1. Nepal Medical College and Teaching Hospital (NMC), Nepal: diackmarie3@gmail.com

*             Correspondence: diackmarie3@gmail.com

Keywords: relational violence, factors, married couples, relationships

1. INTRODUCTION

Intimate partner violence (IPV), commonly referred to as domestic violence or interpersonal violence among married couples, is a disturbing global issue that affects many people, especially women, regardless of their cultural or geographic background. IPV includes a variety of violent activities that take place between people or small groups and can seriously harm the physical and mental health of those who are victims. Globally, it is estimated that 27% (UI 23–31%) of women who have ever been in a relationship and are between the ages of 15 and 49 have at some point in their lives experienced physical, sexual, or both forms of domestic abuse [1]. Scholars have argued in the last ten years or so that elements functioning on several levels must be acknowledged in order to fully comprehend violence against women. Domestic abuse is still a serious public health issue in Pakistan, where it has a substantial impact on people’s personal and family lives. According to a WHO analysis, up to 71% of people in ten developing nations had experienced physical or sexual violence at some point in their lives [2]. Different types of interpersonal violence can occur, ranging in intensity from mild to severe, such as physical, emotional, sexual, and financial abuse. A number of factors, including age, marital status, length of marriage, partner’s education and income, number of children, substance use (alcohol or drugs), HIV infection status, family history of abuse, and unplanned pregnancy, are associated with an increased risk of gender-based violence in emerging nations, where the victim is the wife. Although it’s also typical for in-laws or close family members to be engaged as abusers, the husband is typically the one who attacks [3]. Domestic violence also includes burn injuries, with women accounting for the majority of victims [4]. IPV causes long-term trauma, social isolation, physical harm, mental health problems, and economic instability. Physical abuse cases with deep cuts are caused by money worries, property conflicts, family problems, and land disputes. About one-third of the attackers were personal friends or family members of the victim [5]. Therefore, the effects of intimate partner violence (IPV) on married couples go much beyond the immediate victims and affect the mental, physical, and emotional well-being of the entire family. It also contributes to intergenerational cycles of abuse and trauma in children who see or experience violence in their households [6]. Moreover, IPV can impede social and economic advancement by limiting the potential and production of those who are impacted. Compared to pleasant relationships, romantic partnerships marked by frequent disputes—especially those involving money, jealousy, and challenges to traditional gender roles—are more likely to result in violent incidents. Furthermore, drinking too much alcohol increases the risk of violence. Maternal well-being is influenced by five interrelated factors: poverty, women’s poor socioeconomic status, inadequate nutrition and general health, restricted access to high-quality healthcare services, and insufficient alternatives for contraception [7]. Greater protection against violence is enjoyed by women with greater levels of education, economic independence, and social empowerment. The relationship between empowerment and the likelihood of violence, however, gets more intricate and non-linear below this high threshold. By acknowledging healthcare professionals, policymakers, advocates, and stakeholders to design evidence-based strategies, preventive measures of intimate partner violence (IPV) aim to address the determinants and underlying factors associated with violence within intimate relationships. These include promoting gender equality, empowering women through education and economic opportunities, challenging cultural norms and perpetuating violence, raising awareness, and supporting services to victims. In summary, IPV is a significant healthcare concern due to the vast number of people impacted, the high costs associated with treatment, and the requirement for a multidisciplinary approach [8]. Understanding the scope of the issue and developing focused solutions requires a thorough examination of the prevalence, patterns, risk factors, and effects of interpersonal violence among married couples in Pakistan, which is what this systematic review focuses on.

2. MATERIALS AND METHODS

Three databases were thoroughly searched for this systematic review: PakMediNet, PubMed, and Google Scholar. Articles released between January 2018 and June 2023 were included in the search. MeSH (Medical Subject Headings) and non-MeSH keywords were used, including repercussions, Pakistan, married couple, determinants, marriage, interpersonal violence, and preventive techniques. We used the Boolean operators “AND” and “OR” to further narrow the search. In order to preserve coherence and concentrate on pertinent literature, pieces that were not published in the English language were not taken into account. To enable a more focused review of relevant research, all clinical trials (RCTs), meta-analyses, views, case reports, case series, and gray literature were excluded from the study selection procedure. Based on particular inclusion criteria, the articles were chosen from the pertinent databases. The paper’s publication date was within the previous five years. The defined geographic focus area included items pertaining specifically to Pakistan. Interpersonal violence in all its manifestations—physical, psychological, and sexual—was taken into account. Systematic evaluations, scooping reviews, commentary, and editorials were all included in the review. For all age categories, all IPV variables and their effects were considered, with a particular emphasis on women in married relationships. After the duplicate articles were eliminated, each of the four authors evaluated the titles and abstracts according to the eligibility requirements. The chosen articles then proceeded through the second stage, which involved a comprehensive reading and evaluation of their entire texts. The articles were assessed separately by two of the authors. The remaining author (S.A.) examined the articles to determine their eligibility in the event that there were any doubts or confusions. In order to extract the required elements, the researchers built a PRISMA flowchart by adhering to the PRISMA criteria. They carefully collected all relevant information while adhering to the selection criteria. The paper titles, authors’ names, and publication dates are all included in the summary table. The table provides specifics regarding the several forms of IPV, as well as its causes, effects, mitigation techniques, and impacted regions.

3. RESULTS AND DISCUSSION

3380 articles were found in the first search conducted using three databases: Google Scholar, PubMed, and PakMediNet. Thirty duplicate records were eliminated, leaving 1500 items for evaluation. The total number of publications was further decreased to 584 by applying exclusion criteria, screening titles and abstracts, and performing screening processes. Articles about unmarried couples, research done outside of Nepal, publications written in languages other than English, and those that named family members other than spouses as IPV perpetrators or victims were all excluded. After carefully reviewing the remaining papers, a final selection of 14 articles that satisfied the inclusion requirements was made. With an emphasis on women in married relationships, the inclusion criteria took into account all IPV determinants and their effects on both genders and all age groups. This included all subtypes of interpersonal violence, such as sexual, psychological, and physical aggression. Furthermore, the focus’s geographic scope was specified precisely, with a particular emphasis on publications that dealt with IPV in Nepal. In Pakistan, interpersonal violence—particularly inside marriages—is a common and gravely troubling problem. Even with advancements in a number of social and legal spheres, there are still cultural and historic norms that support the use of violence in intimate relationships. Approximately one third of women worldwide are victims of violence perpetrated by their spouses. This conversation attempts to investigate the root causes of interpersonal violence among Nepali married couples, the effects it has on people and society, and the steps that need to be taken to solve this pressing issue. “Physical harm, sexual misconduct, stalking, and emotional aggression (including manipulative strategies)” committed by a current or former domestic partner is defined as intimate partner violence (IPV) [1]. Furthermore, 18.8% of respondents finished their secondary school, 18.5% of respondents were poor, and 34.8% of spouses had completed their secondary education. Furthermore, according to 20.7% of respondents, their fathers used to beat their mothers, and 33.47% of them gave different explanations for why their spouses should have beaten them [13]. Due to the highly ingrained patriarchal ideals in Nepal, men are typically viewed as the dominating figures in households, which results in an uneven allocation of power and exposes women to abuse as spouses. It was stated that 52% of the women who experienced IPV did not seek assistance or notify anyone9. IPV is frequently more common in societies with inflexible gender norms and unequal power relations between men and women [19]. Conventional values that support male authority and control also play a role in the continuation of violence. Financial strain and reliance can exacerbate interpersonal problems and raise the risk of violence. Both the husband’s and wife’s families have an impact on marital conflict and IPV, and family structure and interference are important factors in both the occurrence and prevention of IPV [23]. IPV is remarkably common, and the differences between regions emphasize how important customs, norms, and culture are [24]. Abuse of alcohol and other drugs can intensify arguments and provoke violent behavior in relationships. Asian countries have high and rising rates of addiction, with alcoholism being the most prevalent type [25]. Misuse of substances plays a role in the emergence of mental health issues. People who suffer from mental health issues, such as anxiety, depression, or personality disorders, may be more likely to engage in or be victims of intimate partner violence [10, 18]. Acts of aggression and dominating behaviors can result from excessive jealousy and possessiveness. In order to mitigate this high frequency and protect Asia from the negative effects of addiction and substance abuse, awareness campaigns and community outreach are important [25]. The dynamics and results of intimate partner relationships can be influenced by child marriage and witnessing domestic abuse; these factors may also create an atmosphere that increases the likelihood of assault. Since, early childhood is the critical time for brain development. Any kind of harm to the brain during this time, whether it be psychological or physical, can have very detrimental effects [26]. It is possible to successfully control the occurrence of future IPV occurrences by taking a holistic approach to resolving this issue. Because arranged marriages often result in couples who do not know one another well before marriage, there may be compatibility problems and arguments that raise the risk of violence. IPV is more common in relationships where there is an unequal power arrangement, with one spouse controlling the other. The patriarchal culture of Nepal restricts women’s independence in their personal and social lives by emphasizing spousal duties and gender norms. Power disparities in society are exacerbated by traditional gender role assumptions that attribute submission and helplessness to feminine characteristics and authority and domination to male attributes [23]. Conflicts can turn violent when there is a lack of effective communication between parties and an incapacity to settle them amicably. Improving women’s life economically requires giving them access to property rights, work opportunities, and education. But in Nepal, obstacles and subjugation confront women, preventing them from achieving economic independence [27]. Several studies show that married women who meet certain educational goals and are independent are less vulnerable to gender-related consequences. Pakistani women may not be as financially independent as they could be since working outside the home is discouraged by social conventions. Because of their monetary reliance on their husbands, they may become targets of abuse and be unable to flee dangerous circumstances. When children witness violence between their parents, it can reinforce the cycle of violence, normalizing abusive behaviors and raising the possibility that they will abuse others or become victims in the future [13]. Furthermore, because of increased stress and trauma, areas undergoing armed conflict or political instability may have greater incidences of violence, including intimate partner violence (IPV). The societal shame and stigma that interpersonal violence victims frequently experience deters them from asking for assistance or reporting the assault. Many women who are abused physically are also abused sexually [27]. Suspicion about their character, physical abuse, spouses having extramarital affairs, and attempts to compel them into prostitution are the main types of violence that push women to seek safety in shelter homes28. People may be reluctant to confront their abusive partners out of fear of condemnation from their communities. Victims of interpersonal violence may experience severe psychological effects such as sadness, anxiety, trauma, and post-traumatic stress disorder (PTSD). The obstacles that victims trying to leave abusive situations must overcome are made even more difficult by these mental health conditions. In Pakistan, intimate partner violence (IPV) is quite prevalent, with emotional abuse outpacing physical abuse [18]. Events involving domestic violence and relationships outside of marriage lead to reflection and even self-harming behaviors. Sexual assault, harassment, social inequality, limited financial resources, and mental health conditions were significant contributors to the rise in suicide rates. The most vulnerable groups to suicide attempts were women, married people, and young people, underscoring the important connection between gender inequality, family strife, and despair that leads to self-harm [29]. When compared to individuals who are not affected by IPV, those who experience IPV also have a higher prevalence of depression [16]. Even though domestic abuse is illegal in Pakistan, there are still several obstacles to implementation and enforcement. A large number of victims are left without legal protection due to the absence of comprehensive law that explicitly addresses marital violence. Particularly in rural areas, the provision of support services like counseling and shelters is sometimes insufficient, making it difficult for victims to get the assistance they so desperately need. The way violence and unhealthy relationships are portrayed in the media has the power to influence societal views and habits. There may be a lack of sufficient training for many people, including law enforcement and medical professionals, to identify and handle situations of interpersonal violence, which results in lost opportunities for early intervention and support. Even though laws exist to protect women and give them the ability to report abuse, women’s economic dependency, vague ideas of ‘honor,’ little awareness of their rights, and society attitudes toward women frequently prevent them from getting the assistance they need [24]. To protect victims and hold offenders accountable, comprehensive laws against domestic abuse must be strengthened and put into place. It is possible to alter society perceptions and encourage healthy relationships by supporting awareness initiatives that question the condonation of violence in married couples. Furthermore, relationship education in schools could teach young people the value of different kinds of relationships, expectations in relationships, communication, and constructive ways to handle conflict and emotion [16]. It is imperative to enhance and broaden the availability of support services, such as counseling, helplines, and shelters, in order to aid victims in escaping abusive situations and starting over. Early interventions and victim assistance can result from teaching law enforcement, medical professionals, and social workers on how to identify and handle incidents of interpersonal violence. Further legislative changes are also required, but the role of healthcare services as a vital and accessible resource for assistance and support for abused women needs to be emphasized. As such, the problem of interpersonal violence in Pakistani marriages is complex, impacted by social, cultural, and economic variables. According to reports, between 70% and 90% of married women report having been the victim of violence by their intimate partners [30]. Finally, suggestions are made for improving the legal and social environment. Addressing intimate partner violence necessitates a multifaceted strategy that includes societal and structural reforms in addition to individual-level interventions. In order to effectively address IPV, it is imperative to promote a culture of respect, equality, and non-violence while providing victims with the necessary resources and support. The well-being of individuals and families is greatly impacted by this issue, making a holistic approach necessary. This approach should include legal reforms, public awareness campaigns, women’s empowerment, support services, and education and training for pertinent parties. Pakistan can only make headway toward ending the cycle of violence and fostering more wholesome and equal relationships within its society by working together. Certain limitations exist in the systematic review that looked at the causes of intimate partner violence (IPV) in Pakistan. Due to the use of broad keywords, it is possible that not all relevant papers were found using the search methodology. The focus on open-access articles may have unintentionally ignored important literature, which could have affected the range of findings. Furthermore, the caliber of user data may have had an impact on the conclusions’ dependability. Incorporating qualitative investigations would have enhanced the understanding of data coverage and yielded a more nuanced and thorough understanding of the topic.

4. CONCLUSION

In conclusion, gender-based domestic violence, often referred to as interpersonal violence among married couples in Nepal, is a serious and intricate problem that has a big impact on people’s lives, families, and society as a whole. With its roots in patriarchal ideas, traditional gender roles, and cultural norms, intimate partner violence (IPV) continues to be a significant problem in the nation, impacting the lives of countless men and women. It might be difficult for victims to leave abusive relationships because of the ubiquity of arranged marriages, collectivistic society, and economic reliance on spouses. The situation is made worse by a lack of comprehensive legislation, societal shame, and restricted access to support services, which deters victims from reporting violent acts and seeking assistance. The psychological effects of IPV are substantial and can result in trauma, anxiety, depression, and other mental health problems. Moreover, the violence-perpetration cycle can span multiple generations, including children who observe abusive behaviors in their households. Pakistan needs to tackle IPV from multiple angles. Legal reforms are essential to fortify current anti-domestic abuse laws and guarantee their efficient application. Campaigns to raise public awareness are essential to challenging the cultural norms that now accept violence in marriages. It is imperative that women be empowered through economic and educational possibilities in order to decrease their susceptibility and enhance their agency in making decisions.

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