Prevalence of co-occurring forms of intimate partner violence against women aged 15-49 and the role of education-related inequalities: analysis of Demographic and Health Surveys across 49 low-income and middle-income countries

Shuangyu Zhao; Shan Liu; Jiuxuan Gao; Ning Ma; Shaoru Chen; Joht Singh Chandan; Rockli Kim; Peter Karoli; John Lapah Niyi; Jayalakshmi Rajeev; Melkamu Aderajew Zemene; Md Nuruzzaman Khan; Hajirani M Msuya; Chunling Lu; S V Subramanian; Feng Cheng; John S Ji; Kun Tang; Pascal Geldsetzer; Zhihui Li

doi:10.1016/j.eclinm.2025.103150

Prevalence of co-occurring forms of intimate partner violence against women aged 15-49 and the role of education-related inequalities: analysis of Demographic and Health Surveys across 49 low-income and middle-income countries

EClinicalMedicine. 2025 Mar 18:82:103150. doi: 10.1016/j.eclinm.2025.103150. eCollection 2025 Apr.

Authors

Shuangyu Zhao¹, Shan Liu¹, Jiuxuan Gao¹, Ning Ma¹, Shaoru Chen¹, Joht Singh Chandan², Rockli Kim^{3

4}, Peter Karoli⁵, John Lapah Niyi⁶, Jayalakshmi Rajeev⁷, Melkamu Aderajew Zemene⁸, Md Nuruzzaman Khan⁹, Hajirani M Msuya¹⁰, Chunling Lu^{11

12}, S V Subramanian^{13

14}, Feng Cheng^{1

15}, John S Ji¹, Kun Tang¹, Pascal Geldsetzer^{16

17}, Zhihui Li^{1

15}

Affiliations

¹ Vanke School of Public Health, Tsinghua University, No. 30, Shuangqing Road, Haidian District, Beijing, PR China.
² Department of Applied Health Sciences, University of Birmingham, Birmingham, United Kingdom.
³ Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, Republic of Korea.
⁴ Division of Health Policy and Management, College of Health Science, Korea University, Seoul, Republic of Korea.
⁵ National Institute for Medical Research, Dar es Salaam, Tanzania.
⁶ Ghana Health Service, Gushegu Municipal Health Directorate, Gushegu, Ghana.
⁷ Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, India.
⁸ Department of Public Health, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia.
⁹ Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.
¹⁰ Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Tanzania.
¹¹ Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
¹² Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States.
¹³ Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, United States.
¹⁴ Harvard Center for Population and Development Studies, Cambridge, MA, United States.
¹⁵ Institute for Healthy China, Tsinghua University, 100084, Beijing, China.
¹⁶ Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
¹⁷ Chan Zuckerberg Biohub - San Francisco, San Francisco, CA, USA.

Abstract

Background: Women experiencing co-occurring forms of intimate partner violence (IPV; ie, physical, sexual, and/or psychological) often face more severe psychological and health consequences than those experiencing a single form. However, research on IPV co-occurrence in low- and middle-income countries (LMICs) remains limited. This study examines the prevalence of IPV co-occurrence in LMICs and its education-based inequalities.

Methods: Data from the most recent Demographic and Health Surveys in 49 LMICs (2011-2023) were used. Our primary outcome was IPV co-occurrence, defined as a woman aged 15-49 ever experiencing any two or three forms of physical, sexual, or psychological IPV from her partner within the past year. We categorised IPV co-occurrence into four subtypes: co-occurrence of (1) physical and sexual IPV, (2) physical and psychological IPV, (3) sexual and psychological IPV, and (4) all three forms of IPV. We analysed the prevalence of IPV co-occurrence and its subtypes by women's education levels, calculating odds ratios to assess inequalities. Nonparametric restricted cubic splines were used to explore nonlinear relationships between education and IPV.

Findings: The study included a total of 344,661 women. The weighted prevalence of IPV co-occurrence varied widely across countries-from 2.4% in Armenia to 38.9% in Papua New Guinea. Overall, women with no education were most at risk, experiencing an adjusted prevalence of 14.3% (95% CI: 13.3-15.2), compared to 11.8% (95% CI: 10.8-12.9) among those with primary education, 9.9% (95% CI: 9.3-10.6) for secondary education, and 5.3% (95% CI: 4.5-6.2) for higher education. The prevalence of IPV co-occurrence involving sexual IPV was highest among women with primary education, with 4.1% (95% CI: 3.4-4.8) reporting concurrent physical and sexual violence, compared to 1.5% (95% CI: 1.1-1.9) to 3.7% (95% CI: 3.2-4.1) among other education levels.

Interpretation: IPV co-occurrence remains high, particularly among women with little or no education. Education-focused interventions are urgently needed to reduce IPV risk and its severe impact. However, the findings may be influenced by potential reporting biases and cross-country variability in IPV measurement methodologies, which may limit generalizability.

Funding: The China National Natural Science Foundation (Grant numbers 72203119) and The Research Fund, Vanke School of Public Health, Tsinghua University.

Keywords: Education-based inequality; Intimate partner violence co-occurrence; Low- and middle-income countries.