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Lakma Gunarathne, Maja Nedeljkovic, Pragalathan Apputhurai, Jahar Bhowmik, Impact of Intimate Partner Violence on mental health among married women in Sri Lanka: a study based on Women’s Wellbeing Survey-2019, Journal of Public Health, Volume 46, Issue 3, September 2024, Pages e410–e418, https://doi.org/10.1093/pubmed/fdae082
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Abstract
Sri Lankan married women have been reported to experience higher rates of intimate partner violence (IPV). However, research on its impact on mental health and how socio-demographic factors contribute to this association is limited. Therefore, this study aimed to examine the impact of IPV on the mental health of married women in Sri Lanka.
In this study, data from 1611 married women who participated in the 2019 Sri Lankan Women’s Wellbeing Survey were analyzed. Two binary outcomes were considered: married women’s mental health and their suicidal ideation. Binary logistic regression models were used to assess the association between mental health and suicidal thoughts in relation to IPV while controlling for socio-demographic factors.
The results revealed that married women who experienced any form of violence by their spouse had a higher risk of having poor mental health conditions [AOR = 2.88 (2.20, 3.78)] and suicidal thoughts [AOR = 5.84 (4.10, 8.32)] compared to those who did not experience IPV.
IPV is a substantial contributor to poor mental health and suicidal thoughts among Sri Lankan married women. There is an urgent need for policy interventions, such as community awareness programs, counseling services and enhanced legal protections for victims.
Introduction
Intimate partner violence (IPV) is a global public health concern, particularly affecting women, as evidenced by the statistics that one in three women becomes a victim of IPV.1,2 As defined by the World Health Organization (WHO), IPV refers to any act or behavior by an intimate partner that causes physical, emotional or sexual harm.1 Globally, IPV is prevalent at an average rate of 30%.3 Notably, IPV prevalence rates are higher in low-and middle-income countries (LMICs).4,5 The most common risk factors associated with higher IPV rates against women include lower education levels, higher numbers of children, early marriage, lower education levels of their partners, living in rural areas, lack of decision-making power and exposure to violence during childhood.6,7 IPV is associated with both immediate and long-term health consequences, including severe physical injuries and mental health issues for women.2 The consequences of IPV affect not only women themselves but also their children, families and communities.4
Previous research shows that there is a strong association between IPV and mental health disorders including anxiety, depression, posttraumatic stress disorder (PTSD), sleep disorders, self-harm, suicide attempts and diminished self-esteem.8,9 According to Devries and Watts,10 mental health disorders resulting from IPV are the most consistent contributors to suicidal behaviors. These mental health challenges impact women’s lives, affecting wellbeing, productivity and caregiving roles, thus indirectly influencing society.
Sri Lanka is one of the LMICs with a high prevalence of IPV against women.11 While ‘The Domestic Violence Act’, a legal framework to protect women, was passed in the country in 2005, the probability of experiencing IPV remains high, with occurrences exceeding five instances throughout a woman’s lifetime.12 In addition, married women in Sri Lanka are at a higher risk of experiencing IPV, as one in five ever-married women has experienced IPV compared to all other women aged over 15 years.13 The high prevalence of IPV among Sri Lankan married women has been demonstrated in past studies, but there has been limited investigation into the effects of IPV on the mental health status of victims. This study fills this crucial gap by exploring the effects of IPV on the mental well-being of married women in Sri Lanka, while considering various socio-demographic vulnerability factors associated with mental health. By analyzing data from the national representative Women’s Well-being Survey (WWS), our analysis seeks to clarify the correlation between IPV and mental health outcomes, while controlling risk factors involved, with the ultimate goal of informing the development of targeted interventions and support services for those affected by IPV.
Methods
Study design and data source
This study used data from the cross-sectional, Sri Lankan national WWS conducted in 2019 as a data source.13 The WWS employed a multistage sampling strategy, stratified by sectors. Initially, 252 census blocks were chosen as primary sampling units (PSUs) using probability proportional to size. Within each stratum, PSUs were sampled. Ten households per PSU were selected using systematic random sampling. From each household, one eligible woman was chosen randomly for interview. Finally, data from the selected households were collected by face-to-face interviewing. For the purpose of this study, a total of 1611 married women’s data were extracted from WWS. After conducting a power analysis using the ‘pwr’ package in R, which involved a general linear model with 14 covariates, and factoring in an 80% power level and 0.05 significance level, along with a 20% attrition rate and medium effect size, a minimum sample size of 188 was determined. Hence, the selected sample size was deemed sufficient for conducting robust logistic regression analysis.
Ethical considerations
Ethics approval was granted by the Human Research Ethics Committee of Swinburne University of Technology (approval number: 20226572-10707).
Variables
Two outcome variables were considered in this study. The first outcome variable was married women’s mental health status, which was assessed using the Kessler Psychological Distress Scale (K6), a dependable assessment method that has undergone thorough validation in prior research.14,15 In our study, Cronbach’s alpha was 0.9, which indicates a high internal consistency. This measure consists of six symptoms of emotional distress, including feeling nervous, hopeless, restless or fidgety, depressed, worthless and feeling that everything was an effort.14 These emotional states were rated by the women on a five-point Likert scale, where 0 (none of the time) and 4 (all the time) based on their experience of those emotions within the last 4 weeks. Based on the total sum of the six items, the K6 score was divided into three categories: no mental distress or low mental distress (K6 < 5), moderate mental distress (5 ≤ K6 < 13) and serious mental distress (K6 ≥ 13).15 In this study, mental health status was classified as ‘healthy’ if a woman was in the none or low mental distress category, and as ‘not healthy’ if she was in the moderate or serious mental distress category. A second outcome variable in this study was whether married women had thoughts about suicide within the last four weeks. It was a binary variable assessed by asking whether they had thoughts of suicide within the past four weeks (Yes) or not (No).
Based on the past literature9,16,17 and variables available in WWS, 13 socio-demographic covariates were selected in the present study: age of the married women (years), their age at marriage (years), area of residence (urban or rural), education levels of both the married women and their partners (primary, secondary or higher), current employment status of both the married women and their partners (working or not working), number of children, husband’s alcohol consumption (yes or no), married women’s views on wife beating (‘accept wife beating’ if the married woman justified any of the situations of a husband hitting or beating his wife (i) she does not complete household work, (ii) she disobeys husband, (iii) she asks from the husband whether he has other relationships, (iv) she refuses to have sexual relationship with the husband, (v) husband suspects that wife is unfaithful to him and (vi) husband find out that wife has been unfaithful to him and ‘do not accept wife beating’ if respondent did not respond yes to any of the situations), married woman’s decision-making ability (recoded binary variable: ‘able to make decisions’ if they made decision on at least one aspect about own health care, participating in income generation project, household expenses and visits to family or friends; ‘not able to make decisions’ otherwise), childhood exposure to violence if ‘yes’ to any of the questions about whether anyone in her family ever did the following regularly when she was a child (i) slapped her, (ii) beat, kicked her, (iii) hit with object, (iv) tied with rope and (v) assaulted her or ‘no’ to all of the questions), socio-economic status (low, medium or high), ages of their partner (years) and experience of IPV (yes or no). We evaluated experiences of any type of intimate partner violence (IPV) using version 12.04.01 of the WHO Multi-country Study on Women’s Health and Life Experiences questionnaire, which has undergone rigorous validation on multiple occasions.18 This survey assessed the physical, sexual and psychological aspects of IPV with 13 questions. The obtained Cronbach’s alpha value for this dimension, 0.902, demonstrated strong internal consistency across the items. In line with previous similar studies, married women categorized their experience of IPV as ‘Yes’ if they answered yes to any question related to physical (slapping, kicking, etc.), sexual (forced or unwanted sex) or psychological violence (insults, belittlement, etc.) and as ‘No’ if they did not respond yes to any question.19 For modeling purposes, survey weight was also extracted.
Statistical analysis
Missing values were removed list-wise assuming data were missing completely at random.20,21 Sociodemographic variables were assessed for their associations with outcome variables using Pearson Chi-square and independent sample t-tests. To analyze the impact of demographic variables on mental health status and suicidal thoughts in the past four weeks among married women, three generalized linear regression models (GLMs) were fitted, adjusting for survey weights using R package svyglm. Results were considered significant at P < 0.05. The data were analyzed using SPSS (v29) and R (4.2.0).
Results
The study analyzed data from 1611 married women, primarily residing in rural areas (84.3%). Among them, 26% reported husband-perpetrated violence, and 30% reported poor mental health, while 14% reported suicidal thoughts. The women aged 20–81 (mean = 48, SD = 13.48), married at ages 15–39 (mean = 23.1, SD = 4.95). Table 1 offers detailed sociodemographic characteristics.
Sociodemographic characteristics of the married women participated in the survey (N = 1611)
| Variables . | N/Mean . | Percentages/SD . |
|---|---|---|
| Area of residence | ||
| Urban | 253 | 15.7 |
| Rural | 1358 | 84.3 |
| Level of education | ||
| Primary | 231 | 14.3 |
| Secondary | 936 | 58.1 |
| Higher | 444 | 27.6 |
| Current working status | ||
| Working | 529 | 32.8 |
| Not working | 1082 | 67.2 |
| Number of children | ||
| 0 or one child | 315 | 19.6 |
| Two children | 636 | 39.5 |
| Three children | 435 | 27 |
| Four or more children | 225 | 14 |
| Husband’s level of education | ||
| Primary | 268 | 16.6 |
| Secondary | 958 | 59.5 |
| Higher | 385 | 23.9 |
| Husband’s working status | ||
| Working | 1416 | 87.9 |
| Not working | 195 | 12.1 |
| Husband’s alcohol usage | ||
| Yes | 950 | 59 |
| No | 661 | 41 |
| Attitudes toward wife beating | ||
| Accept wife-beating | 592 | 36.7 |
| Do not accept wife beating | 1019 | 63.3 |
| Decision-making ability | ||
| Able to make decisions | 1151 | 71.4 |
| Not able to make decisions | 460 | 28.6 |
| Childhood exposure to violence | ||
| Exposed to violence | 404 | 25.1 |
| Not exposed to violence | 1207 | 74.9 |
| Socio-economic status | ||
| Low | 498 | 30.9 |
| Medium | 574 | 35.6 |
| High | 539 | 33.5 |
| Experience of IPV | ||
| Yes | 425 | 26.4 |
| No | 1186 | 73.6 |
| Mental health status (based on K6) | ||
| Healthy | 1129 | 70.1 |
| Not healthy | 482 | 29.9 |
| Having suicidal thoughts (past 4 weeks) | ||
| Yes | 226 | 14.0 |
| No | 1385 | 86.0 |
| Age* | 47.95 | 13.48 |
| Age at marriage* | 23.11 | 4.95 |
| Variables . | N/Mean . | Percentages/SD . |
|---|---|---|
| Area of residence | ||
| Urban | 253 | 15.7 |
| Rural | 1358 | 84.3 |
| Level of education | ||
| Primary | 231 | 14.3 |
| Secondary | 936 | 58.1 |
| Higher | 444 | 27.6 |
| Current working status | ||
| Working | 529 | 32.8 |
| Not working | 1082 | 67.2 |
| Number of children | ||
| 0 or one child | 315 | 19.6 |
| Two children | 636 | 39.5 |
| Three children | 435 | 27 |
| Four or more children | 225 | 14 |
| Husband’s level of education | ||
| Primary | 268 | 16.6 |
| Secondary | 958 | 59.5 |
| Higher | 385 | 23.9 |
| Husband’s working status | ||
| Working | 1416 | 87.9 |
| Not working | 195 | 12.1 |
| Husband’s alcohol usage | ||
| Yes | 950 | 59 |
| No | 661 | 41 |
| Attitudes toward wife beating | ||
| Accept wife-beating | 592 | 36.7 |
| Do not accept wife beating | 1019 | 63.3 |
| Decision-making ability | ||
| Able to make decisions | 1151 | 71.4 |
| Not able to make decisions | 460 | 28.6 |
| Childhood exposure to violence | ||
| Exposed to violence | 404 | 25.1 |
| Not exposed to violence | 1207 | 74.9 |
| Socio-economic status | ||
| Low | 498 | 30.9 |
| Medium | 574 | 35.6 |
| High | 539 | 33.5 |
| Experience of IPV | ||
| Yes | 425 | 26.4 |
| No | 1186 | 73.6 |
| Mental health status (based on K6) | ||
| Healthy | 1129 | 70.1 |
| Not healthy | 482 | 29.9 |
| Having suicidal thoughts (past 4 weeks) | ||
| Yes | 226 | 14.0 |
| No | 1385 | 86.0 |
| Age* | 47.95 | 13.48 |
| Age at marriage* | 23.11 | 4.95 |
*metric variables; SD: standard deviation
Sociodemographic characteristics of the married women participated in the survey (N = 1611)
| Variables . | N/Mean . | Percentages/SD . |
|---|---|---|
| Area of residence | ||
| Urban | 253 | 15.7 |
| Rural | 1358 | 84.3 |
| Level of education | ||
| Primary | 231 | 14.3 |
| Secondary | 936 | 58.1 |
| Higher | 444 | 27.6 |
| Current working status | ||
| Working | 529 | 32.8 |
| Not working | 1082 | 67.2 |
| Number of children | ||
| 0 or one child | 315 | 19.6 |
| Two children | 636 | 39.5 |
| Three children | 435 | 27 |
| Four or more children | 225 | 14 |
| Husband’s level of education | ||
| Primary | 268 | 16.6 |
| Secondary | 958 | 59.5 |
| Higher | 385 | 23.9 |
| Husband’s working status | ||
| Working | 1416 | 87.9 |
| Not working | 195 | 12.1 |
| Husband’s alcohol usage | ||
| Yes | 950 | 59 |
| No | 661 | 41 |
| Attitudes toward wife beating | ||
| Accept wife-beating | 592 | 36.7 |
| Do not accept wife beating | 1019 | 63.3 |
| Decision-making ability | ||
| Able to make decisions | 1151 | 71.4 |
| Not able to make decisions | 460 | 28.6 |
| Childhood exposure to violence | ||
| Exposed to violence | 404 | 25.1 |
| Not exposed to violence | 1207 | 74.9 |
| Socio-economic status | ||
| Low | 498 | 30.9 |
| Medium | 574 | 35.6 |
| High | 539 | 33.5 |
| Experience of IPV | ||
| Yes | 425 | 26.4 |
| No | 1186 | 73.6 |
| Mental health status (based on K6) | ||
| Healthy | 1129 | 70.1 |
| Not healthy | 482 | 29.9 |
| Having suicidal thoughts (past 4 weeks) | ||
| Yes | 226 | 14.0 |
| No | 1385 | 86.0 |
| Age* | 47.95 | 13.48 |
| Age at marriage* | 23.11 | 4.95 |
| Variables . | N/Mean . | Percentages/SD . |
|---|---|---|
| Area of residence | ||
| Urban | 253 | 15.7 |
| Rural | 1358 | 84.3 |
| Level of education | ||
| Primary | 231 | 14.3 |
| Secondary | 936 | 58.1 |
| Higher | 444 | 27.6 |
| Current working status | ||
| Working | 529 | 32.8 |
| Not working | 1082 | 67.2 |
| Number of children | ||
| 0 or one child | 315 | 19.6 |
| Two children | 636 | 39.5 |
| Three children | 435 | 27 |
| Four or more children | 225 | 14 |
| Husband’s level of education | ||
| Primary | 268 | 16.6 |
| Secondary | 958 | 59.5 |
| Higher | 385 | 23.9 |
| Husband’s working status | ||
| Working | 1416 | 87.9 |
| Not working | 195 | 12.1 |
| Husband’s alcohol usage | ||
| Yes | 950 | 59 |
| No | 661 | 41 |
| Attitudes toward wife beating | ||
| Accept wife-beating | 592 | 36.7 |
| Do not accept wife beating | 1019 | 63.3 |
| Decision-making ability | ||
| Able to make decisions | 1151 | 71.4 |
| Not able to make decisions | 460 | 28.6 |
| Childhood exposure to violence | ||
| Exposed to violence | 404 | 25.1 |
| Not exposed to violence | 1207 | 74.9 |
| Socio-economic status | ||
| Low | 498 | 30.9 |
| Medium | 574 | 35.6 |
| High | 539 | 33.5 |
| Experience of IPV | ||
| Yes | 425 | 26.4 |
| No | 1186 | 73.6 |
| Mental health status (based on K6) | ||
| Healthy | 1129 | 70.1 |
| Not healthy | 482 | 29.9 |
| Having suicidal thoughts (past 4 weeks) | ||
| Yes | 226 | 14.0 |
| No | 1385 | 86.0 |
| Age* | 47.95 | 13.48 |
| Age at marriage* | 23.11 | 4.95 |
*metric variables; SD: standard deviation
Table 2 shows unweighted bivariate associations between married women’s mental health status and suicidal thoughts, with socio-demographic variables. Factors like education levels, children count, husbands’ alcohol consumption, decision-making abilities, childhood violence exposure, intimate partner violence experience, age of women and age of marriage significantly associated with mental health and suicidal thoughts among married women (P < 0.05). Cramer’s V and Cohen’s d values reveal that IPV experience, marriage age, decision-making ability and education level significantly relate to married women’s mental health. IPV experience, mental health, marriage age, decision-making, husband’s alcohol use and employment significantly impact married women’s suicidal thoughts.
Bi-variate unweighted associations of married women’s mental health status and their suicidal thoughts with the selected socio-demographic variables; N = 1611
| Variables . | Mental health status . | P-value (Cramer’s V/Cohen’s d) . | Having suicidal thoughts . | P-value (Cramer’s V/Cohen’s d) . | ||
|---|---|---|---|---|---|---|
| Healthy (N = 1129) . | Not healthy (N = 482) . | Yes (N = 226) . | No (N = 1385) . | |||
| N (%) . | N (%) . | N (%) . | N (%) . | |||
| Experience of IPV | ||||||
| Yes | 213 (50.1) | 212 (49.9) | <0.001 (0.261) | 150 (35.3) | 275 (64.7) | <0.001 (0.367) |
| No | 916 (77.2) | 270 (22.8) | 76 (6.4) | 1110 (93.6) | ||
| Area of residence | ||||||
| Urban | 168 (66.4) | 85 (33.6) | 0.164 (0.035) | 34 (13.4) | 219 (86.6) | 0.769 (0.007) |
| Rural | 961 (70.8) | 397 (29.2) | 192 (14.1) | 1166 (85.9) | ||
| Level of education | ||||||
| Primary | 140 (60.6) | 91 (39.4) | <0.001 (0.119) | 42 (18.2) | 189 (81.8) | 0.002 (0.090) |
| Secondary | 644 (68.8) | 292 (31.2) | 143 (15.3) | 793 (84.7) | ||
| Higher | 345 (77.7) | 99 (22.3) | 41 (9.2) | 403 (90.8) | ||
| Working status | ||||||
| Working | 372 (70.3) | 157 (29.7) | 0.883 (0.004) | 104 (19.7) | 425 (80.3) | <0.001 (0.113) |
| Not working | 757 (70.0) | 325 (30.0) | 122 (11.3) | 960 (88.7) | ||
| Number of children | ||||||
| 0 or one child | 234 (74.3) | 81 (25.7) | 0.003 (0.093) | 33 (10.5) | 282 (89.5) | 0.067 (0.067) |
| Two children | 464 (73.0) | 172 (27.0) | 86 (13.5) | 550 (86.5) | ||
| Three children | 291 (66.9) | 144 (33.1) | 75 (17.2) | 360 (82.8) | ||
| Four or more children | 140 (62.2) | 85 (37.8) | 32 (14.2) | 193 (85.8) | ||
| Husband’s level of education | ||||||
| Primary | 165 (61.6) | 103 (38.4) | 0.004 (0.084) | 35 (13.1) | 233 (86.9) | 0.013 (0.074) |
| Secondary | 685 (71.5) | 273 (28.5) | 153 (16.0) | 805 (84.0) | ||
| Higher | 279 (72.5) | 106 (27.5) | 38 (9.9) | 347 (90.1) | ||
| Husband’s working status | ||||||
| Working | 991 (70.0) | 425 (30.0) | 0.823 (0.006) | 202 (14.3) | 1214 (85.7) | 0.460 (0.018) |
| Not working | 138 (70.8) | 57 (29.2) | 24 (12.3) | 171 (87.7) | ||
| Husband’s alcohol usage | ||||||
| Yes | 644 (67.8) | 306 (32.2) | 0.016 (0.060) | 168 (17.7) | 782 (82.3) | <0.001 (0.126) |
| No | 485 (73.4) | 176 (26.6) | 58 (8.8) | 603 (91.2) | ||
| Attitudes toward wife beating | ||||||
| Accept wife beating | 407 (68.8) | 185 (31.3) | 0.374 (0.022) | 103 (17.4) | 489 (82.6) | 0.003 (0.074) |
| Do not accept wife beating | 722 (70.9) | 297 (29.1) | 123 (12.1) | 896 (87.9) | ||
| Decision making ability | ||||||
| Able to make decisions | 862 (74.9) | 289 (25.1) | <0.001 (0.166) | 109 (9.5) | 1042 (90.5) | <0.001 (0.208) |
| Not able to make decisions | 267 (58.0) | 193 (42.0) | 117 (25.4) | 343 (74.6) | ||
| Childhood exposure to violence | ||||||
| Exposed to violence | 264 (65.3) | 140 (34.7) | 0.016 (0.060) | 79 (19.6) | 325 (80.4) | <0.001 (0.092) |
| Not exposed to violence | 865 (71.7) | 342 (28.3) | 147 (12.2) | 1060 (87.8) | ||
| Socio-economic status | ||||||
| Low | 345 (69.3) | 153 (30.7) | 0.424 (0.033) | 78 (15.7) | 420 (84.3) | 0.432 (0.032) |
| Medium | 395 (68.8) | 179 (31.2) | 78 (13.6) | 496 (86.4) | ||
| High | 389 (72.2) | 150 (27.8) | 70 (13.0) | 469 (87.0) | ||
| Mental health status (based on K6) | ||||||
| Healthy | 83 (7.4) | 1046 (92.6) | <0.001 (0.294) | |||
| Not healthy | 143 (29.7) | 339 (70.3) | ||||
| Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | |||
| Age* | 47.46 (13.55) | 49.11 (13.27) | 0.024 (0.123) | 46.94 (11.97) | 48.12 (13.71) | 0.182 (0.087) |
| Age at marriage* | 23.19 (4.72) | 22.57 (4.64) | 0.016 (0.131) | 21.43 (4.71) | 23.26 (4.65) | <0.001 (0.391) |
| Variables . | Mental health status . | P-value (Cramer’s V/Cohen’s d) . | Having suicidal thoughts . | P-value (Cramer’s V/Cohen’s d) . | ||
|---|---|---|---|---|---|---|
| Healthy (N = 1129) . | Not healthy (N = 482) . | Yes (N = 226) . | No (N = 1385) . | |||
| N (%) . | N (%) . | N (%) . | N (%) . | |||
| Experience of IPV | ||||||
| Yes | 213 (50.1) | 212 (49.9) | <0.001 (0.261) | 150 (35.3) | 275 (64.7) | <0.001 (0.367) |
| No | 916 (77.2) | 270 (22.8) | 76 (6.4) | 1110 (93.6) | ||
| Area of residence | ||||||
| Urban | 168 (66.4) | 85 (33.6) | 0.164 (0.035) | 34 (13.4) | 219 (86.6) | 0.769 (0.007) |
| Rural | 961 (70.8) | 397 (29.2) | 192 (14.1) | 1166 (85.9) | ||
| Level of education | ||||||
| Primary | 140 (60.6) | 91 (39.4) | <0.001 (0.119) | 42 (18.2) | 189 (81.8) | 0.002 (0.090) |
| Secondary | 644 (68.8) | 292 (31.2) | 143 (15.3) | 793 (84.7) | ||
| Higher | 345 (77.7) | 99 (22.3) | 41 (9.2) | 403 (90.8) | ||
| Working status | ||||||
| Working | 372 (70.3) | 157 (29.7) | 0.883 (0.004) | 104 (19.7) | 425 (80.3) | <0.001 (0.113) |
| Not working | 757 (70.0) | 325 (30.0) | 122 (11.3) | 960 (88.7) | ||
| Number of children | ||||||
| 0 or one child | 234 (74.3) | 81 (25.7) | 0.003 (0.093) | 33 (10.5) | 282 (89.5) | 0.067 (0.067) |
| Two children | 464 (73.0) | 172 (27.0) | 86 (13.5) | 550 (86.5) | ||
| Three children | 291 (66.9) | 144 (33.1) | 75 (17.2) | 360 (82.8) | ||
| Four or more children | 140 (62.2) | 85 (37.8) | 32 (14.2) | 193 (85.8) | ||
| Husband’s level of education | ||||||
| Primary | 165 (61.6) | 103 (38.4) | 0.004 (0.084) | 35 (13.1) | 233 (86.9) | 0.013 (0.074) |
| Secondary | 685 (71.5) | 273 (28.5) | 153 (16.0) | 805 (84.0) | ||
| Higher | 279 (72.5) | 106 (27.5) | 38 (9.9) | 347 (90.1) | ||
| Husband’s working status | ||||||
| Working | 991 (70.0) | 425 (30.0) | 0.823 (0.006) | 202 (14.3) | 1214 (85.7) | 0.460 (0.018) |
| Not working | 138 (70.8) | 57 (29.2) | 24 (12.3) | 171 (87.7) | ||
| Husband’s alcohol usage | ||||||
| Yes | 644 (67.8) | 306 (32.2) | 0.016 (0.060) | 168 (17.7) | 782 (82.3) | <0.001 (0.126) |
| No | 485 (73.4) | 176 (26.6) | 58 (8.8) | 603 (91.2) | ||
| Attitudes toward wife beating | ||||||
| Accept wife beating | 407 (68.8) | 185 (31.3) | 0.374 (0.022) | 103 (17.4) | 489 (82.6) | 0.003 (0.074) |
| Do not accept wife beating | 722 (70.9) | 297 (29.1) | 123 (12.1) | 896 (87.9) | ||
| Decision making ability | ||||||
| Able to make decisions | 862 (74.9) | 289 (25.1) | <0.001 (0.166) | 109 (9.5) | 1042 (90.5) | <0.001 (0.208) |
| Not able to make decisions | 267 (58.0) | 193 (42.0) | 117 (25.4) | 343 (74.6) | ||
| Childhood exposure to violence | ||||||
| Exposed to violence | 264 (65.3) | 140 (34.7) | 0.016 (0.060) | 79 (19.6) | 325 (80.4) | <0.001 (0.092) |
| Not exposed to violence | 865 (71.7) | 342 (28.3) | 147 (12.2) | 1060 (87.8) | ||
| Socio-economic status | ||||||
| Low | 345 (69.3) | 153 (30.7) | 0.424 (0.033) | 78 (15.7) | 420 (84.3) | 0.432 (0.032) |
| Medium | 395 (68.8) | 179 (31.2) | 78 (13.6) | 496 (86.4) | ||
| High | 389 (72.2) | 150 (27.8) | 70 (13.0) | 469 (87.0) | ||
| Mental health status (based on K6) | ||||||
| Healthy | 83 (7.4) | 1046 (92.6) | <0.001 (0.294) | |||
| Not healthy | 143 (29.7) | 339 (70.3) | ||||
| Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | |||
| Age* | 47.46 (13.55) | 49.11 (13.27) | 0.024 (0.123) | 46.94 (11.97) | 48.12 (13.71) | 0.182 (0.087) |
| Age at marriage* | 23.19 (4.72) | 22.57 (4.64) | 0.016 (0.131) | 21.43 (4.71) | 23.26 (4.65) | <0.001 (0.391) |
*t-test for metric variables
Bi-variate unweighted associations of married women’s mental health status and their suicidal thoughts with the selected socio-demographic variables; N = 1611
| Variables . | Mental health status . | P-value (Cramer’s V/Cohen’s d) . | Having suicidal thoughts . | P-value (Cramer’s V/Cohen’s d) . | ||
|---|---|---|---|---|---|---|
| Healthy (N = 1129) . | Not healthy (N = 482) . | Yes (N = 226) . | No (N = 1385) . | |||
| N (%) . | N (%) . | N (%) . | N (%) . | |||
| Experience of IPV | ||||||
| Yes | 213 (50.1) | 212 (49.9) | <0.001 (0.261) | 150 (35.3) | 275 (64.7) | <0.001 (0.367) |
| No | 916 (77.2) | 270 (22.8) | 76 (6.4) | 1110 (93.6) | ||
| Area of residence | ||||||
| Urban | 168 (66.4) | 85 (33.6) | 0.164 (0.035) | 34 (13.4) | 219 (86.6) | 0.769 (0.007) |
| Rural | 961 (70.8) | 397 (29.2) | 192 (14.1) | 1166 (85.9) | ||
| Level of education | ||||||
| Primary | 140 (60.6) | 91 (39.4) | <0.001 (0.119) | 42 (18.2) | 189 (81.8) | 0.002 (0.090) |
| Secondary | 644 (68.8) | 292 (31.2) | 143 (15.3) | 793 (84.7) | ||
| Higher | 345 (77.7) | 99 (22.3) | 41 (9.2) | 403 (90.8) | ||
| Working status | ||||||
| Working | 372 (70.3) | 157 (29.7) | 0.883 (0.004) | 104 (19.7) | 425 (80.3) | <0.001 (0.113) |
| Not working | 757 (70.0) | 325 (30.0) | 122 (11.3) | 960 (88.7) | ||
| Number of children | ||||||
| 0 or one child | 234 (74.3) | 81 (25.7) | 0.003 (0.093) | 33 (10.5) | 282 (89.5) | 0.067 (0.067) |
| Two children | 464 (73.0) | 172 (27.0) | 86 (13.5) | 550 (86.5) | ||
| Three children | 291 (66.9) | 144 (33.1) | 75 (17.2) | 360 (82.8) | ||
| Four or more children | 140 (62.2) | 85 (37.8) | 32 (14.2) | 193 (85.8) | ||
| Husband’s level of education | ||||||
| Primary | 165 (61.6) | 103 (38.4) | 0.004 (0.084) | 35 (13.1) | 233 (86.9) | 0.013 (0.074) |
| Secondary | 685 (71.5) | 273 (28.5) | 153 (16.0) | 805 (84.0) | ||
| Higher | 279 (72.5) | 106 (27.5) | 38 (9.9) | 347 (90.1) | ||
| Husband’s working status | ||||||
| Working | 991 (70.0) | 425 (30.0) | 0.823 (0.006) | 202 (14.3) | 1214 (85.7) | 0.460 (0.018) |
| Not working | 138 (70.8) | 57 (29.2) | 24 (12.3) | 171 (87.7) | ||
| Husband’s alcohol usage | ||||||
| Yes | 644 (67.8) | 306 (32.2) | 0.016 (0.060) | 168 (17.7) | 782 (82.3) | <0.001 (0.126) |
| No | 485 (73.4) | 176 (26.6) | 58 (8.8) | 603 (91.2) | ||
| Attitudes toward wife beating | ||||||
| Accept wife beating | 407 (68.8) | 185 (31.3) | 0.374 (0.022) | 103 (17.4) | 489 (82.6) | 0.003 (0.074) |
| Do not accept wife beating | 722 (70.9) | 297 (29.1) | 123 (12.1) | 896 (87.9) | ||
| Decision making ability | ||||||
| Able to make decisions | 862 (74.9) | 289 (25.1) | <0.001 (0.166) | 109 (9.5) | 1042 (90.5) | <0.001 (0.208) |
| Not able to make decisions | 267 (58.0) | 193 (42.0) | 117 (25.4) | 343 (74.6) | ||
| Childhood exposure to violence | ||||||
| Exposed to violence | 264 (65.3) | 140 (34.7) | 0.016 (0.060) | 79 (19.6) | 325 (80.4) | <0.001 (0.092) |
| Not exposed to violence | 865 (71.7) | 342 (28.3) | 147 (12.2) | 1060 (87.8) | ||
| Socio-economic status | ||||||
| Low | 345 (69.3) | 153 (30.7) | 0.424 (0.033) | 78 (15.7) | 420 (84.3) | 0.432 (0.032) |
| Medium | 395 (68.8) | 179 (31.2) | 78 (13.6) | 496 (86.4) | ||
| High | 389 (72.2) | 150 (27.8) | 70 (13.0) | 469 (87.0) | ||
| Mental health status (based on K6) | ||||||
| Healthy | 83 (7.4) | 1046 (92.6) | <0.001 (0.294) | |||
| Not healthy | 143 (29.7) | 339 (70.3) | ||||
| Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | |||
| Age* | 47.46 (13.55) | 49.11 (13.27) | 0.024 (0.123) | 46.94 (11.97) | 48.12 (13.71) | 0.182 (0.087) |
| Age at marriage* | 23.19 (4.72) | 22.57 (4.64) | 0.016 (0.131) | 21.43 (4.71) | 23.26 (4.65) | <0.001 (0.391) |
| Variables . | Mental health status . | P-value (Cramer’s V/Cohen’s d) . | Having suicidal thoughts . | P-value (Cramer’s V/Cohen’s d) . | ||
|---|---|---|---|---|---|---|
| Healthy (N = 1129) . | Not healthy (N = 482) . | Yes (N = 226) . | No (N = 1385) . | |||
| N (%) . | N (%) . | N (%) . | N (%) . | |||
| Experience of IPV | ||||||
| Yes | 213 (50.1) | 212 (49.9) | <0.001 (0.261) | 150 (35.3) | 275 (64.7) | <0.001 (0.367) |
| No | 916 (77.2) | 270 (22.8) | 76 (6.4) | 1110 (93.6) | ||
| Area of residence | ||||||
| Urban | 168 (66.4) | 85 (33.6) | 0.164 (0.035) | 34 (13.4) | 219 (86.6) | 0.769 (0.007) |
| Rural | 961 (70.8) | 397 (29.2) | 192 (14.1) | 1166 (85.9) | ||
| Level of education | ||||||
| Primary | 140 (60.6) | 91 (39.4) | <0.001 (0.119) | 42 (18.2) | 189 (81.8) | 0.002 (0.090) |
| Secondary | 644 (68.8) | 292 (31.2) | 143 (15.3) | 793 (84.7) | ||
| Higher | 345 (77.7) | 99 (22.3) | 41 (9.2) | 403 (90.8) | ||
| Working status | ||||||
| Working | 372 (70.3) | 157 (29.7) | 0.883 (0.004) | 104 (19.7) | 425 (80.3) | <0.001 (0.113) |
| Not working | 757 (70.0) | 325 (30.0) | 122 (11.3) | 960 (88.7) | ||
| Number of children | ||||||
| 0 or one child | 234 (74.3) | 81 (25.7) | 0.003 (0.093) | 33 (10.5) | 282 (89.5) | 0.067 (0.067) |
| Two children | 464 (73.0) | 172 (27.0) | 86 (13.5) | 550 (86.5) | ||
| Three children | 291 (66.9) | 144 (33.1) | 75 (17.2) | 360 (82.8) | ||
| Four or more children | 140 (62.2) | 85 (37.8) | 32 (14.2) | 193 (85.8) | ||
| Husband’s level of education | ||||||
| Primary | 165 (61.6) | 103 (38.4) | 0.004 (0.084) | 35 (13.1) | 233 (86.9) | 0.013 (0.074) |
| Secondary | 685 (71.5) | 273 (28.5) | 153 (16.0) | 805 (84.0) | ||
| Higher | 279 (72.5) | 106 (27.5) | 38 (9.9) | 347 (90.1) | ||
| Husband’s working status | ||||||
| Working | 991 (70.0) | 425 (30.0) | 0.823 (0.006) | 202 (14.3) | 1214 (85.7) | 0.460 (0.018) |
| Not working | 138 (70.8) | 57 (29.2) | 24 (12.3) | 171 (87.7) | ||
| Husband’s alcohol usage | ||||||
| Yes | 644 (67.8) | 306 (32.2) | 0.016 (0.060) | 168 (17.7) | 782 (82.3) | <0.001 (0.126) |
| No | 485 (73.4) | 176 (26.6) | 58 (8.8) | 603 (91.2) | ||
| Attitudes toward wife beating | ||||||
| Accept wife beating | 407 (68.8) | 185 (31.3) | 0.374 (0.022) | 103 (17.4) | 489 (82.6) | 0.003 (0.074) |
| Do not accept wife beating | 722 (70.9) | 297 (29.1) | 123 (12.1) | 896 (87.9) | ||
| Decision making ability | ||||||
| Able to make decisions | 862 (74.9) | 289 (25.1) | <0.001 (0.166) | 109 (9.5) | 1042 (90.5) | <0.001 (0.208) |
| Not able to make decisions | 267 (58.0) | 193 (42.0) | 117 (25.4) | 343 (74.6) | ||
| Childhood exposure to violence | ||||||
| Exposed to violence | 264 (65.3) | 140 (34.7) | 0.016 (0.060) | 79 (19.6) | 325 (80.4) | <0.001 (0.092) |
| Not exposed to violence | 865 (71.7) | 342 (28.3) | 147 (12.2) | 1060 (87.8) | ||
| Socio-economic status | ||||||
| Low | 345 (69.3) | 153 (30.7) | 0.424 (0.033) | 78 (15.7) | 420 (84.3) | 0.432 (0.032) |
| Medium | 395 (68.8) | 179 (31.2) | 78 (13.6) | 496 (86.4) | ||
| High | 389 (72.2) | 150 (27.8) | 70 (13.0) | 469 (87.0) | ||
| Mental health status (based on K6) | ||||||
| Healthy | 83 (7.4) | 1046 (92.6) | <0.001 (0.294) | |||
| Not healthy | 143 (29.7) | 339 (70.3) | ||||
| Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | |||
| Age* | 47.46 (13.55) | 49.11 (13.27) | 0.024 (0.123) | 46.94 (11.97) | 48.12 (13.71) | 0.182 (0.087) |
| Age at marriage* | 23.19 (4.72) | 22.57 (4.64) | 0.016 (0.131) | 21.43 (4.71) | 23.26 (4.65) | <0.001 (0.391) |
*t-test for metric variables
Table 3 shows logistic regression results for married women’s mental health and suicidal thoughts, adjusting for socio-demographics and survey weights. The odds of negative mental health status and suicidal thoughts were nearly three times (AOR = 2.88, 95% CI: 2.20, 3.78) and six times (AOR = 5.84, 95% CI: 4.10, 8.32) higher among married women experiencing IPV than those who did not. Compared to married women with a primary level of education, those with a higher level of education showed significant results with a 47% lower likelihood of having a negative mental health status (AOR = 0.53, 95% CI: 0.34, 0.83) and a 49% lower likelihood of having suicidal thoughts (AOR = 0.51, 95% CI:0.26, 0.98). Furthermore, married women whose husbands possessed a secondary level of education were 31% less likely to encounter unhealthy mental health conditions than those with husbands educated at the primary level (AOR = 0.69, 95% CI: 0.49, 0.97). However, married women with secondary-level educated husbands were 70% more likely to have suicidal thoughts compared to married women with primary-level educated husbands (AOR = 1.70, 95% CI: 1.02, 2.83). In comparison with married women who were not participating in decision-making, married women having decision-making power were 40% (AOR = 0.60, 95% CI: 0.46, 0.78) less likely to have a poor mental health status and 42% (AOR = 0.58, 95% CI: 0.41, 0.81) less likely to have suicidal thoughts.
Results of the logistic regression models for mental health status: having suicidal thoughts and having suicidal thoughts with mental health status added as a covariate, after controlling for socio-demographic covariates and adjusting for survey weights
| . | Mental health status (past 4 weeks) . | Having suicidal thoughts in last 4 weeks . | Having suicidal thoughts with mental health status as a covariate . | ||||
|---|---|---|---|---|---|---|---|
| Factors . | AOR . | 95% CI . | AOR . | 95% CI . | AOR . | 95% CI . | |
| Experience of any form of IPV (ref: no) | Yes | 2.88 | 2.20–3.78 | 5.84 | 4.10–8.32 | 4.65 | 3.22–6.72 |
| Area of residence (ref: urban) | Rural | 0.74 | 0.54–1.01 | 0.81 | 0.52–1.24 | 0.87 | 0.55–1.36 |
| Respondent education (ref: primary) | Secondary | 0.79 | 0.55–1.13 | 0.65 | 0.40–1.07 | 0.71 | 0.42–1.20 |
| Higher | 0.53 | 0.34–0.83 | 0.51 | 0.26–0.98 | 0.65 | 0.32–1.30 | |
| Working status (ref: not working) | Working | 0.98 | 0.76–1.25 | 1.84 | 1.32–2.55 | 1.94 | 1.39–2.72 |
| Number of children (ref: 0 or 1 child) | Two children | 1.12 | 0.79–1.56 | 1.35 | 0.84–2.17 | 1.33 | 0.81–2.21 |
| Three children | 1.35 | 0.92–1.97 | 1.62 | 0.97–2.71 | 1.56 | 0.90–2.68 | |
| Four or more children | 1.47 | 0.92–2.33 | 1.20 | 0.60–2.44 | 1.07 | 0.51–2.21 | |
| Husband’s level of education (ref: primary) | Secondary | 0.69 | 0.49–0.97 | 1.70 | 1.02–2.83 | 1.77 | 1.05–2.99 |
| Higher | 0.87 | 0.57–1.36 | 1.77 | 0.92–3.41 | 1.75 | 0.89–3.43 | |
| Husband’s working status (ref: not working) | Working | 1.26 | 0.85–1.88 | 1.18 | 0.67–2.11 | 1.10 | 0.61–1.97 |
| Husband’s alcohol usage (ref: no) | Yes | 1.01 | 0.79–1.29 | 1.33 | 0.93–1.90 | 1.38 | 0.95–2.01 |
| Attitudes toward wife beating (ref: do not accept wife beating) | Accept wife beating | 0.86 | 0.67–1.10 | 1.10 | 0.79–1.55 | 1.16 | 0.81–1.66 |
| Decision-making (ref: respondent not able to make decisions) | Able to make decisions | 0.60 | 0.46–0.78 | 0.58 | 0.41–0.81 | 0.68 | 0.47–0.97 |
| Childhood exposure to violence (ref: not exposure to violence) | Exposure to violence | 1.18 | 0.90–1.53 | 1.32 | 0.93–1.88 | 1.26 | 0.87–1.82 |
| Socio-economic status (ref: low) | Medium | 1.08 | 0.81–1.43 | 0.86 | 0.58–1.26 | 0.81 | 0.54–1.23 |
| High | 0.95 | 0.71–1.27 | 0.84 | 0.56–1.26 | 0.80 | 0.53–1.22 | |
| Respondent age | 1.01 | 0.99–1.02 | 0.99 | 0.98–1.01 | 0.99 | 0.98–1.01 | |
| Age at marriage | 1.01 | 0.97–1.03 | 0.95 | 0.91–0.99 | 0.94 | 0.91–0.99 | |
| Mental health status (ref: healthy) | Not healthy | 3.85 | 2.73–5.44 | ||||
| . | Mental health status (past 4 weeks) . | Having suicidal thoughts in last 4 weeks . | Having suicidal thoughts with mental health status as a covariate . | ||||
|---|---|---|---|---|---|---|---|
| Factors . | AOR . | 95% CI . | AOR . | 95% CI . | AOR . | 95% CI . | |
| Experience of any form of IPV (ref: no) | Yes | 2.88 | 2.20–3.78 | 5.84 | 4.10–8.32 | 4.65 | 3.22–6.72 |
| Area of residence (ref: urban) | Rural | 0.74 | 0.54–1.01 | 0.81 | 0.52–1.24 | 0.87 | 0.55–1.36 |
| Respondent education (ref: primary) | Secondary | 0.79 | 0.55–1.13 | 0.65 | 0.40–1.07 | 0.71 | 0.42–1.20 |
| Higher | 0.53 | 0.34–0.83 | 0.51 | 0.26–0.98 | 0.65 | 0.32–1.30 | |
| Working status (ref: not working) | Working | 0.98 | 0.76–1.25 | 1.84 | 1.32–2.55 | 1.94 | 1.39–2.72 |
| Number of children (ref: 0 or 1 child) | Two children | 1.12 | 0.79–1.56 | 1.35 | 0.84–2.17 | 1.33 | 0.81–2.21 |
| Three children | 1.35 | 0.92–1.97 | 1.62 | 0.97–2.71 | 1.56 | 0.90–2.68 | |
| Four or more children | 1.47 | 0.92–2.33 | 1.20 | 0.60–2.44 | 1.07 | 0.51–2.21 | |
| Husband’s level of education (ref: primary) | Secondary | 0.69 | 0.49–0.97 | 1.70 | 1.02–2.83 | 1.77 | 1.05–2.99 |
| Higher | 0.87 | 0.57–1.36 | 1.77 | 0.92–3.41 | 1.75 | 0.89–3.43 | |
| Husband’s working status (ref: not working) | Working | 1.26 | 0.85–1.88 | 1.18 | 0.67–2.11 | 1.10 | 0.61–1.97 |
| Husband’s alcohol usage (ref: no) | Yes | 1.01 | 0.79–1.29 | 1.33 | 0.93–1.90 | 1.38 | 0.95–2.01 |
| Attitudes toward wife beating (ref: do not accept wife beating) | Accept wife beating | 0.86 | 0.67–1.10 | 1.10 | 0.79–1.55 | 1.16 | 0.81–1.66 |
| Decision-making (ref: respondent not able to make decisions) | Able to make decisions | 0.60 | 0.46–0.78 | 0.58 | 0.41–0.81 | 0.68 | 0.47–0.97 |
| Childhood exposure to violence (ref: not exposure to violence) | Exposure to violence | 1.18 | 0.90–1.53 | 1.32 | 0.93–1.88 | 1.26 | 0.87–1.82 |
| Socio-economic status (ref: low) | Medium | 1.08 | 0.81–1.43 | 0.86 | 0.58–1.26 | 0.81 | 0.54–1.23 |
| High | 0.95 | 0.71–1.27 | 0.84 | 0.56–1.26 | 0.80 | 0.53–1.22 | |
| Respondent age | 1.01 | 0.99–1.02 | 0.99 | 0.98–1.01 | 0.99 | 0.98–1.01 | |
| Age at marriage | 1.01 | 0.97–1.03 | 0.95 | 0.91–0.99 | 0.94 | 0.91–0.99 | |
| Mental health status (ref: healthy) | Not healthy | 3.85 | 2.73–5.44 | ||||
AOR – adjusted odds ratio, CI—Confidence Interval
Results of the logistic regression models for mental health status: having suicidal thoughts and having suicidal thoughts with mental health status added as a covariate, after controlling for socio-demographic covariates and adjusting for survey weights
| . | Mental health status (past 4 weeks) . | Having suicidal thoughts in last 4 weeks . | Having suicidal thoughts with mental health status as a covariate . | ||||
|---|---|---|---|---|---|---|---|
| Factors . | AOR . | 95% CI . | AOR . | 95% CI . | AOR . | 95% CI . | |
| Experience of any form of IPV (ref: no) | Yes | 2.88 | 2.20–3.78 | 5.84 | 4.10–8.32 | 4.65 | 3.22–6.72 |
| Area of residence (ref: urban) | Rural | 0.74 | 0.54–1.01 | 0.81 | 0.52–1.24 | 0.87 | 0.55–1.36 |
| Respondent education (ref: primary) | Secondary | 0.79 | 0.55–1.13 | 0.65 | 0.40–1.07 | 0.71 | 0.42–1.20 |
| Higher | 0.53 | 0.34–0.83 | 0.51 | 0.26–0.98 | 0.65 | 0.32–1.30 | |
| Working status (ref: not working) | Working | 0.98 | 0.76–1.25 | 1.84 | 1.32–2.55 | 1.94 | 1.39–2.72 |
| Number of children (ref: 0 or 1 child) | Two children | 1.12 | 0.79–1.56 | 1.35 | 0.84–2.17 | 1.33 | 0.81–2.21 |
| Three children | 1.35 | 0.92–1.97 | 1.62 | 0.97–2.71 | 1.56 | 0.90–2.68 | |
| Four or more children | 1.47 | 0.92–2.33 | 1.20 | 0.60–2.44 | 1.07 | 0.51–2.21 | |
| Husband’s level of education (ref: primary) | Secondary | 0.69 | 0.49–0.97 | 1.70 | 1.02–2.83 | 1.77 | 1.05–2.99 |
| Higher | 0.87 | 0.57–1.36 | 1.77 | 0.92–3.41 | 1.75 | 0.89–3.43 | |
| Husband’s working status (ref: not working) | Working | 1.26 | 0.85–1.88 | 1.18 | 0.67–2.11 | 1.10 | 0.61–1.97 |
| Husband’s alcohol usage (ref: no) | Yes | 1.01 | 0.79–1.29 | 1.33 | 0.93–1.90 | 1.38 | 0.95–2.01 |
| Attitudes toward wife beating (ref: do not accept wife beating) | Accept wife beating | 0.86 | 0.67–1.10 | 1.10 | 0.79–1.55 | 1.16 | 0.81–1.66 |
| Decision-making (ref: respondent not able to make decisions) | Able to make decisions | 0.60 | 0.46–0.78 | 0.58 | 0.41–0.81 | 0.68 | 0.47–0.97 |
| Childhood exposure to violence (ref: not exposure to violence) | Exposure to violence | 1.18 | 0.90–1.53 | 1.32 | 0.93–1.88 | 1.26 | 0.87–1.82 |
| Socio-economic status (ref: low) | Medium | 1.08 | 0.81–1.43 | 0.86 | 0.58–1.26 | 0.81 | 0.54–1.23 |
| High | 0.95 | 0.71–1.27 | 0.84 | 0.56–1.26 | 0.80 | 0.53–1.22 | |
| Respondent age | 1.01 | 0.99–1.02 | 0.99 | 0.98–1.01 | 0.99 | 0.98–1.01 | |
| Age at marriage | 1.01 | 0.97–1.03 | 0.95 | 0.91–0.99 | 0.94 | 0.91–0.99 | |
| Mental health status (ref: healthy) | Not healthy | 3.85 | 2.73–5.44 | ||||
| . | Mental health status (past 4 weeks) . | Having suicidal thoughts in last 4 weeks . | Having suicidal thoughts with mental health status as a covariate . | ||||
|---|---|---|---|---|---|---|---|
| Factors . | AOR . | 95% CI . | AOR . | 95% CI . | AOR . | 95% CI . | |
| Experience of any form of IPV (ref: no) | Yes | 2.88 | 2.20–3.78 | 5.84 | 4.10–8.32 | 4.65 | 3.22–6.72 |
| Area of residence (ref: urban) | Rural | 0.74 | 0.54–1.01 | 0.81 | 0.52–1.24 | 0.87 | 0.55–1.36 |
| Respondent education (ref: primary) | Secondary | 0.79 | 0.55–1.13 | 0.65 | 0.40–1.07 | 0.71 | 0.42–1.20 |
| Higher | 0.53 | 0.34–0.83 | 0.51 | 0.26–0.98 | 0.65 | 0.32–1.30 | |
| Working status (ref: not working) | Working | 0.98 | 0.76–1.25 | 1.84 | 1.32–2.55 | 1.94 | 1.39–2.72 |
| Number of children (ref: 0 or 1 child) | Two children | 1.12 | 0.79–1.56 | 1.35 | 0.84–2.17 | 1.33 | 0.81–2.21 |
| Three children | 1.35 | 0.92–1.97 | 1.62 | 0.97–2.71 | 1.56 | 0.90–2.68 | |
| Four or more children | 1.47 | 0.92–2.33 | 1.20 | 0.60–2.44 | 1.07 | 0.51–2.21 | |
| Husband’s level of education (ref: primary) | Secondary | 0.69 | 0.49–0.97 | 1.70 | 1.02–2.83 | 1.77 | 1.05–2.99 |
| Higher | 0.87 | 0.57–1.36 | 1.77 | 0.92–3.41 | 1.75 | 0.89–3.43 | |
| Husband’s working status (ref: not working) | Working | 1.26 | 0.85–1.88 | 1.18 | 0.67–2.11 | 1.10 | 0.61–1.97 |
| Husband’s alcohol usage (ref: no) | Yes | 1.01 | 0.79–1.29 | 1.33 | 0.93–1.90 | 1.38 | 0.95–2.01 |
| Attitudes toward wife beating (ref: do not accept wife beating) | Accept wife beating | 0.86 | 0.67–1.10 | 1.10 | 0.79–1.55 | 1.16 | 0.81–1.66 |
| Decision-making (ref: respondent not able to make decisions) | Able to make decisions | 0.60 | 0.46–0.78 | 0.58 | 0.41–0.81 | 0.68 | 0.47–0.97 |
| Childhood exposure to violence (ref: not exposure to violence) | Exposure to violence | 1.18 | 0.90–1.53 | 1.32 | 0.93–1.88 | 1.26 | 0.87–1.82 |
| Socio-economic status (ref: low) | Medium | 1.08 | 0.81–1.43 | 0.86 | 0.58–1.26 | 0.81 | 0.54–1.23 |
| High | 0.95 | 0.71–1.27 | 0.84 | 0.56–1.26 | 0.80 | 0.53–1.22 | |
| Respondent age | 1.01 | 0.99–1.02 | 0.99 | 0.98–1.01 | 0.99 | 0.98–1.01 | |
| Age at marriage | 1.01 | 0.97–1.03 | 0.95 | 0.91–0.99 | 0.94 | 0.91–0.99 | |
| Mental health status (ref: healthy) | Not healthy | 3.85 | 2.73–5.44 | ||||
AOR – adjusted odds ratio, CI—Confidence Interval
Among married women who were currently working, 84% (AOR = 1.84, 95% CI: 1.32, 2.55) were more likely to have suicidal thoughts than those who were not working. The risk of suicidal thoughts decreased by 5% (AOR = 0.95, 95% CI: 0.91, 0.99) for every additional year of married women’s age at marriage. In married women analyzed for suicidal thoughts, considering mental health status as a covariate, those with unhealthy mental health were nearly four times more likely (AOR = 3.85, 95% CI: 2.73, 5.44) to have suicidal thoughts than those with healthy mental health.
Discussion
Main findings of this study
This study examined the effect of IPV on the mental health of married women in Sri Lanka using recent population data. Results highlight that IPV-exposed women face increased risks of mental health issues and suicidal thoughts. The study also identified some socio-demographic factors associated with married women’s mental health status and their suicidal thoughts, including women’s education level, husband’s education level, employment status, involvement with decision-making and age. Particularly, women with higher education levels, married to higher-educated spouses and actively involved in decision-making exhibit greater resilience to mental health challenges. Additionally, in the model accounting for mental health as a covariate and suicidal thoughts as the outcome, it was observed that married women with poor mental health were more prone to suicidal thoughts, even when adjusting for socio-demographic factors.
What is already known on this topic and what this study adds
A strong association was found between IPV and mental health outcomes among married women, which is consistent with previous literature.8,9,17 When women experience IPV, they may experience diminished feelings of self-worth, autonomy and self-esteem, which may lead to developing conditions such as depression, anxiety and post-traumatic stress disorder.22 These negative mental health outcomes can lead to the development of suicidal thoughts in women.23,24 Moreover, the social stigma associated with IPV along with societal expectations related to gender roles often discourage women from seeking help or sharing their experiences,23 which further contributes to the development of mental health problems.
Consistent with previous research, this study found that married women with higher levels of education were less likely to have an unhealthy mental health status and less likely to have suicidal thoughts.8,25 Higher levels of education provide opportunities for women to enhance their knowledge using the available resources (such as help services), decision-making power and coping mechanisms, which may contribute to better mental health outcomes and a reduced risk of suicidal thoughts. Furthermore, married women with a higher level of education are less likely to experience IPV,26,27 and a lower likelihood of experiencing IPV is associated with better mental health outcomes.17
Echoing prior findings, our study revealed that married women with highly educated husbands experienced lower instances of poor mental health. This connection may stem from educated husbands being more supportive, respectful of their wives’ rights, thereby reducing IPV occurrences and enhancing women’s overall mental wellbeing.26,28 Even though married women with highly educated husbands are less likely to experience negative mental health, our study found that they are more likely to have suicidal thoughts. There is a similar pattern in previous research in Sri Lanka, showing that individuals with high levels of active suicidal ideation are less likely to be diagnosed with mental illness.29,30 Furthermore, in Sri Lanka, social and cultural norms play a significant role due to its collectivist society, where individuals tend to prioritize social relationships, and the concept of self is deeply interconnected with communal values and expectations.29 As a result, women married to secondary educated husbands may face additional pressures to conform to social expectations, both within and outside the household. Those pressures may contribute to their higher likelihood of suicidal thoughts.31 Further research is needed to understand how husbands’ education impacts married women’s mental health, considering socioeconomic factors and cultural norms.
Studies conducted in the past confirm the finding of the current study that married women with employment are more likely to have suicidal thoughts.32,33 Furthermore, several studies have shown that women who work in LMICs are more vulnerable to IPV, mainly because of traditional and cultural gender norms and gender inequality.34,35 The overlap of IPV and work stressors like discrimination and harassment might add stress and challenges for married women, heightening their risk of suicidal thoughts.
Women who are able to make decisions tend to experience greater levels of self-esteem, self-control and general wellbeing, which protects them from poor mental health outcomes,36,37 and this is consistent with the findings of the current study. For women, decision-making abilities reduce the likelihood of experiencing IPV,4,7 which further mitigates IPV’s negative mental health impacts. Given that decision-making can protect against mental health issues and suicidal thoughts, interventions should prioritize educating and supporting married women to improve their decision-making skills.
In several studies, it has been observed that women who marry later in life are less likely to suffer from suicidal thoughts. This is further supported by the current study findings.38,39 Marrying at an older age provides women with additional time for personal development, education and a sense of self-worth, which then enhances independence, improves decision-making capability, facilitates access to resources and assists in preventing suicidal thoughts.36,40 Furthermore, these opportunities resulting from marrying at a later age may also reduce the likelihood of experiencing IPV,41 thereby reducing the mental health consequences associated with it.
Limitations of this study
This study has limitations. (i) It focuses solely on married women, cautioning against broad generalizations. (ii) Mental health status is measured by only six survey questions, possibly oversimplifying mental health assessment. (iii) IPV severity, frequency, type and duration were not considered, potentially impacting mental health outcomes. (iv)Unobserved factors may bias results, stressing the need for further research. (v) Additionally, the cross-sectional design precludes causal interpretations.
Conclusions
This study provides valuable insight into the negative impact of IPV on married women’s mental health status and their suicidal thoughts in Sri Lanka, which highlights variations based on their sociodemographic characteristics. The findings indicate that the level of education, employment status, education of the husband, decision-making ability and age at marriage were also found to be significantly associated with women’s mental health outcomes. These findings make it clear that when addressing the mental health of married women in relation to IPV, it is crucial to consider associated sociodemographic factors. To mitigate the adverse effects of IPV on the mental health of married women in Sri Lanka, effective national-level interventions and policies should aim to promote education, women empowerment, decision-making autonomy, legal assistance for the victims, and mental health support services including counseling and trauma-informed treatment, while also focusing on preventing IPV. Additionally, it is essential to recognize the need for mental health policies specifically tailored to IPV victims. Policies such as these can provide targeted support and resources to address the unique mental health challenges faced by women who experience IPV. Through the implementation of targeted policies that will facilitate access to essential mental health, social and legal services and resources, Sri Lanka can provide better support to IPV survivors.
Acknowledgements
This study was conducted as part of a Ph.D. study at Swinburne University of Technology in Australia, and we are grateful for the award of a Tuition Fee Scholarship (TFS) by the university. A special thanks is extended to the Department of Census and Statistics in Sri Lanka for providing the Women’s Wellbeing Survey 2019 data.
Conflict of interest
The authors had no conflict of interest. All authors reviewed and approved the final manuscript.
Data availability
The de-identified secondary data set analyzed in the current study are freely available upon request from the Department of Census and Statistics (DCS) in Sri Lanka (http://www.statistics.gov.lk/).
Lakma Gunarathne, PhD Student
Maja Nedeljkovic, Professor
Pragalathan Apputhurai, Lecturer and Director
Jahar Bhowmik, Associate Professor and Postgraduate Applied Statistics Course Director
