Violence is a major public health

Violence is a major public health, human development and human rights problem worldwide. It places an enormous burden on the economics of countries, costing large amounts of money and other resources that has to be put towards healthcare, lost productivity and law enforcement.
Violence is defined by the World Health Organization 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” (WHO, 2018). There are three sub-types of violence, self-directed, interpersonal, and collective violence which can be inflicted through four modes namely sexual, physical, deprivation and psychological attack (WHO, 2018). Self-directed violence is subdivided into suicide and self-abuse, where the perpetrator and the victim are the same individual. Interpersonal violence is subdivided into intimate partner violence, family violence and community violence. Some examples of interpersonal violence includes elder abuse, child maltreatment, intimate partner violence, youth violence, assaults, violence related to property crimes and workplace violence. Collective violence is subdivided into political, economic and social violence committed by large groups.
According to the World Health Organization, violence is the cause for 1.4 million deaths each year and of these deaths, 56 percent are suicides, 33 percent are homicides, and 11 percent are the result of war or other collective violence (WHO, 2018). People living in the poorest communities suffer the most from violence, as a result developing and middle in-come countries have higher rates of death due to violence.
Violence against women is a tenacious and global problem that takes place in every social and cultural group. Worldwide, at least one in every three women has been assaulted, forced sexually, or abused in her lifetime. These violence’s are most often by someone she knows, the perpetrator could be an employer or a co-worker and often times a family member. Violence against women has been called “the most pervasive yet least recognized human rights abuse in the world” because it endangers the freedom, psychological integrity, bodies and lives of women worldwide. Violence against women is often known as “gender-based” violence because it relatively stems from women’s inferior status in society.

Gender based violence (GBV) also known as violence against women is a human rights violation which stems from women’s inferior/ unequal status to men in society. It consist of any act or threat by a male that causes sexual, physical and psychological harm or suffering to a girl or woman based on their gender (WHO, 2017). Gender based violence occurs in both public and private spheres of life, across all social, cultural, economic and political classes and in all societies. The four types of gender-based violence are psychological abuse which includes forced marriages, deprivation of liberty and sexual harassment; treatment of women as commodities which includes trafficking or women and girls for sexual exploitation; physical abuse which includes sexual assault and battering; and deprivation of resources such as nutrition, health care, and education (WHO, 2018). The most prevalent form of gender-based violence is intimate partner violence. Intimate partner violence defined by the Centers for Disease Control and Prevention is, “any sexual violence, physical violence, stalking and psychological aggression by a current or former intimate partner” (CDC, 2017).
Risk factors specifically associated with intimate partner violence are individual factors where there may be depression, alcohol or drug use or server personality traits; relationship factors where there are marital conflict, tension and other struggles, dominance and control of the relationship by one partner over the other, economic stress, past history of violence and lack of communication between partners; community factors like poverty and weak community sanctions against intimate partner violence; and societal factors like traditional gender norms such as ‘men support the family and make the decisions in a home (CDC, 2017, WHO, 2018).
Women who experience intimate partner violence/abuse are more likely to display behaviors that represent further health risks like alcoholism, drug abuse and suicide. They suffer from anxiety disorders, post-traumatic stress, sleep difficulties and depression (WHO, 2017). They may lack the drive to participate in regular activities, care for themselves or their young children, they may be unable to go to work which can lead to loss of wages and sometimes loss of employment (WHO, 2017). There is an increased likelihood of a miscarriage, stillbirth, pre-term delivery and low birth weight babies of women and girls who are forced sexually through intimate partner violence. Studies show that women who experienced intimate partner violence were 16% more likely to suffer a miscarriage and 41% more likely to have a pre-term birth (WHO, 2017).
There are economic consequences and costs of intimate partner violence, sexual assault, and stalking for victims and survivors that consist of medical expenses, lower pays as a result of less education, lost wages from missed work and job loss, debt and poor credit, and costs related to housing instability (McLean et al, 2017). The long-term psychological effects can affect the victims’ ability to study or hold a job; at times, perpetrators go as far as interfering with the victims’ employment (McLean et al, 2017). Often victims are constantly distracted and afraid that their abusers will show up to their workplace making it difficult for them to concentrate and carry out their job duties (McLean et al, 2017). Economic abuse can take multiple forms as inhibiting financial access and resources generates debt which in turn can leave victims facing economic uncertainty and poor credit (McLean et al, 2017). In a 2005 study done by the Maine Department of Labor and Family Crisis Services of 1,200 working adults, 64 percent of domestic violence victims reported that their ability to work was affected and 60 percent had to either quit their job or were fired as a result of the abuse (McLean et al, 2017).

Children who live in homes where there is violence are impacted to where they may have nightmares, they may wet their beds and they often suffer emotional problems like anger, shame, sadness or helplessness, they are also likely to experience violence or perpetrate violence later in their life (WHO, 2017). Others who also experience sexual violence as a child are more likely to lead to increased abuse of alcohol and drugs and risky sexual behaviors when they grow up, males tend to be perpetrators of violence and females, victims of violence (WHO, 2017).
The key contributing factors to gender-based violence are gender inequality and discrimination. When women and girls freedoms, opportunities and choices are restricted there is an increased risk for violent relationships, exploitation and abuse (Smith M., et al). Social and cultural norms brand males to be controlling, powerful, unemotional, and aggressive, and this backs the social acceptance of men as dominant. In the same way, females are expected to be nurturing, passive, submissive, and emotional which also emphasize women’s roles as weak, powerless, and dependent upon men. The culturally accepted belief that women should be dependent on men economically and that women and children are to be under a man’s control and they are his possessions, are beliefs and practices that continues to perpetuate the unequal status of men and women (Smith M., et al). This can affect their decision making power, they cannot participate in decisions pertaining to family affairs making it impossible for them to even be a part of the decision of how many children they can have (WHO, 2017).
In societies of developing countries, it is culturally acceptable for women to depend on men economically. Even though in developing countries men are given the credit for performing three quarters of all economic activities, according to the United Nations, in actuality it is women who perform 53 percent of the work (Negash A., 2016). In a study done by the Bahaudin Zakariya University in Pakistan, researchers found that there is a link between economic dependency and decision making power of women, even though women tend to contribute considerably in work both inside and outside of the household (Bhutta, R., et al).
I believe the term “silent global pandemic” which is often used to describe violence against women is appropriate because even though we are in the twenty first century, social and cultural norms in many countries still hold to the practices of gender based violence. Perpetrators are not held responsible and most of the time gender based violence incidents go unreported for one reason or another (Abdi M., 2016). Victims may live in remote areas where they cannot get to facilities that can help them or they may fear for their life and the lives of their children if they reported abuse to the police.
According to statistics by the United Nations, women make up two thirds of victims of intimate partner/family related homicides and there is a prevalence intimate partner violence of 50 percent in Africa (Abdi M., 2016). The United Nations discovered that in most countries where gender based violence is prevalent, 1 in 3 women experienced violence at some point in their lives and less than 40 percent of them sort any help (Abdi M., 2016). These social and cultural norms, attitudes and behaviors can be changed over time in order to help in the prevention of gender based violence. It is essential to take the steps to end and prevent the problem of gender based violence and it is going to require addressing gender standards of power that continue to fuel inequality and discrimination between men and women (UN Women, 2015). It is also going to take the involvement of men in the process of combating gender based violence.
Over the years, in discussions on gender based violence, men’s violence against women has been one of the main focus and the other being providing help to women who have undergone gender based violence (Lorentzen J., 2005). The possibility to involve men in combating the violence has not been discussed as often, however there has been a shift over time to engage men in the process for a better approach in the understanding of gender based violence and fight to bring it to an end. It is now understood that if only victimized women are helped, it does not bring an end to the issue of violence, because men will continue to be violent, however, if men and boy are also worked with there is a better chance to put an end to violence (Lorentzen J., 2005).
There are some trends which have led to the conclusion to engage men in the work against gender based violence. Internationally, there is an increase in the knowledge of the degree and the consequences of men’s violence as taboos of the topic of violence against women are decreasing (Lorentzen J., 2005). There has been increase in research on the causes of men’s violent behavior making it possible to provide treatment options for men. Research also show that men also suffer violence from women in intimate relationships although it is not the same extent or have the same physical or emotional magnitudes as men’s violence on women (Lorentzen J., 2005).
Nevertheless, this knowledge helps in increasing the engagement and involvement of men on the much needed cause to end violence. There are campaigns around the world that try to reach and involve men in the work to put a stop to violence against women. The White Ribbon Campaign in Toronto Canada which began in 1991, has educated and changed the perspectives of millions of men around the world, men and boys wear a white ribbon to symbolize their opposition to men’s violence against women (Lorentzen J., 2005). Another program that involves men in the process to end violence against women is Save the Children Sweden-Denmark, they develop strategies and action plans that helps to increase men and boys interest to address violence against boys and girls (Lorentzen J., 2005). They focus on the socialization of boys, the perception of masculinity, gender inequality and principles of basic human rights (Lorentzen J., 2005).

The United Nations Trust Fund to End Violence against Women supported Instituto Promundo a Brazilian NGO, in a multi-country project that promoted gender equality and involved men and boys in the prevention of violence against women (Instituto Promundo, 2012). The project was done in four countries and through four different interventions India (community), Chile (sports), Brazil (health sector) and Rwanda (work-place) (Instituto Promundo, 2012). In India, as a result of the workshops, men reported they were participating more in household responsibilities and boys reported promoting the idea of their sister’s rights to get an education (Instituto Promundo, 2012).
In Brazil, results showed that through the workshops boys and men communicated more about inequality and violence against women (Instituto Promundo, 2012). In Chile, participants of the workshops increased their use of condoms and their knowledge on violence helped in their rejection to gender based violence (Instituto Promundo, 2012). In Rwanda, after the training there was a more equal division of labor in the work place and men became more inquisitive on the issue to gender based violence, there also was a decrease on the number of gender based violence cases (Instituto Promundo, 2012). There should be more initiatives taken to expand the knowledge of masculinity and what it means to be a man, as this can help shape societal and cultural views in developing better ways to help put an end to gender based violence.
Providing evidence-based prevention programs can be beneficial in stopping violence before it even happens, preventing first occurrences and reoccurrences. A good example is a randomized controlled trial study done in Kampala, Uganda by SASA!, “a community mobilization intervention seeking to change community attitudes, norms and behaviors that result in gender inequality, violence and increased HIV vulnerability for women” (Abramsky, T. et al, 2016). The study focused on how to promote a critical analysis and discussion of power and its inequalities – how power is misused among men and women and its effects on relationships and communities, as well as, how one can use their power to positively affect themselves and their community as a whole (Abramsky, T. et al, 2016). The SASA! intervention involved the community through its four phases of approach Start, Awareness, Support, Action, which included community leaders, community activists, professionals and institutions through each of the four phases (Abramsky, T. et al, 2016).

Four phases of SASA!
These groups of actors were trained and mentored, improving their knowledge and communication skills on gender inequality and violence and then sent out to mobilize their communities and educate others on what they had learned. Results from the study showed a reduction in women’s past year experience of physical intimate partner violence as well as men’s perception of intimate partner violence (Abramsky, T. et al, 2016). They also saw a reduction of men’s suspicion of infidelity from their partners, an improved sex communication in relationships as well as men’s acceptability of being perpetrators of intimate partner violence (Abramsky, T. et al, 2016). These results points out how important community-level norm-change is when looking at community-wide reductions when it comes to the risk of intimate partner violence (Abramsky, T. et al, 2016).
Another important stakeholder in the efforts to eradicate intimate partner violence is health systems. Health systems play a critical role in the multi-sectoral response in addressing violence. Health systems can and must provide access to adequate and inclusive services for survivors of intimate partner violence. Their role in improving data collection and providing evidence to help improve policies and programs geared toward prevention and response is of great importance and urgency.
As recent as April of 2018, the U.S. Preventive Services Task Force (USPSTF) released its draft recommendation statement on routine screening for intimate partner violence (Esposito L, 2018). This statement recommends that clinicians and healthcare providers screen all women from ages 12 to 49, to identify women or girls who are experiencing violence and may not ask for help (Esposito L, 2018). The routine screening is either done in a private face-to-face discussion with the physician or healthcare provider, an online questionnaire can be filled or a written questionnaire can be filled (Esposito L, 2018). Ongoing support like multiple contact through community or home-based visits is provided for women and girls who screen positive, their situation is assessed and further support is given where needed (Esposito L, 2018).
The involvement of physicians and health care providers is important because they are able to talk to patients about their health and give them incite on what is most important for an improved health. Physicians and health care providers also have the expertise to talk with a patient/victim in a caring and empathetic way making them feel safe enough to reveal abuse. They can provide appropriate care and referrals and address problems associated with violence such as alcohol and drug abuse. The health sector can integrate health education and promotion activities while educating patients and communities about human rights violations and harmful health and other concerns related to violence against women, the need to pursue proper and timely care, and prevention (WHO, 2017).