economic costs of domestic violence: a community study in south africa

HealthMED - Volume 5 / Number 6 - Suppl. 1 / 2011

Journal of Society for development in new net environment in B&H 1931

The present study estimated economic costs of domestic violence against women who sou-ght help from a community care centre in South Africa. It aimed to relate the victims’ income and victims’ family income to violence related inju-ries and related costs. This was a cross sectional study with face-to-face interviews in a community care center in which victims of domestic violence sought various kinds of assistance. In total, 261 women were interviewed. The average economic cost of each domestic violence incidence was 691 USD while average cost for medical expenditure was 29 USD and average loss of income due to

-es and higher individual and family incomes were protective factors for severity of violence related injuries. Pain and discomfort due to domestic vio-lence emerged as expensive for both medical costs and productivity losses. Considering the average monthly income of 482 USD, domestic violence averaged a cost per incident of 691 USD during

-hold budget. We found that domestic violence against women resulted with expensive injuries, pain and discomforts.

economic costs, violence against women, IDDO model, South Africa.

Introduction

Violence is one of the most expensive public health problems globally 1 – 5 -come countries account for more than 90% of vio-lence related health and socioeconomic burden6. The WHO and others have indicated that cost calculation and economic analysis of violence,

particularly in low-income countries, should be a prioritized task in the policy-making process3,6. In addition, health economists have strongly ad-vocated for methodological improvements in the cost calculation of violence, particular in low-income countries3, 7. Furthermore, WHO’s multi-country study advocates for more studies due to the gaps in research on violence against women, particularly in relation to intimate partner violence in developing countries8. Stopping violence against women is a social

responsibility and not doing this is a violation of women’s human rights9. Societies are obligated to provide protection of their women and to provide counseling for them10. Furthermore, societies are expected to provide police servcies, as well as ju-stice systems for these women11. Domestic violence results in different physi-

cal and psychological health problems. A high number of physically abused women have injuries

-ing bruises, wounds, pelvic pain, back pain, head-aches and fractured bones12 -14. Physically abused reproductively active women also encounter gy-naecological problems including terminated preg-nancies, low-weight babies, peri-natal deaths and sexually transmitted diseases such as HIV/AIDS 8, 13, 15 -17. Psychological consequences of women victims of domestic violence are depression, anxi-ety, low self-esteem, fear of intimacy and post-traumatic stress disorder 12, 13, 18, 19. Besides physi-cal and psychological problems, female victims of violence exhibit risk-taking behaviours like un-healthy feeding habits, substance abuse, alcohol-ism and even suicidal behaviours12, 19, 20. Abused women also use higher proportion of community and healthcare services4, 12, 19. However few stud-ies have examined the economic consequences of domestic violence3, 6, 8, 21.

Koustuv Dalal1, Suraya Dawad2

1

2

1932


Journal of Society for development in new net environment in B&H

In South Africa, a ‘culture of violence’ is a strong pervasive feature of post-apartheid lega-cy, which often induce violence against women22. Studies suggest that there are relatively high le-vels of acceptance of domestic violence in South Africa23. One in every four women has experi-enced physical violence at some stage in her life24. Those subjected to violence, particularly violence against women, are often afraid to report this to legal authorities or friends and family because of fear of social stigma and the wide level of social acceptance of violence4, 25. Domestic violence and gender-based violence aimed at women is high across all economic and racial groupings26. Several studies have reported on risk factors

and social consequences of domestic violence1-5, 27- 29. However, less information is available on the economic costs of domestic violence against wo-men, though policy makers may be better convin-ced by monetary values for adopting preventative strategies3, 4. In particular, knowledge is lacking about the cost of domestic violence in relation to injuries. Yodanis and his colleagues argue that the cost for acts of physical, sexual, and psychologi-cal abuse against women and children falls on the victims, their friends, relatives, and employers 9. Furthermore, governments also “incur” expenses in terms of their justice and legal systems, medical and social systems, refuge and support, re-housing and public assistance9, 1. Several studies have indicated that identifying

the victims of domestic violence, especially in the developing countries is a methodological problem

violence2 -4. Furthermore, the victims of domestic violence in the developing countries are reluctant to disclose the information regarding their victimi-zation in absence of regular screening at the health care facilities3. The Chatsworth Community Care

-ded the unique opportunity to study the victims of domestic violence. CCCC is the only communi-ty care centre at the big community, Chatsworth, providing services to the victim women for more than a decade and is well acquainted with the trust of the women regarding their private issues30. This current study aimed to estimate economic

costs of domestic violence against women who sought help from a community care centre in Sou-

th Africa. It also aimed to relate the victims’ inco-me and victims’ family income to violence related injuries and related costs.

This was a cross-sectional study that was un-

Africa. For this study, only related costs and inju-ries due to violence against women were conside-red in the current study. The study was conducted during August – October 2008.

Study AreaChatsworth is a large township within the Dur-

ban Metropolitan area, which was created during the apartheid regime, as an area for housing pe-ople of ‘Indian’ population. It remains predomi-nantly inhabited by the Indian population, and in-formal settlements in and around Chatsworth pro-vide housing for refugees and other black urban populations. The total population of Chatsworth is approximately 750 000.

Chatsworth Community Care CentreIn 2002 the Institute for Security Studies pu-

blished Violence Against Women, exploring women’s experiences of gender-based violence in South Africa 26. This highlighted the limited sup-port women received from police, government de-partments and the healthcare sector and the crucial

in providing counseling and support for survivors of domestic violence 26. Chatsworth Community

-vides counseling and a wide range of support for victims of domestic violence in Chatsworth 30.

Study populationIn absence of registry data a complete list of wo-

men who have been victims domestic violence is unavailable in South Africa. All female victims of domestic violence who visited CCCC for rendering any sort of service constituted the study population. Average number of women who sought assistance from CCCC per month is between 500 and 550. We used the WHO guidelines and terminologies to

2.



Sampling techniqueTo identify their economic losses and severity

of injuries as a result of domestic violence, victims who sought the services of CCCC were intervi-ewed. Every second female victim who visited CCCC was selected for the study and interviewed

Research InstrumentsStructured pre-tested questionnaires with clo-

se-ended questions were administered by CCCC volunteers. Questions were asked regarding vic-tims’ age, education, number of family members, income, severity of injuries, expenditure for trea-tment, victims/relative’s loss of income due to the

costs. Questions were asked about family income, mode of income and family economic issues. Se-

--

and visited medical doctor or hospital emergency -

mitted to hospital2. However in absence of health care set up including trained nurses and physici-ans, we had relied on victim’s report on injuries, pain and discomfort and could not use established

to measure injuries. The questionnaire regarding economic elements was validated and used in pu-blished literatures3, 31.

Data collection proceduresData were collected by the volunteers at CCCC

over a period of 3 months (August – October

and counseling to the victims of domestic violen-ce at CCCC for the previous 10 years. They were further trained to administer the questionnaire and conducting the face-to-face interviews.

Variables of interestThe following variables were used: age group,

education, number of family members, victims in-come, family income, mode of income, per capita family income, total medical costs, income loss due to victimization of domestic violence.Severity of injury due to domestic violence

-

Injured and visited medical doctor and admitted to

did not visit medical doctor.In South Africa the education system has the

following grades: No education, Primary educati-

-

Cost calculationsAs the study consisted of a sample of women

who had experienced domestic violence, the co-sts accounted for here were based on their injury severity, pain and discomfort. For each category the victims were asked about the amount spent for treatment and related loss of income. As South Africa has no registry system like the Scandinavi-an countries, the authors had to rely on self repor-ted information. The counselors of CCCC were regarded as trustworthy in the eyes of victims who sought assistance for handling such personal information for more than a decade30. Therefore, maximum disclosure of fact by the victim was hi-ghly expected. According to researchers, there different met-

hodologies are use to measure direct and indirect costs: proportionality, econometric and accoun-ting3, 32. The current study employed accounting methods for estimating the costs3. The average

-mestic violence incidence.Cost elements in the study were for previous 30

days from the date of interview. All the monetary

Statistical analysisHealth economic analysis of violence and inju-

ries had not developed many instruments to mea-sure the costs. Most commonly used instrument is

suggest that no amount of statistical analysis is probably able to compensate for poor quality of cost data presented in simple statistics33, 34. There-fore for cost estimation we mainly used arithmetic mean, mode and standard deviation. After esti-mating the cost elements, the study grouped them

1934



according the quartile distribution for better stati-stical analysis.

performed to examine the relationship between severity of injuries due to violence and demograp-hic and economic variables.A pie-diagram was used to represent the sour-

ces of money for treatment of victims of violence.SPSS version 18 was used for statistical anal-

ysis.

Ethical permissionThe study received ethical permission from the

Human and Social Sciences Ethics Committee of

the research adhered to the strict guidelines set out for research into domestic violence by the World Health Organization35.

Every measure was put in-place to make certain that respondents granted us informed consent be-fore being interviewed. Verbal consent was obta-ined from the respondents. Due to literacy pro-blem we could not seek written consent from the respondents. In all cases, autonomy, privacy and rights of withdrawal were maintained. CCCC was involved in all aspects of arranging and managing interviews and was available to provide counse-ling to any of those interviewees who required it.

Among the 261 respondents, 44% of the wo-men had minor injuries (injured but did not visit

-red and visited medical doctor and/or hospital

Table. 1. Demographics of violence related injuries, pain and discomforts

medical doctor

- -tor and admitted to

Age group

Total = 261

57124755344570402537

2982128293020202537

761362118

101313

Education

Total = 261

52304325

13442950

131313

No. of family members

Total = 222

13343116 6

11343416 5

13383312 4



and 17% had pain and discomfort due to violence. The average cost per incidence for visiting

-

-tal medical expenditure per incidence was 28.89

income due to victimization of domestic violen-

the total cost of domestic violence incidence was

Women in their thirties were most affected by domestic violence (Mean Age = 35.58, SD =

are concerned, women in their late forties (45 -49

-

-

Women with no education suffered the most

primary education suffered most from moderate

most from violence related pain and discomforts.

four members’ in their families. More than 70% of women responded about

their family income and almost 58% provided res-ponses about their personal income. Respondents’ monthly average income was 481.64 USD (3400

mode average monthly income was 133.16 USD -

pita family income (= total family income/ number

Table 2. Victims individual and family income per month and injury victimization

medical doctor

medical doctor doctor and admi- -

Victims income pm p=0.0441271022

37262611

4534714

49271113

Family income pm p= 0.024626325

40291417

49281013

44301016

Mode of income p= 0.0448221614

40301317

2728817

40153015

Per capita family income p=0.085026717

36291322

5024917

44281117

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-gher family size had proportionally less exposure to violence related injuries, pain and discomforts. The lower was the income, higher was the

-portional inverse relation between family income and injury and utilization of medical facilities was observed. Women who were sole providers in the family were affected the most in terms of violence. With regards to medical costs that victims had

to pay themselves, the average, was 28.89USD ( -

the victims of domestic violence paid (out of poc-

for physicans, 30% on purchasing medicines, 7% on medical investigations such as x-rays, blood tests, 24% on transport to visit medical facilities. The majority of the victims had spent up to 16.85

high enough with an average loss of income of

Among the respondents, 150 women had some

Table 3 indicates that 54 – 92% of female victims

Women from higher income groups had spent proportionally more for higher amount of medical

women from higher average family income had

Table 3. Relationship between economic losses and injury severities

medical doctor

medical doctor doctor andadmitted to

Total medical costs p= 0.0027461611

82639

6314023

24471316

Income loss p=0.022727 937

46181818

316180

4118410

Table 4. Relationship between economic losses and per capita family income of the victims

n

Per capita Per capita Per capita Per capita

2666 & Above

Total medical costs p= 0.0128321822

402824 8

19153333

11112256

Income loss p= 0.0325372513

0173350

11111167

20 0 080



highest proportions of income loss due to dome-stic violence.

own medical costs. Only 20% victims had received

Figure 1. Financing sources of medical trea-tments for injuries due to domestic violence

This study tried to estimate the cost burden of domestic violence from a community care centre where victims of violence seek assistance. Avera-ge economic cost of each domestic violence inci-dent was 691 USD, while average cost for medi-cal expenditure was 29 USD and average loss of income due to domestic violence was 2092 USD. Women in their 30s were most affected by do-

mestic violence. This could possibly be attributed to the fact that these women are ages when they are reproductively active, and need to negotiate issues around contraceptive use, protected versus unprotected sexual intercourse etc. This, at times could become quite contentious resulting in vio-

from Africa and Asia4, 13, 26, 27, 36, 37. Proportionally, women with no education suf-

those with primary education suffered most from

suffered most from violence related pain and dis-comfort. This is in line with previous studies in which higher education was associated with less

violence4, 8, 27, 36. We concur with the reasons offe--

cation might have more choice in partners and mi-ght be able to choose to either get married or not, and are probably able to negotiate more control and autonomy within the marriage. Women with higher education might be able to view things in a different light compared to those who were not

those with higher education are more literate and

those with lower education do not perceive certain acts to be violence against them and hence do not report them as such. Hence, it appears that educa-tion has a protective effect not only on violence in-cidence also on economic losses due to violence. The study also considered the number of fami-

ly members in the household. It appears that as the number of family members in the household increases, the number of incidences of violence decreases. This could be that too many people or senior members in the household serves as a de-terrent to perpetrators of violence. Those who reported lower personal and family

income were more likely to report being victims of violence. The main reason here was that lack

violence2, 4, 8, 19, 36, 37. Usually, lack of money le-ads to frustration, which may translates into vio-lent attacks. In the home, victims of these violent

-men in poorer families more than it affects their richer counterparts2, 4, 8, 24. Women who are sole earners in the family were at highest risk of being victims of domestic violence. When the husband can not earn or receive economic support from his wife, the situation might hurt his ego which indu-

study from India 38. Since Chatsworth is predomi-nantly occupied by people of Indian origin, simi-lar socio-cultural beliefs might be adopted among those families where economic empowerment of women is not willingly warranted. Pain and discomfort were major problem for

victims of domestic violence. Proportionally they constitute highest numbers for both medical ex-penditures and for income loss. However, psycho-logical aspects of domestic violence have multipl-

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a long-term policy implication because economic loss for pain and discomfort generated from do-

victims themselves or by relatives. This study also -

nanced by perpetrators. This study had some limitations. The answers

to questions might have been affected by recall bias. The study has also potential social desira-bility bias, and response bias particularly for the SES measures. Economic elements of domestic violence are not normally distributed as the high values of standard deviations indicated large vari-ation. Also health economic analysis of cost ele-ments support the concept that as health impact varies among human beings, cost elements do not exhibit normal distribution 39. The study did not consider the societal costs such as hospital costs, judicial costs and police costs. The study was con-ducted in a suburb of Durban. A nationwide study is required in South Africa to estimate the eco-nomic costs of domestic violence better. The study used a convenience, help-seeking sample, and was thus not representative of female violence victims. Furthermore, we do not know what percentage of those women approached for participation in the

were apparent between participants and non-par-

registry data. Actual prevalence of violence aga-inst women is unknown in the study area or even in South Africa in general. In the absence of regi-stry or household survey the best way to estima-te domestic violence and related cost identifying victims from hospital records, police records, and women service centers 3, 4. However, such samples may well not be representative of the female po-pulation in South Africa, or even of all abused vic-tims. Given the focus of the research, it is especi-ally important that this was a highly economically marginalized sample who sought help as victim. Surveillance of violence and injuries at health care facilities and community service centers is recom-mended which is effective for better estimation of incidence and cost41.

Considering average monthly income of 482

women seems to be very expensive as the average

the home being the place where most violence

haven for women. Steps need to be taken to revert to the home being a safe haven. It has been evi-denced that economic empowerment with higher education of the women are protective factor 2, 8, 40. Therefore policy makers can emphasize on those protective issues. The cumulative effect of abuse and violence was noted in the WHO study in whi-ch the recent experience of ill-health was associ-ated with a lifetime of violent experiences 8. This adds to the notion that violence does not have a once time price to be paid, but rather the effects can be felt years down the line. Hence, one act of violence today could lead to various episodes of ill-health in the future.Studies looking at economic costs of violence,

like this study, can aid in the promotion of social policy and reduction of violence against women. Findings of studies like these illustrate how vio-lence against women has the potential to adver-sely affect governments, businesses and families

potential to encourage policy makers and decisi-on makers to address the issue of violence against women, thereby reducing their own costs as well.



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Corresponding author Koustuv Dalal, Department of Public Health Science, School of Life Sciences, University of Skovde, Sweden, E-mail: [email protected]

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economic costs of domestic violence: a community study in south africa

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