The health-related impacts and costs of violence against women and girls on survivors, households and communities in Ghana.

Past research on violence in Ghana primarily discusses domestic violence and some types of sexual violence, but lacks a comprehensive analysis of violence against women and girls (VAWG) and its wider costs and impacts. Our study on the social costs of VAWG is a unique contribution, which aims to fill that gap. Through indepth interviews (IDIs) and focus group discussions (FGDs) with adult women and men, we explored the health impact of VAWG and the resulting social and economic consequences on survivors, their families and their communities. The research, which took place in the Eastern, Central, and Greater Accra regions of Ghana, points to several physical and mental health outcomes among survivors including physical injuries and disability, as well as impacts on mental health such as anxiety and suicidal ideation. Many VAWG survivors also experience stigma and social isolation. Our findings also reveal that survivors' families can bear various social and economic costs. Lack of public and private service provision and shelters for survivors heighten these impacts. Without institutional support for survivors, families and communities absorb these costs of VAWG.

Introduction

Violence against women and girls (VAWG) is defined as …any act of genderbased violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life.[1-3] VAWG is widespread in Ghana; a recent nationally representative study found that 28 per cent of women report experiencing some form of violence in their home by partners or other family members in the 12 months prior to the survey.[4] Additionally, the 2009 Ghana Demographic and Health Survey (DHS) found that, during their lifetime, 23 per cent of women experienced physical and/or sexual intimate partner violence (IPV) and 4 per cent experienced non-partner sexual violence (SV).[5]

The World Health Organization (WHO) Multi-Country Study and other international publications[1-2,4] link VAWG to physical, mental, sexual, and reproductive healthrelated outcomes. Physical and sexual violence can result in injuries such as cuts, bruises, lacerations, welts, headaches, fractures, broken bones and teeth, gastrointestinal disorders, chronic pain syndromes, and abdominal and thoracic injuries.[6-9] Gynaecological disorders, including chronic pelvic pain, pelvic inflammatory disease, vaginal bleeding or infection, fibroids, urinary tract infections, and infertility, are especially prominent.[7] Experiencing physical IPV during pregnancy increases the risk of miscarriage, preterm birth, stillbirth, antepartum haemorrhage, foetal distress and injury, and low birth weight, adversely impacting the health of expectant mothers and their children.[6,10,11] Additionally, women who experience IPV report emotional distress, thoughts of suicide, attempted suicide,[12] substance abuse, poor selfesteem, post-traumatic stress disorder, and unsafe sexual behaviour.[13]

In Ghana, the link between VAWG and health is explored in a nationally representative mixed-methods study conducted in 2016, which found that 43.8 per cent of women who had experienced domestic physical violence in the previous 12 months had been ill in the 30 days prior to the survey, compared to 31.2 per cent of women who had not experienced this type of domestic violence.[3] An earlier study by Issahaku[14] identified the health implications of IPV on women in northern Ghana using face-to-face interviews with 443 women contacted at health facilities. Participants in this study reported health problems associated with violence, including injury, thoughts of suicide, sleep disruption, and fear of partner.[14] Another study in Ghana found that women who experienced IPV reported health problems such as feelings of worthlessness, sleeplessness, suicidal ideation, hypertension, genital sores, and premature termination of pregnancy.[15]

While these studies shed light on the health impacts of violence on women themselves, very few focus on households and communities; how they are impacted and the costs they bear.[3,14-21] Our study addresses this evidence gap through a framework that includes all three domains of impact; the survivor, the household and the community. Specifically, our research explores the impact of VAWG on a survivor’s health, as well as the resulting social and economic costs on the survivor, their families and their communities.

Materials and Methods

The qualitative research presented in this paper is part of a larger multi-country mixed-methods study investigating the social and economic costs of VAWG in Ghana, South Sudan and Pakistan led by the National University of Ireland-Galway (NUI Galway), the International Center for Research on Women (ICRW), and Ipsos MORI This study combines qualitative and quantitative methods to generate knowledge and evidence on the economic and social costs of VAWG in Ghana, South Sudan, and Pakistan. The quantitative component included a nationally representative survey that contained several modules to identify IPV and SV, as well as harassment in public and work spaces that will allow the authors to calculate the prevalence of these forms of violence and their cost to businesses and society. In Ghana, the participants in the quantitative survey were asked whether they would consent to a follow up qualitative interview. The qualitative sample was selected from among those who consented. Participants were selected based on their experiences of violence, age and location of residence (urban/rural), and included survivors of IPV and non-partner sexual violence (NPSV) as well as women who did not report experiencing violence in their lifetime (Table 1). A total of 24 participants took part in the IDIs that probed on the social and non-monetized economic costs of VAWG. Eight groups of 6 to 10 women and men were recruited for FGDs to explore gender norms and perceptions of violence against women.

Table 1.

Number of participants and locale.

Interview type	Sex of participants	Location	Number
Focus Group Discussion	Female	Rural	2
Focus Group Discussion	Male	Rural	2
Focus Group Discussion	Female	Urban	2
Focus Group Discussion	Male	Urban	2
In-Depth Interview	Female	Rural	15
In-Depth Interview	Female	Urban	15
Key Informant Interview	Male/Female	Rural	5
Key Informant Interview	Male/Female	Urban	5
Total	48

Following safeguards delineated in Researching violence against women: a practical guide for researchers and activists,[2] the FGDs with men were conducted in different towns from where the FGDs with women were conducted; however, the selected towns had similar characteristics. Interviews were conducted in Ga and Twi, transcribed, translated into English, then coded and analysed using Nvivo. Ten key informant interviews (KIIs) were conducted. Key informants were selected based on their involvement in addressing and preventing VAWG in Ghana. The KIIs included men or women that hold formal and informal leadership positions in the community where the study took place and who had lived there for more than 5 years.

The NUI Galway Research Ethics Committee provided ethical approval for the study on 14th September 2015. In addition, the research was submitted to the University of Ghana’s Ethics Committee for the Humanities, with approval given on 25th November 2015.

Results

Participants reported a wide range of acts that can be classified as VAWG, including physical, psychological, sexual, and economic violence perpetrated by partners, other household members, community members, and strangers. These forms of violence were interconnected, and women experienced multiple forms; for instance, often women who reported experiencing sexual violence perpetrated by their partner also reported experiencing psychological and physical violence. Because of this complexity, in this study we do not discuss the impacts of different types of violent acts separately. Instead, we describe the aggregate impacts of all forms of VAWG at the individual, household and community levels. We focus our presentation of results on the health-related impacts of VAWG, and the resulting subsequent social and economic costs.

Impacts on women and girls who experience violence

Participants were asked to identify physical, psychological, economic and social impacts of VAWG on survivors. Many highlighted physical injuries, chronic pain and disability as a result of beating, hitting, slapping or other physically violent acts. Participants also discussed mental health impacts such as anxiety, depression, insomnia and other psychological issues. Women also suffered from chronic fear after being raped, which participants indicated could turn into intense and persistent worry that could cause women to lose [their] sanity (Rural In-Depth Interview, Female). Many participants suggested that women abuse alcohol or drugs as a form of self-medication to help [them] forget [them] problems (Rural, In-Depth Interview, Female) or to treat their pain without going to a medical facility:

…I was drinking [alcohol] so that I could bring out the unwanted blood that was stuck in my chest. I never went to the hospital. (Rural In-Depth Interview, Female).

Participants also highlighted impacts on sexual and reproductive health. They felt that physical and sexual abuse were linked to miscarriages and bleeding, and some mentioned contracting infectious diseases such as human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) as a result of sexual violence. Several women believed that the physical and mental injuries resulting from abuse may make it hard for a woman to conceive in the future. Participants also reported that many young girls attempt to abort pregnancies that are the result of rape. Abortion is not legal in Ghana; therefore, these attempts are often unsafe and may be fatal. Fatalities as a result of VAWG were mentioned, and included depression leading to suicide or fatal complications of unsafe abortions.

These mental and physical health impacts also had economic and social consequences. Participants reported both absenteeism (not going to work or school due to injuries) and presenteeism (going to work but being inefficient due to inability to concentrate) due to the impacts of VAWG. One woman discussed presenteeism of a woman who has experienced VAWG as follows:

…She may go to work, but will not focus on her work, so part of the time will be spent on thinking. If she is a seamstress, she might even spoil some people’s cloth… (Urban In-Depth Interview, Female).

Women and men mentioned that the psychological impacts of VAWG; the fear, shame, and embarrassment that women and girls feel limits their mobility. In some rural communities, there may be only one market or school to attend, meaning that women completely avoid these places and are no longer able to access the services they provide:

…She will not be able to go there [market]. She will fear that the man will show up over there to disgrace her. It is a market where a lot of people are found. If he shows up over there, the woman will feel bad so she will not go there, so that she will save herself of the disgrace. If she wants something from the market, she will send someone… (Rural In-Depth Interview, Female).

Participants felt that women in urban areas were not as vulnerable to an accidental encounter with the perpetrator of violence because they had more options for places to go in order to avoid a potential undesirable encounter. However, urban women also described experiencing reduced mobility in order to avoid stigma from peers.

Social stigma and isolation, may also deteriorate women’s social networks and inhibit their ability to hold leadership positions. Participants highlighted that in Ghana, women’s social networks are related to their ability to demonstrate a consistent pattern of wisdom in their decisions. When a woman is known to have experienced IPV, people may believe she was unwise in either choosing her partner or in acting in a way that encouraged the aggressor’s violence, and thus lose respect for her. These attitudes were common; multiple participants either felt that women may behave in ways that justify violence against them or put themselves at risk. These behaviors included being disrespectful or starting arguments, staying out late, having multiple male friends or spending time alone with men, and use of alcohol. Therefore, the weight of consequences of violence is often placed solely on the survivor, suggesting that men’s abusive behavior is considered normal. These perceptions normalize VAWG for both men and women, giving men impunity and making it less likely that women will speak out, access needed care or seek justice.

Impacts on household members

Participants identified several mental health effects of VAWG on relatives of survivors. They spoke about depression and feelings of guilt among household members, especially when violence was fatal. Some participants also mentioned worry caused by threats from the perpetrator and stigma from peers. Additionally, participants described how household members may be isolated and avoid public gatherings, or that the survivor’s children might be shunned.

Households face economic impacts in the form of increased expenses and/or loss of income or productivity due to the health impacts of violence on women. In extreme cases, financial hardship caused by VAWG led to household dissolution or homelessness. Some participants emphasized that these financial burdens fall onto the woman’s family because there is a lack of formal social support for affected women and their families. Women who have survived IPV often return home to live with their maternal family, increasing the financial burden of the household. However, many survivors cannot count on this familial support due to the stigma attached to experiencing VAWG. Because of the lack of familial support, shelters and public support for VAWG survivors, women mentioned staying in marriages despite IPV out of concern for the welfare of their children. Families are burdened by hospital bills when survivors require medical care for physical injuries, pregnancy, STIs or mental health issues as a result of VAWG. If the woman is no longer able to care for her children (e.g. due to death, long-term injury), their care becomes an additional financial burden.

Mental health impacts on children were a common theme in interviews. Respondents discussed worry and pain experienced by children who witness VAWG in the household. They reported that female children may become uncomfortable in the presence of men, avoid places where there are male-dominated gatherings and be deterred from marriage and relationships. Participants also emphasized concerns about violence being considered normal among children who grow up in households where DV is common. A few respondents also described how the daughters of women who experience IPV may go on to think it is normal to experience IPV in their own relationships. Children in households with violence also tend lack proper nutrition, and funds for necessities such as school fees, medical care.

Community level impacts

The participants were asked about impacts of VAWG on their communities, with probes focusing particularly on social cohesion. The discussions reveal concerns that VAWG negatively impacts communities’ sense of safety, belonging, trust, and reduces community engagement. Respondents mention that women who experience violence often withdraw from community engagement and can lose their status in the community as leaders. These respondents explained that a female leader who experiences VAWG would be seen as one who no longer has the qualities of a leader or is qualified to give her opinion on issues in the community; she would no longer be deemed a good role model and would be forced or required to voluntarily give up their leadership position as a result of VAWG.

Violence, especially sexual violence, also results in a sense of vulnerability among women and girls in the community and can make them retreat from public life. They may stop attending school, going to the market and using public transport to avoid violence, which in turn affect may affect the social and economic wellbeing of the community as a whole.

When communities witness how nonresponsive institutions can be to reported cases of VAWG, they lose trust in the organizations designed to support survivors. Our study participants reported that they lacked trust in the police and the justice system for reporting cases of VAWG. The fact that IPV is considered a household matter limits support for survivors by community members and also affects the likelihood of reporting incidents. Regarding institutions where survivors can seek help in violent situations, many described seeking informal advice rather than formal support. Some looked for support from the Department of Social Welfare, police, and assemblymen but also from chiefs, traditional community elders, family elders and religious leaders such as church elders; it is noteworthy that these positions are traditionally held by men. Much of the support they receive from traditional authorities leads to conciliation practices such as marriage between the survivor and perpetrator of sexual violence if the survivor is young and unmarried. Participants did not discuss being able to utilize shelters run by government or private organizations.

Discussion

This study discusses the impacts of VAWG beyond the individual effects of specific forms of violence. In line with other studies in Ghana,[15-21] participants in our study reported physical, reproductive and mental health problems stemming from their experiences of violence. Participants discussed how women use alcohol and other drugs to help them ameliorate their anxiety, which is consistent with research that links experiencing VAWG with increased use of alcohol and drugs and/or dependency.[22] In line with the international literature,[1-2,4] participants also reported fatal outcomes related to depression and unsafe abortions performed on young girls. Our findings also point to various impacts on families of survivors particularly children, which include mental distress and additional economic and social costs of seeking services for VAWG.

Our findings also suggest that VAWG hinders women’s mobility and their ability to occupy leadership positions, and thus undermines the capability of women and girl survivors. The self-blame by survivors, victim-blaming by peers and institutions, and systemic justification of VAWG described by our study participants are in line with social norms identified in previous studies in Ghana.[15-21]

Conclusions

Thus far, the government of Ghana has mostly responded to VAWG through legal channels.[16] The government ratified the Convention on the Elimination of All Forms of Discrimination Against Women, in 1986 and is also a signatory to major international and applicable regional treaties concerning human rights.[16] The Ghanaian parliament has approved laws that support women’s rights and prevent human rights violations, most recently for domestic violence. While the Domestic Violence Act[23] emphasises the role of the judiciary in protecting domestic violence victims, including provisions for protection orders, it does not include provisions related to marital rape or laws against sexual harassment.[17] Ghana does have a law criminalising rape,[17] and the constitution prohibits all injurious traditional and cultural practices that dehumanize or can injure a person’s physical and mental well-being. However, while cultural practices such as trokosi, the ritual servitude of young girls, are prohibited in law, they persist outside of the formal justice system. [17]

The most important instrument in VAW response is the district-level Domestic Violence Victims Services Unit (DOVVSU), established within the police service and operating across several districts. Despite DOVVSU’s key role in implementing the law and policy on VAWG in Ghana, the units are inadequately resourced, resulting in a very small proportion of VAWG cases sent to the courts.[16-17] Some[16] argue that several factors endemic of the social norms in Ghana can explain the lack of more comprehensive action from the government as well as the services providers essential in VAW response, including the security and justice sectors. Cantalupo et al.[16] discuss the belief held by many judges and informal authorities around maintaining family units regardless of IPV or DV.

The impacts of VAWG that emerge from our study argue for government commitment and action to ensure that women and their families have access to the protections and essential services that they need to mitigate these impacts which are often significant and lasting. In addition, specific measures may be needed to ensure these essential services and key protections are accessible to survivors and their families. As our research reveals, norms, stigma and constrained mobility can limit women’s ability to access these services and to speak out about their experience and seek help.