better will be able to inform public health policy to prevent GBV and its negative consequences as well as advocacy for survivors of GBV.
Aims: 1) explore the incidence and prevalence of GBV and 2) to describe the burden of disease in patients exposed to all forms GBV.
Population and data sources: All patients who contribute to CPRD GOLD, AURUM and linked HES admitted patient data between 1st January 2001 to 1st January 2022
Exposure: All forms of gender-based violence (GBV) which includes intimate partner violence (IPV), physical abuse, sexual abuse, emotional abuse, domestic violence, female genital mutilation (FGM), dating violence, and stalking.
Outcomes (Relevant to aim 2): The risk of developing a variety of conditions (those included in the Global Burdens of Disease e.g. HIV/AIDs, communicable diseases, maternal disorders, neonatal disorders, nutritional deficiencies & malnutrition, cancers, cardiovascular disease etc).
Study design: 1) Annual incidence rates will be calculated by dividing the number of eligible patients, who for the first time meet the GBV exposure criteria (numerator) by the total number of person-years at risk (denominator) for the given year. 2) Annual point prevalence will be the proportion of patients with GBV exposure on 1 January each year of the study. 3) We propose to undertake a series of population based retrospective open cohort studies to explore the risk of such negative consequences following exposure to GBV and in particular if the risk varies in certain sub-groups of those exposed. We will calculate the incidence rate of each outcome of interest and where suitable use a Cox proportional Hazard model to describe risk.
Intended benefits: 1) Improve estimation of the burden of GBV to support policy makers and commissioners and highlight under-recording of sub-types in relation to existing surveys (e.g. CSEW) and 2) indicate the estimated associated health burden and identify particular conditions which could benefit from targeted preventive approaches in those exposed to GBV.
Objective 1: Epidemiology of GBV
· Annual incidence rate per million person years will be calculated stratified by age, sex, region, socio-economic status and ethnicity.
· Annual prevalence per million population will be calculated stratified by age, sex, region, socio-economic status and ethnicity
Objective 2: Outcomes of GBV
In line with the Global Burdens of Disease study design; we aim to explore the risk of the following outcomes (following exposure to GBV) listed here https://www.thelancet.com/gbd/summaries
These include outcomes of the following categories: HIV/AIDs; communicable diseases; maternal disorders; neonatal disorders; nutritional deficiencies & malnutrition; cancers; cardiovascular disease; chronic respiratory diseases; digestive diseases; neurological disorders; mental disorders; substance use disorders; diabetes mellitus; renal disorders; skin and subcutaneous disorders; sense organ diseases; musculoskeletal disorders; congenital defects; urinary diseases; gynaecological disorders; endocrine & metabolic disorders; blood & immune disorders; transport injuries; unintentional injuries; and self-harm & interpersonal violence. The overall headings for each category e.g. maternal disorders are the primary outcomes but the secondary outcomes are those covered within this definition e.g. gestational diabetes.
Rationale for extensive outcome search:
The negative impacts of gender-based violence on health are well documented in the literature.(1–4) Consequences can be immediate and fatal including physical injuries and health(5,6) but beyond this, there are associated medium and longer-term effects on different aspects of health, including physical, mental, sexual and reproductive.(7) The impact of GBV on health can be both direct and indirect. GBV can threaten access to healthcare services for individuals, and this can exacerbate adverse health outcomes and prevent health risk factors from being addressed in a timely manner.(8)
Exposure to GBV often consists of experiences leading to acute and chronic stress responses, which some suggest results in the dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.(9,10) Biochemical effects of the stress in maltreatment survivors have been hypothesised to alter normal functioning of the immune, metabolic, neuroendocrine and autonomic systems.(11) Due to disruption of these systems, some survivors of abuse have been shown to have higher levels of markers relating to sustained inflammation (such as increased circulating interleukins, tumour necrosis factor and C-reactive protein levels).(12–14) To further exacerbate these biochemical effects, some survivors of abuse may adopt poor lifestyle choices (physical inactivity, substance misuse and poor diet)(2,11,15–17) as well as developing psychopathological changes as a result of the abuse leading to mental ill health.(18,19) One such psychological hypothesis thought to be demonstrated in abuse survivors is the ‘fear avoidance model’, where individuals who have experienced traumatic abuse episodes may be unable to regulate the severity of pain responses precipitating a cycle of ‘pain-related fear’.(20,21) Another important neurobiological change seen in some subgroups of maltreated individuals are changes in the structural and functional organisation of their developing brain network which may be associated with an increased risk of psychopathology.(22) Due to the breadth of potential pathways for ill health subsequent to abuse it is possible that those who have been abused may experience any number of conditions (even those not previously considered in depth such as renal disease (23)) subsequent to their abuse, hence the importance of clearly outlining the epidemiology and pathways to disease in this population.
The World Health Organization has curated a database of studies describing the relationship between violence against women and children with subsequent health outcomes.(24) However, the database is not regularly maintained. Furthermore, much of the literature focuses on specific forms of violence and narrowly defined healthcare outcomes. Other forms of biolence such as psychological violence, stalking, and coercive control, for example, remain less well expored.(1,25) Further research is needed to explore the impact of these forms of violence and to explore the impacts of GBV on a broader range of healthcare outcomes to capture the disease burden associated with it to inform health policy globally.
Joht Singh Chandan - Chief Investigator - University of Birmingham
Joht Singh Chandan - Corresponding Applicant - University of Birmingham
Sonica Minhas - Collaborator - University of Birmingham
HES Admitted Patient Care;Patient Level Index of Multiple Deprivation;Practice Level Index of Multiple Deprivation