Association between Sociodemographic Factors and Abuse by a Parent or Intimate Partner Violence among Haitian Women: A Population-Based Study

One in three Haitian women, and two in three Haitian children, experience physical abuse. This study aims to assess characteristics of abused Haitian women and identify effective sources of support. This cross-sectional study used multiple logistic regression models to analyze sociodemographic characteristics of Haitian women, associations with abuse-exposure from a parent/intimate partner (IPV)/any perpetrator, and impacts of seeking help for abuse, from police/doctors/family. About 9.1% experienced abuse by a parent, 8.6% from IPV. Women abused by a parent were less likely to be employed (OR = 0.74, [95% CI = 0.59–0.93]) and more likely to have an often-drunk partner (2.10, [1.54–2.87]). IPV-exposed women were more likely to have primary education (1.56, [1.12–2.16]), an often-drunk partner (3.07, [2.24–4.22]) and less likely to live rurally (0.65, [0.47–0.89]). Seeking help from own family for IPV exposure was strongly associated with having a job (2.00, [1.04–3.89]) (P for interaction = 0.039) and seeking help from partner’s family for IPV was strongly associated with having an often-drunk husband (8.80, [3.07–25.23]) (p for interaction <0.001). We recommend family-based interventions targeting men’s perceptions about abuse and their alcohol consumption, introducing programs/policies integrating women into the workforce, and havens for abuse victims to confidentially receive individualized support.


Introduction
While parts of the world find physical violence to be unacceptable, many patriarchal countries/communities accept it as a normal part of life [1,2]. Although the public health impact of domestic abuse is well known globally, cultural and societal perceptions can affect the identification and interpretation of abuse both by perpetrators and victims. Women are considered inferior to men, are culturally expected to submit to their husbands (who have the right to punish/beat their wives) [3][4][5] and are often financially dependent on men. This, as different studies have confirmed, results in the normalization of physical abuse [6] and a reduced rate of identifying and reporting domestic abuse/violence, especially in rural areas [1,5]. According to the United Nations Population Fund (2021), approximately 273,200 women experience physical or sexual violence in Haiti annually, and in 2020, genderbased violence increased by 37.7% [7]. One in three Haitian women experiences intimate partner violence (IPV) [8] and two in three Haitian children experience physical abuse at the hands of their parents or caregivers annually [9]. The Demographic Health Survey (DHS) describes physical violence as being pushed, shaken, thrown, slapped, having arm twisted, hair pulled, punched, kicked, dragged, or beaten up by any perpetrator since the age of fifteen [10,11]. Research shows that physical violence against children in Haiti is common [12] and is most frequently perpetrated by a member of their nuclear family. Friedemann-Sánchez and Lovatón (2012), Xiang et al. (2018), and Yan and Karatzias (2016) all found that anxiety, fear, a reduced self-worth, normalization of abusive behavior, and an increased risk of exposure to IPV were all long-term fallouts from exposure to childhood abuse [13][14][15].
Different studies have conflicting views regarding the characteristics of abused women in Haiti. Because there are more private than public schools in Haiti-a country where nearly 60% live below the poverty line and in rural areas [16]-more than half the population are unable to afford a good education and only have a primary school education or less [16,17]. In Haiti, a primary education is similar to having no education and has a limited impact on a woman's ability to be socially and financially empowered through reasonable wages [17]. The study by Gabriel et al. (2016) found that economic empowerment through gainful employment increased the risk of IPV among Haitian women [5].
Although domestic abuse is a widely studied subject, the subtle differences in Haiti's cultural, political, and social environment makes it important to assess the characteristics of women exposed to domestic abuse. The findings of this study could allow us to identify appropriately targeted interventions that would reduce the domestic abuse burden in the country. Dissimilar to many developed countries, Haitian police are more likely to see abuse as a family issue and there are not as many places to report abuse in Haiti or to receive support for domestic abuse when compared to countries such as the US [18]. Part of surviving abuse is acknowledging it and seeking help. According to Malihi et al. (2021), help-seeking among abused women can be influenced by sociodemographic characteristics, as well as the availability of support systems for the abused [19].
The purpose of this study is (1) to assess the prevalence of physical abuse by a parent as well as the prevalence of abuse by a partner/husband (IPV), (2) to study the factors that lead to abuse, and (3) to analyze the impact of seeking help from family (informal sources), doctors, or the police (formal sources) [19] on these associations, so that appropriate preventive measures can be established to reduce the disease burden of domestic abuse in Haiti. We hypothesize that education, rural residence, the wealth index, and a partner suffering from alcoholism increase the risk of abuse, and that help seeking would be protective against domestic abuse.

Sample Characteristics
The final sample for analysis consisted of 4466 women who had responded to the questions on domestic violence at the hands of a father, mother, or husband/partner. Although 17.7% of the women reported exposure to domestic violence by any perpetrator, only 9.1% reported exposure to parental domestic abuse, while 8.6% reported exposure to IPV. About 57.3% of the sample population had a primary education or less, 59% lived in rural areas, 41.9% were rich, 38.2% poor, 55.7% were never married, and roughly 96.7% were over 18 years old. Only 9.4% had no religion, whereas 51.3% identified as Protestant and 1.8% as Vodouisant. Approximately 58.3% of women in the study were working at the time of the study. Approximately 39.7% of the women had a husband/partner with at least a secondary school education, 20.1% had a husband/partner who was drunk sometimes, and 59.9% had a partner who drank during their pregnancy.

Characteristics of Haitian Women Based on Type of Abuse Exposure
Among Haitian women who experienced domestic violence by any perpetrator, less than half (41.9%) had a secondary school education or more, lived in urban areas (47.0%), were poor (33.0%), rich (44.8%), or married (49.6%). Over 95.8% of them were more than 18 years old, 38.5% were Catholics, and 44.2% Protestants. Over two in five (45.4%) were working at the time of the survey, 40.8% had a husband/partner with at least a secondary school education, 31.6% had a husband/partner who was sometimes drunk, 21.5% a husband/partner who was often drunk, and 46.9% a husband/partner who was never drunk.
Of those who experienced abuse by a parent, 50.0% had at least a secondary school education, 54.5% lived in a rural area, 31.8% were poor, 18.5% middle class, 49.8% rich, 42.1% married, and over 94.3% more than 18 years old at the time of the survey. About 39.9% were Catholic, 48.5% Protestants, 51.5% were currently working, and 61.4% had a husband/partner who had at least a secondary school education. Approximately 29.4% of them had a husband/partner who was sometimes drunk, 16.7% a husband/partner who was often drunk, and 53.9% a husband/partner who was never drunk.
Of those who experienced IPV, over three in five (68.7%) had a primary school education or less, 51.3% lived in a rural area, 34.5% were poor, 26.2% middle class, and 42.6% were never married. The majority (97.4%) was over 18 years old, 37% were Catholic, 39.6% Protestant, 4.1% Vodouisants, and 42.1% not currently working. Two in five of them (32.1%) had a husband/partner who had at least a secondary school education, 33.7% a husband/partner who was sometimes drunk, 26.7% a husband/partner who was often drunk, and 39.6% a husband/partner who was never drunk. Table 1 summarizes the sociodemographic distribution among Haitian women based on exposure to the domestic abuse variables of interest.  Table 2 summarizes the prevalence of seeking help from family (own family or husband/partner's family) or from persons of authority (doctor or police) by Haitian women who experienced IPV in our study. We found that Haitian women were 1.7 times more likely to seek help from their own family (52.7%) than from their husband/partner's family (30.9%). Of those who sought help from their own families, 75 (38.9%) had a secondary school education or more, 99 (51%) lived in urban areas, and 98 (50.8%) were married. Only 9 (2.3%) Haitian women exposed to IPV sought help from their doctor and 52 (14%) from law enforcement. Three in five women who sought help from their husband/partner's family were married (65.8%) or lived in an urban area (62.7%).  Table 3 shows the association between sociodemographic characteristics of Haitian women between 15 and 49 years old and their exposure to physical abuse at the hands of a parent or at the hands of their intimate partner. Based on our findings, having only a primary school education significantly increased the odds of experiencing any abuse (odds ratio (OR) = 1.35; 95% confidence interval (CI) = 1.07-1.72) and experiencing IPV (OR= 1.56; 95% CI = 1.12-2.16) compared to having a secondary school education or more. Living in rural areas reduced the odds of IPV (OR = 0.65, 95% CI = 0.47-0.89) compared to urban dwelling. Married women had increased odds of experiencing any abuse (OR = 1.31; 95% CI = 1.09-1.59) and IPV (OR = 1.77; 95% CI = 1.35-2.32). Compared to having no religion, being a Catholic (OR = 0.68, 95% CI = 0.51-0.90) or Protestant (OR = 0.61; 95% CI = 0.46-0.82)) significantly reduced the odds of any abuse. IPV exposure was also reduced for Catholics (OR = 0.44; 95% CI = 0.31-0.61) and for Protestants (OR = 0.42; 95% CI = 0.30-0.60) in this study. Compared to women who were not working, those who were working had lower odds of experiencing any abuse (OR = 0.83; 95% CI = 0.69-0.99) or abuse by a parent (OR = 0.74; 95% CI = 0.59-0.93).

Seeking Help from Family or Authorities for Domestic Abuse
Seeking help from family, doctors, or the police did not significantly affect the characteristics of Haitian women exposed to abuse by a parent. Seeking help from a doctor or the police also did not significantly affect the characteristics of Haitian women exposed to IPV. Seeking help from a woman's own family strengthened the association between IPV and primary education (OR = 2.89; 95% CI = 1.30-6.44) (p for interaction = 0.010). Women exposed to IPV and who were working at the time had higher odds of seeking help from their own family (OR = 2.00; 95% CI = 1.04-3.89]) (p for interaction = 0.039). Seeking help from the husband/partner's family was more likely among IPV-exposed women whose husbands/partners drank often (OR = 8.80; 95% CI = 3.07-25.23) (p for interaction <0.001) as shown in Table 4.

Discussion
This study used data from the 2016-2017 DHS survey of Haitian women [11], examined the prevalence of both abuse by a parent and IPV in Haitian women between 15 and 49 years of age, and investigated the characteristics of women exposed to abuse in Haiti. We also looked at the modifying effects of seeking help from formal (doctor or police) and informal (woman's own family or husband/partner's family) sources on the sociodemographic characteristics of women exposed to IPV and women exposed to abuse by a parent.

Main Findings
Multivariable analyses revealed that women who had a primary school education, were married, or had husbands/partners who were often drunk all had significantly higher odds of experiencing IPV or any abuse compared to those with secondary education than never married women or whose husband/partner was never drunk, respectively. Living in rural areas as well as being a Christian significantly reduced the odds of IPV. Working women had lower odds of exposure to abuse by a parent and to exposure to any abuse. Finally, alcohol abuse by the husband/partner was also associated with higher odds of abuse by a parent.

Interpretation of Findings
Our findings showed that a secondary school education or more was protective against abuse by any perpetrator and by IPV supported other studies [5,15,20] where education also protected against IPV. Weitzman (2018) found that education increased women's understanding of abuse, their self-worth, employability, occupational prestige, and personal/economic resources, empowering them and reducing their financial dependency on their partners. A previous study by Gabriel et al. (2016) found that men who at least graduated from secondary school were less likely to be abusive. Women exposed to abuse by a parent in our study were more likely to have partners with a primary school education or less, and less likely to be gainfully employed. The reduced odds of any abuse or abuse by a parent among women with gainful employment was similar to findings from other studies [21][22][23], where gainful employment economically and socially empowered women and protected them against domestic abuse.
Although women living in rural areas were less likely to experience IPV in our study, results from other studies were contrary to ours [3,18]. Where Peek-Asa et al. (2011)'s US sample population had access to domestic shelters and could report abuse to law enforcement and judicial personnel, the Haitian population in our study had limited places to report abuse. The police were more likely to treat abuse as a family issue to be handled/managed within the family. The abuse victims also had limited access to support services for victims-especially in rural areas [2]. Research shows that women who lived in rural areas where they were perceived as 'less than the men' had higher tendencies of accepting domestic violence as the status quo and were less likely to challenge the men in their lives [24,25]. Interestingly, Sikweyiya et al. (2020) found that men who lived in rural areas felt less threatened and were, therefore, less likely to exert dominance over the women [26]. A recent study by Onwutuebe (2019) suggests that cultural and patriarchal inclinations are more ingrained in rural areas than in urban areas [27] and may explain our results. The rural dwelling Haitian women may, therefore, be less aware of what abuse is, what their rights as women within and outside their marriages are, and how to identify abusive behavior. Their perception/interpretation of abuse might be different from that of urban dwellers, making them less likely to identify and report IPV. Therefore, although our results showed rural dwelling as protective against IPV, our findings might have been skewed by a possible lack of awareness and/or the justification of abusive behavior among Haitian women in rural areas compared to urban dwelling Haitian women.
Being married was a risk factor for both IPV and abuse by any perpetrator in our study. Since about half of the Haitian women in our study were married, it stands to reason that the IPV risk would be higher among these married women when compared to those who had never been married. In our study, Christians had lower odds of experiencing IPV or any abuse compared to those with no religion. This was similar to Kim's 2021 case-controlled study, which found that religiosity was protective against IPV. Although Kim (2021) suggests that Christianity promotes compassion and love through teachings of sacrifice [28], the reason for this protective characteristic in our study was not clear and warrants further research. We found that having a husband/partner who was often drunk was a risk factor for both abuse by a parent and by IPV [29][30][31]. According to Berg et al. (2010), men who have alcohol consumption problems are more likely to abuse their wives than those who do not have drinking issues. This may explain the increased risk of IPV among Haitian women with husbands/partners that were sometimes or often drunk in our study. The impaired cognitive function reduces self-control, and financial strain linked to frequent alcohol consumption [30] may increase the risk of abuse.

Strengths and Limitations
Our study used the large national Demographic and Health Survey, which was weighted using individual weights with women as the unit of analysis, to increase the generalizability of our findings. Despite this strength, there were several limitations which are important to point out in this study. The study used cross-sectional data relying on the participant's ability to remember and accurately report events from their past. Therefore, causality could not be established, and recall bias was a limitation for this study. The risk of underreporting exposure to IPV and/or abuse by a parent due to social preference bias [32] may explain the low rate of abuse reported in this study and may have impacted our findings. The cultural differences that promote domestic violence and patriarchy in Haiti may also explain the potential underreporting of violence among Haitian women. The prevalence of IPV using the DHS data may have been lower in our study than in studies that used other datasets, due to possible differences in approaches to the questions on domestic violence (physical acts that constitute violence such as slaps, kicks, or by addressing subscales of emotions associated with domestic violence). Additionally, it is unclear if the women specifically sought help for IPV or if they also sought help for other forms of domestic abuse. Although our study concentrated on physical abuse in Haitian women, we acknowledge that sexual violence is also a pressing form of violence that should also be assessed in Haiti as well as globally [7]. We recommend further studies considering exposure to sexual violence in Haiti. We did not consider the disability status/levels among the Haitian women who were exposed to domestic abuse in our study.

Study Design
We obtained data from the 2016-2017 Demographic and Health Survey (DHS) that used standardized questionnaire modules tailored to Haiti. The cross-sectional Haiti DHS 2016-2017 survey used a stratified two-stage cluster design at the regional, residential, and national levels (detailed information can be found in the Haiti DHS final report) [10]. The dataset was provided with sample weights by the DHS to increase generalizability. The unit of analysis for this study was women between 15 and 49 years of age. From the 13,546 households selected for the DHS interview, 15,513 women, men, and children were successfully interviewed for a 99.7% survey response rate. Sample inclusion for our study was limited to women that had responded to the questions regarding experiencing domestic abuse from either parent or from their current husband/boyfriend. Of the 15,513 observations in the original dataset, 11,047 people did not respond to any of the questions on domestic abuse and were excluded from the study. The final sample size used for this cross-sectional study was 4466 women between 15 and 49 years of age. Data deidentified for Haiti were obtained with the permission of the DHS [33]. This study did not require formal consent and was approved by the Adelphi University's Institutional Review Board. The DHS ethics statement and IRB approvals can be found here: https://dhsprogram.com/ Methodology/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm (accessed on 17 January 2022) [34].

Domestic Abuse
Abuse by any perpetrator combined the responses to the parental and IPV variables and was categorized into 'Yes' and 'No' responses. Abuse by a parent represented physical abuse by one's mother or father and was measured using the question: "Have you ever been slapped, pushed, kicked, punched, or beaten by mother or father?" (Yes, No). Similar to other studies [35], IPV in our study was described as physical violence by husband or partner and was measured using the question: "Have you ever been slapped, pushed, kicked, punched, or beaten by husband or boyfriend" [32] (Yes, No).

Main Sociodemographic Variables
(1) Education level was assessed by the question "What is the participant's highest education level?" and recoded into a three-category response variable ('No education', 'Primary education', '≥ Secondary education'). (2) Residence location was obtained from the question "Where did the participant live at time of survey?" ('Urban', 'Rural'). (3) Wealth index was originally classified by the DHS using a principal component analysis into a five-response categorical classification. Similar to other studies [36][37][38], our study recoded rich or very rich women into 'Rich', poor or very poor women into 'Poor', while middleclass women remained as 'Middle class'. (4) Current work status was categorized as 'Not working' and 'Working'.

Other Variables
Participants' ages were recoded as teenagers (≤18 years old) and adults (>18 years old) [39]; marital status was categorized as 'Married' and 'Never married'; religion as 'No religion', 'Catholic', 'Protestant', and 'Vodouisants'; husband/partner's age as '≤18 years old' and '>18 years old'; husband/partner's education level as 'No education', 'Primary education', and '≥ Secondary education'; frequency of husband/partner being drunk on alcohol as 'Never', 'Sometimes', and 'Often'. Seeking help from a doctor, the police, a woman's own family, or the husband/partner's family was measured using dichotomous 'Yes' and 'No' variables. Formal help-seeking characteristics were measured using the question(s): "Did the participant seek help for abuse from a doctor?" and "Did the participant seek help for abuse from the police?", while informal help seeking was measured with the questions "Did the participant seek help for abuse from their own family?" and "Did the participant seek help for abuse from their husband or boyfriend's family?"

Data Analysis
We used multivariate logistic regression models to examine the association between the main sociodemographic variables (educational level, wealth index, woman's current working status, and residence) and 'domestic abuse variables (IPV, abuse by parent, or any physical abuse) after adjusting for main confounders (marital status, woman's age, religion, husband/partner's education level, husband/partner's age, and frequency of alcohol use by husband/partner). We also used multiple regression models to assess the modifying effect of seeking help for abuse on the associations between physical abuse and the sociodemographic characteristics of these Haitian women. Statistical significance was set at 2-tailed p < 0.05 and analyses were performed using IBM SPSS v.26 [40].

Conclusions
In this study, we used DHS data for Haiti [33] to examine the sociodemographic characteristics of Haitian women exposed to abuse by a parent and IPV, as well as the modifying effect of seeking help from family or authorities on the relationship between abuse by a parent/IPV exposure and sociodemographic characteristics. Since marriage was associated with IPV in our study, public health interventions using family-based programs [41] that address Haitian men's perceptions about women and their place in the home/society, as well as their perceptions of abuse, are recommended. Interventions that use modelling, roleplay, and home-practice to teach positive family relationship and parenting skills have been used in other communities and are encouraged in Haiti [31]. Providing and promoting opportunities for Haitian women to at least complete their secondary school education is recommended. It is advisable that targeted public health interventions aimed at shifting the social norms that normalize violence and the perception of the Haitian woman about female subjugation be encouraged, especially since IPV was higher in women with a primary education level compared to those with secondary education or more in our study. Because women currently working outside their home had reduced risks of experiencing any abuse or abuse by a parent in our study, programs and policies that support and promote the integration of Haitian women into the workforce [42] are strongly recommended. Due to the increased risk of IPV abuse, any abuse, and abuse by a parent faced by women whose partners were sometimes or often drunk, implementing programs and policies that help decrease alcohol abuse [43] by Haitian men is also highly recommended.
Haitian women in our study were more likely to seek help from family than from authorities. Therefore, providing a safe haven for abuse victims to confidentially report abuse should be encouraged. Domestic violence advocacy programs aimed at assessing personal risks and identifying ways to increase personal safety of Haitian women through the development and maintenance of victim-centered services as well as first responder and civil legal protection services [41] are encouraged in Haiti. These targeted interventions may promote discourse about domestic abuse and its long-term effects on Haitian women. The family is central to the development of norms and values, and family-based programs would raise parental awareness and change attitudes of parents and children to domestic abuse. Institutional Review Board Statement: Ethical review and approval were waived for this study due to the use of secondary cross-sectional data from the Demographic Health Survey. The participants were deidentified for this cross-sectional dataset.