Social Science & Medicine 55 (2002) 13851399

Whos at risk? Factors associated with intimate partner violence in the Philippines
Michelle J. Hindina,*, Linda S. Adairb
a

Department of Population and Family Health Sciences, The Bloomberg School of Public Health, The Johns Hopkins University, 650 N Wolfe Street, E4139, Baltimore, MD 21205, USA b Carolina Population Center, University of North Carolina, University Square, CB#8120, 123 West Franklin Street, Chapel Hill, NC 27516, USA

Abstract We describe the individual and household characteristics associated with intimate partner violence (IPV) in the Philippines, using data from the Cebu Longitudinal Health and Nutrition Survey (CLHNS). We also examine 56 indepth interview transcripts to explore the context of IPV. We focus our analysis on patterns of household decisionmaking as a measure of the interpersonal dynamics between husbands and wives. Thirteen percent of women in our sample reported IPV. While economic factors are often implicated in the cycle of violence in households, we nd employment status and relative earnings do not predict IPV. Lower levels of household wealth and urban residence are associated with a higher likelihood of IPV. Patterns of household decision-making emerge as strong predictors of violence. The greater the number of decision-making domains men dominate, the more likely they are to use IPV; however, we also nd that when women dominate household decisions, they are also more likely to experience IPV. Only 6% of women reported IPV when all household decisions were made jointly compared to 25% when no decisions were made jointly. r 2002 Elsevier Science Ltd. All rights reserved.
Keywords: IPV; Abuse; Gender relations; Decision-making; Philippines; Domestic violence

Introduction Violence against women is a serious public health concern and recognized as a global health problem. Violence against women is as serious a cause of death and incapacity as cancer and a greater cause of illness than trac accidents and malaria combined (World Bank, 1993). It is estimated that at least 20% of the worlds women have been physically or sexually assaulted by a man (World Bank, 1993) and that between 16% and 52% of women have been physically assaulted by an intimate partner (WHO, 1997). Despite the prevalence of intimate partner violence (IPV), few studies have examined what happens in the household to spark spousal violence, although the relationship
*Corresponding author. Tel.: +1-410-502-6038; fax: +1410-955-2303. E-mail address: mhindin@jhsph.edu (M.J. Hindin).

between selected measures of womens autonomy and IPV is starting to be explored (Koenig, Hossain, Ahmed, & Hagga, 1999; Jejeebhoy & Cook, 1997). How couples negotiate decisions, both large and small, may be an important risk factor for IPV.1 We use the term IPV throughout this study. There is a substantial body of literature that describes the variation in denition and measurement issues (for a good summary see Desai & Saltzman, 2001). While IPV can include emotional, psychological, and sexual violence, the current study focuses only on physical violence.

1 We use the term IPV throughout this study. There is a substantial body of literature that describes the variation in denition and measurement issues (for a good summary see Desai & Saltzman, 2001). While IPV can include emotional, psychological, and sexual violence, the current study focuses only on physical violence.

0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 2 7 3 - 8

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Patterns of household decision-making characterize the interpersonal dynamics between husbands and wives. Interdisciplinary research has focused on the reasons why one spouse may dominate decision-making (Blood & Wolfe, 1965; Blumberg, 1991) and how within families, when one individual decides for others, they may not consider the well-being of all family members (Sen, 1990; Thomas, 1990; Dwyer & Bruce, 1988). Few studies have looked at the impact of spousal domination of decision-making on the well-being of women. Researchers are beginning to explore impact of patterns of decision-making on the well-being of women (Hindin, 2000a), reproductive health and decision-making (e.g. Hindin, 2000b; Basu, 1996; Gwako, 1997), and some measures of womens status are being explored in connection with IPV (Koenig, Hossain, Ahmed, & Hagga, 1990; Jejeebhoy & Cook, 1997; Heise, Ellsberg, & Gottenmoeller, 1999). In addition, a recent review of the literature on IPV suggests that understanding the origins and dynamics of dierent kinds of control in relationships will lead to progress in understanding domestic violence... (Johnson & Ferraro, 2000, p. 955). In this study, we explore the social factors related to IPV, including domination of household decisions. We aim to determine whether gender relations in marriage are related to IPV in the Philippines. Womens economic empowerment and IPV It is theoretically plausible that womens economic empowerment through the process of development may be linked to IPV. On the one hand, women who earn an income and help themselves and their families have means to get out of a bad marriage or not to marry at all. When women have more options, this should decrease the likelihood of their being in an abusive relationship. Kabeer (1999, p. 149) suggests that poor women are often most vulnerable to violence because they are most exposed to the risk of violence and least able to remove themselves from violent situations. On the other hand, womens economic empowerment may promote male insecurity and feelings of economic inadequacy, leading to more violence in relationships. In support of the idea that economic empowerment can decrease IPV, Blumberg (1991) provides evidence that having their own income improves womens ability to have say over fertility preferences, input into household decision-making, and self-esteem. Accordingly, when women feel empowered, they are better able to take action at the household level to improve their own and their childrens well-being (Blumberg, 1991). Further, outside the household, they may bring issues of concern to women, such as domestic violence, to the forethrough mobilization of womens groups, political organization, and media coverage. (e.g. Rakowski, 1991). In India, Rao (1997) nds that even after

controlling for total household income, that the greater the wifes income, the lower the likelihood that she will be beaten. In contrast to the inverse association between womens economic empowerment and domestic violence, Blumberg (1991) also points to evidence that as women gain more domestic power due to earned income, they may also face resistance and violence from their spouses (see Roldan, 1988 for evidence of violence in households where husbands are unemployed and women are employed). Oropesas study of Mexican households shows that in households where women are sole or dual-earners, there is no more or less violence than in households where husbands are the breadwinners, providing evidence that there is no relationship between womens economic empowerment and abuse. He does nd that when both spouses are unemployed there is a greater risk of violence. However, Oropesa (1997) does not look separately at models where the women are the sole earners, where there may, in fact be more IPV. Theoretical framework A report issued by the National Research Council (1996) suggests that a wide range of factors are implicated in the cycle of violence against women. However, these factors cannot be considered in isolation. The report suggests that multiple causes need to be considered at once and these causes can range from the individual to the macro-level. Dobash & Dobash (1998) suggest that the theoretical advances in the quest for an explanation of violence against women have often been narrowed by disciplinary lines. They highlight the importance of mixed methods of gathering data as well as the importance of taking a context-specic approach. In our study, we incorporate both qualitative and quantitative methodologies to provide a couple-level context of violence. We consider the status of women at the national or society level as well as their status within the household. We explore household decision-making within couples as an indicator of power relations between men and women. We feel that deviations from the normative marital dynamic, as described below, may result in more reports of IPV. Womens status and household decision-making in marriage in the Philippines On the surface, the public image is that women have high status relative to men. According to Licuanan (1993, p. 259), observing the highly visible women in Philippine society, including a woman president, women in Congress, in the Supreme Court, and in the Cabinet as well as in business and the private sector, most Filipino men (and women) sincerely believe that Filipino

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women enjoy equal status to men. In addition to their public presence, legally, women are seen as equals to men. Womens educational attainment is quite similar to mens, unlike the situation in many developing nations. Despite this visible evidence of equality, gender relations within households and families may vary. Based on the results of a ve-country study, Mason (1996) concludes that women in the Philippines have more autonomy than most Asian women. Historically, it appears that women in the Philippines had substantial power within their households, particularly in comparison to other women in Asia. Alcantara (1994) and Medina (1991) describe evidence of egalitarian relationships pre-colonization. They also point out that some of womens roles were undermined with the arrival of the Spanish and Christianity. Medina (1991, p. 151) points out that, compared to other Asian women, a Philippine woman has a relatively high and respected position which dates back to the pre-Spanish era when customary laws gave women the right to be equal to men... Womens status in the household may be tied to womens legal standing. Historically, women had little recourse if they were in a problematic marriage. In recognition of the needs of women in marriage, the Family Code (art. 55), enacted in 1988, recognized a host of reasons, including physical violence, as grounds for legal separation (Feliciano, 1994). While today the husband is considered the legal head of the family, in a review of numerous studies, Medina (1991) and David (1994) show that most studies nd that joint decisionmaking is the norm in Filipino homes. Even within the norm of joint decisions, there is often a clear division or specialization of mens and womens roles. For example, both Alcantara (1994) and Medina (1991), conclude that women have the power to decide about nancial resource allocation and are seen as treasurers of the household. Additional evidence of the norm of joint decisionmaking with specialization is shown in the work of David (1994) and Alcantara (1994). David (1994) nds that in examining individual domains, decisions about the household budget allocation are consistently dominated by the wife and decisions about family nances and investments are dominated by husbands. The author suggests that these results reect one member of the couple deferring to the other, who is supposed to have more skills in the area. David (1994) shows that women with more education have more inuence in the nancial and family planning realm, while education increases husband involvement in the household budget. As for family planning use, men more often have nal say, however, David nds that women do not necessarily accept their spouses authority. Alcantara (1994) nds similar results to David (1994) using a dierent data set. Using the domains of resource allocation and fertility,

the author nds that decisions are generally made jointly. Surprisingly, these results are not mediated by income or relative income and only moderately associated with womens education. The data also show that parity is a key factor in womens ability to contribute to fertility decisions. A recent study (David, Chin, & Herradura, 1998) in the Western Visayas region of the Philippines shows that IPV is related to womens employment status, with one in three of the working or socially active women surveyed reporting abuse (David et al., 1998). Based on gender relations in the Philippines, we explore how decision-making is related to IPV. Given the history of joint decision-making, we expect that couples with this normative pattern of gender relations are least likely to have IPV. In addition, we expect that in couples where men dominate more of the household decisions, women will experience more IPV due to unequal power relations in the household. Based on the IPV literature in the developing world, it would seem that women who work may be at greater risk of IPV. Frequency of violence in the Philippines The 1993 Demographic and Health Surveys (DHS) included a nationally representative Safe Motherhood Survey on the reproductive health of women in the Philippines, with a series of questions on IPV (National Statistics Oce & Macro International, 1994). Nationally, 10% of women reported that someone (including a family member or friend) hit, slapped, kicked or physically harmed them and the highest regional rate (18.9%) was reported in the Central Visayas region, which includes Cebu Province where our study was conducted. Eight percent of the women in the Central Visayas reported that the person who harmed them was their spouse, and most of these women (62%) said that the violence only happened once or twice. The rates for being physically harmed while pregnant were also highest in the Central Visayas (5.5% compared to 2.8% on average). Almost 4% of women in this region report being raped (as compared to almost 3% nationally). In this paper, a host of factors that could be associated with IPV are considered. In addition to demographic variables, we consider the possible relationship between abuse and household income distribution to assess the possible relationship between womens economic empowerment and IPV. We also consider relationship issues and autonomy in household decisionmaking. We are particularly interested in the possible link between patterns of household decision-making and abuse since decision-making is a valuable indicator of the interpersonal dynamics between husbands and wives. Household decision-making is thought to be an

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important factor in a wide range of marital outcomes from fertility related behavior (Mason, 1984; Jejeebhoy, 1995) to womens nutritional well-being (Hindin, 2000a). In particular, we explore how either spouses domination of household decisions is related to physical abuse of women to determine whether womens empowerment protects against or promotes abuse. We explore these relationships in Cebu, Philippines, where women have an unusually high level of autonomy in decision-making, particularly compared to other women in Asian countries.

Methods Study setting and sample This study is part of the Cebu Longitudinal Health and Nutrition Survey (CLHNS) which has followed a cohort of women since 1983. The CLHNS initially recruited all pregnant women in 33 randomly selected urban and rural communities of Metro Cebu. As the second largest metropolitan area of the Philippines, Cebu has a population of nearly two million. Women were followed intensively for two years after giving birth, then re-surveyed in 19912 and 19945 (See Cebu Study Team (1991, 1992) for further details of the study design and sample). The 19945 survey included 2279 women (68% of original participants), with 2133 reporting that they were currently married at the time of the survey. The present study focuses on 2050 currently married women from the 1994 CLHNS, which is the rst round to contain questions on IPV and household decision-making. Of the excluded women, 15 were never married, 69 were widowed and not remarried, 62 were separated, and 83 had husbands who were not included in the household rosters because they were not regularly in the households at the time of the interviews. Since the decision-making dynamic for couples with an absent spouse are likely to be quite dierent than for couples where the husband is generally present, we excluded the households with absent husbands. A subset of 60 CLHNS participants were purposively selected for an additional set of three, two-hour in-depth interviews. Thirty cases each were selected from both rural and urban areas, and were distributed among the 33 barangays sampled in the CLHNS. Following the 1994 CLHNS interviews, a list of women in each barangay was generated. Women were randomly selected for interviews based on a further stratication of family planning use and parity. Only ve of the selected women refused. Two had employment constraints, one was uncommunicative, one discontinued participation, and one was not sure she would remain in her home long enough to complete the interviews (Avila & Perez, 1999).

The in-depth interviews lasted between ve to seven hours and the interviewers were given a guide of topics to be covered. Interviews were transcribed in Cebuano and translated to English. Of the 60 interviews, 56 were included in this analysis since four of the women were not married at the time of the survey (three were divorced and one was separated). These interviews were analyzed and coded by the authors. We read for patterns of conict within the couple and noted incidents of violence. Of the 56 women interviewed, nine reported abuse. Despite the selectivity of the sample, a paper comparing the in-depth interview sample to the CLHNS nds that samples are demographically similar in regards to age, occupation, and other characteristics. In addition, the authors found consistency in the womens reports on the same questions from both the in-depth interviews and the surveys (Avila & Perez, 1999). Instruments Interviews were conducted in the homes of respondents by highly trained and experienced interviewers. Many of the sta have worked on the survey since its inception. All rounds of the CLHNS include modules on household composition, income and assets, environment, patterns of work and time allocation and income, pregnancy history and family planning, and a wide range of maternal and child health outcomes. The 1994 CHLNS included an additional module with questions about household decision-making, womens status and IPV. The in-depth surveys were open-ended, but followed an interview guide to focus discussion of courtship and marriage, childbearing, family planning, and womens decision-making. Denition of main outcome variable The household decision module contained three questions concerning physical violence: (1) When your husband gets angry, does he physically hurt you?; (2) What usually causes him to get angry whenever he hurts you?; (3) How many times does this happen in a year? There were no substantial dierences in characteristics of women or in the association of risk factors to violence related to frequency. Therefore, for simplicity, we use a dichotomous measure of IPV (any versus none) in the analyses. Measures of independent variables The decision module asks who in the household decides about: buying the wife shoes, buying the childrens clothes, the childrens schooling, taking children to the doctor, gifts for relatives, major household purchases, buying or selling land, the wife working

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outside the home, the wife traveling outside Cebu, using family planning, and family planning method choice. For each decision, women were asked: (1) Do you consult with someone when you have to decide on this matter? If yes, who do you consult?; (2) Whose will prevails on this matter? Most decisions involved husbands and wives having the nal say, with only a small minority involving other household members. Since we are interested in the dynamic between husbands and wives, we focus on three categories of response: the woman has the nal say, the husband has the nal say, or the couple decides together, and ignore other decision-makers. In addition, we created three indices. The rst measures the number of major decisions in which the husband has the nal say alone. The items included in this index are major purchases, buying or selling land, say over the wife working outside the home, whether the wife can travel outside Cebu, use of family planning, and method choice for family planning. These seven dichotomous items (1=yes, 0=no) were added together to form a summed index ranging from 0 to 7. An identical index was developed for the number of times the women have the nal say alone in these same decisions. A third index measures the number of items in which the couple jointly makes the nal say in all the decisions (eleven items, see Table 2) listed above. For multivariate analyses we standardized the indices (by dividing by the number of items in the index). Missing values occurred most often when the named decision was not made in the household. If respondents were missing on any one question, we coded them as missing for the indices. To better understand the factors related to spousal domination of decision-making or joint decision-making, we model the decision-making indices as dependent variables, as well as independent variables in the models including IPV. Residence was classied as rural or urban, and household wealth was represented as the mean number of selected items in households (iron, TV, VCR, refrigerator, electric fan, bicycle, living room set, air conditioner, bed, bed with mattress) and whether or not the house had an electrical connection. Other demographic variables included the wifes age (2658), the husbands age (1969), the number of grades the wife and husband completed in school (019), whether or not the wife and husband work for pay (yes or no), and the wifes and husbands church attendance (never, occasionally, about once a month, about once a week, and more than once a week). The survey also asked questions concerning how money is allocated in the household. We determined the wifes contribution to the household income (p50% or >50%), whether the husband turns over all earnings to the wife as is culturally expected since women are usually in charge of household budgeting (yes or no), whether the husbands earning are enough for the

household expenses (yes or no) and the amount of money spent on a weekly basis on alcohol (none or some). We looked at whether or not the couple had sexual relations in the past week (yes or no) and whether they had ever used a modern method of contraception (yes or no) as measures of other potentially volatile issues. Data analysis The statistical analyses are done in four parts. First, we describe the characteristics of the study population, considering of the percentage of women experiencing IPV by the socio-demographics, household income distribution, and relationship issues. Second, we show the univariate distribution of how couples make decisions and the bivariate associations with IPV. Third, we show the factors associated with either spouse dominating decisions or having the couple make joint decisions using multiple ordinary least squares (OLS) regression with the decision-making indices as the outcomes. Fourth, we use multiple logistic regression to predict the factors associated with women experiencing physical violence. All analyses were conducted using STATA version 6 (Startcorp, 1999). Using both the CLHNS and the in-depth interviews, we describe the reasons that women provide as a rationale for why their husbands physically hurt them. To gain a better understanding of the context of violence, for each in-depth interview, we examine how couples resolve conicts. In many of the interviews, the question of violence emerged as a relevant factor when women were asked about conicts with their spouses. In cases where the issue of violence did not emerge spontaneously, the interviewers asked directly if their spouses ever hurt them physically. We use excerpts from these interviews to provide greater depth for the context of violence.

Results Characteristics of the study population and reporting of IPV Thirteen percent (2 6 7) of the 2050 married women in Cebu report that they have experienced physical violence from their husbands when the husbands get angry. Of the women who experienced IPV, 58% (2 5 5) report that the IPV occurs once a year, while 27% report experiencing abuse two to four times in a year, and 15% report episodes of IPV more than four times a year. Of the 267 women reporting being physically hurt by their husbands, 27% say it is because they talk back to their spouses, 24% say it is because they nag their spouses, 18% say it is because their husbands are

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jealous, 13% say it is because their husbands are drunk, 9% women say it is over the children, and the remaining 10% of women either gave multiple reasons or other reasons for abuse. The in-depth interviews shed light on the complex nature of how violence occurs in households and suggest that the reason the violence occurs is often multi-faceted. More than half of the women who were interviewed indepth and report abuse (ve out of nine or 56%) report that their husbands are abusive when drunk. In some cases, women report that they dont know why their spouses are violent, but they are drunk at the time when the IPV erupts. For example, a 41-year old urban woman who had experienced abuse from her husband and physical abuse when her husband was drunk in an incident the week before the interview describes the incident as follows: Interviewer: Why did he kick you also? Respondent: I dont know what got into him. He was very drunk at that time. Interviewer: And if hes drunk, do you ght? Respondent: Yes, we do ght! I try to avoid him when hes drunk. I am afraid that I might ght back. If he punches me, Im afraid I might punch him back. However, it is not necessarily the husbands drunkenness that is the cause of the argument, though the abuse may erupt on a repeated basis when the husband is drunk. For example, a 48 year-old urban women left her husband to return to the place where she grew up and then later returned to her husband. She left, in part, because of his drinking and abuse which were exacerbated by her learning about and confronting him about an aair he was having: Respondent: Yes, all of us [left] other than him. We were not able to sleep at home when it happened. He was so drunk that he chased us with a large knife because he had wanted to kill us. If we wouldnt run for our lives, we would surely die. He was never without a large knife. Thats what I am scared of because everytime he gets drunk, he immediately takes that knife, making us the object of his drunken disposition. Interviewer: What does he do? Respondent: He hits me with his st. He also slaps me. When we are ghting and he would sense he wasnt going to win, he would get a piece of wood and hit us. Sometimes, my eldest child becomes the object of his anger. Even with a little mistake, he reacts at once and hits the child badly. I asked him when will you stop your drinking? Interviewer: And if he is not drunk? Respondent: He is good. He is only bad when he is drunky

Three of the nine women reported that violence erupted when there were arguments about money. In one of the situations, described below, the wife confronted her husband about not turning over all of his salary. In another, the husband was gambling away substantial amounts of money, and in a third situation, the husband was upset about his wife working and earning a salary. A 46 year-old urban women describes what happens when she told her husband she knew that he was not turning over all of his salary: Interviewer: What were you ghting about? Respondent: It was about his salary that he got from his employer at that time. He only gave me half of his salary and kept the other half of it. I knew it from my cousin who used to receive the full amount of her husbands salary. In my case I only received half of the amount that my cousin said she received from her husband. Interviewer: Did you confront him about it? Respondent: Yes, but he denied it. Interviewer: Then, what happened? Respondent: He hit me hard by my nape. I fell down with my feet stretched apart and got dislocated. I managed to run after that. I was miserable at that time. Imagine, he told me that he was going to nish my life. I saw him get his tools and I think he took his bolo [a machete-type tool with a small handle and a long blade used for agriculture]. I immediately escaped from home. During our ght I told him that I was going to the other house because I did not want to receive his money anymorey These accounts point to the multiple causes for IPV and suggest the limitations of the survey data which only covers physical abuse perpetrated by the husbands. There are often a multitude of reasons for physical abuse, though for some women it is clearly tied to one type of behavior or circumstance. The in-depth data show that some women live in fear of violence although their spouses have not yet hit them. Further complicating the picture is that some of the time, women initiate physical violence or are the sole perpetrators. Some women report that their husbands were very physically aggressive with their children but not with them. Factors related to IPV Among the sociodemographic characteristics in Table 1, IPV is more common in urban areas, in households with fewer assets, with younger wives and husbands, and among women whose husbands are unemployed or attend church less frequently. There are no signicant associations with education, the wifes employment status, or wifes church attendance.

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Table 1 Distribution of variables and percentage experiencing IPV by socio-demographics, household income distribution, and relationship issuesa Characteristics Total sample Socio-demographics Residence Rural (reference) Urban Household wealth, mean (SD), items Low (02 items) Medium (35 items) High (612 items) Wifes education, mean (SD), grades completed p7 grades completed >7 grades completed Husbands education, mean (SD), grades completed p7 grades completed >7 grades completed Wifes age, mean (SD), years p37 years >37 years Husbands age, mean (SD), years p40 years >40 years Wife works for Pay No Yes Husband works for Pay No Yes Wifes church attendance, mean (SD) Never to once a month (reference) Once a week or more Husbands church attendance, mean (SD) Never to once a month (reference) Once a week or more Household income distribution Wife contributes >50% to household income No Yes Husband turns over all of his income No Yes Husband earns enough income No Yes Total no. (%) 2050 (100.0) % experiencing IPV 13.0

577 (28.1) 1473 (71.9) 4.5 (3.2) 686 (33.5) 619 (30.2) 745 (36.3) 7.2 (3.8) 1190 (58.1) 860 (41.9) 7.6 (3.9) 1096 (53.5) 954 (46.5) 37.8 (6) 1096 (53.5) 954 (46.5) 40.3 (6.8) 1167 (56.9) 883 (43.1)

8.0*** 15.0

16.0 *** 14.0 9.4

13.4 12.6

13.5 12.5

14.5* 11.2

14.4 * 11.2

552 (26.9) 1498 (73.1)

11.2 13.5

159 (7.8) 1891 (92.2) 2.5 (0.8) 837 (40.8) 1213 (59.2) 2.1 (1.0) 1141 (55.7) 909 (44.3)

17.6 11.9

14.7 11.9 16.0 *** 9.2

577 (28.1) 1473 (71.9)

12.3 * 16.7

537 (26.2) 1510 (73.8)

20.3 *** 10.4

1175 (58.1) 849 (41.9)

14.8 ** 10.5

1392 Table 1 (continued) Characteristics

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Total no. (%)

% experiencing IPV

Any expenditures on alcohol No Yes Relationship issues Couple Had Sexual Relations in Past Week No Yes Couple Ever Used a Modern Contraception No Yes
a

1117 (54.6) 932 (45.5)

11.4 * 15.0

1024 (50.0) 1026 (50.0)

11.6 14.4

576 (28.1) 1474 (71.9)

8.7*** 14.7

Notes: Total number of subjects is 2050 unless otherwise noted. All data are presented as percentages unless otherwise indicates. CI indicated condence interval. Signicance tests are based on a w2 test of dierences in percent experiencing IPV. Reference refers to the group chosen to be the reference group in the multivariate models. ***Po0:001; **Po0:01; *Po0:05:

All of the household income distribution variables and relationship issue variables are associated with IPV. However, it must be acknowledged that with all of these associations, the data are cross-sectional and this lack of temporal specicity makes interpretation of the results dicult. When women earn >50% of the household income, they report more IPV than those who earn less. IPV is higher among women who report that their husband keeps some or all of his earnings (20%) than when the husband turns over all of his earnings (10%). When women perceive that their husbands do not earn enough to cover expenses, there is more IPV than if the women think the earnings are adequate. If any money is spent on alcohol for weekly expenses, women more often experience IPV (14%) compared to households where no money is spent on alcohol (11%). Women in couples who had sexual relations in the last week report more IPV (14%) than women who did not have sexual relations (11.5%) (p 0:06). Women who report ever using modern family planning report higher levels of IPV than non-users.

40% 30% 20% 10% 0% 0 1 2 3 4 5 6 Panel A: Number of Major Decisions Dominated by Husband 40% 30% 20% 10% 0% 0 1 2 3 4 5 6 Panel B: Number of Major Decisions Dominated by Wife 40% 30% 20%

How couples make decisions and associations with abuse Table 2 shows the patterns of decision-making and their associations with IPV. In terms of decisionmaking, we nd that the women in our survey report that in six domains, decisions are most often made jointly. In the remaining ve domains, decisions are most often ultimately made by the wife. In contrast to earlier studies, there does not seem to be a pattern of male dominance in family planning decisions or major purchases. Our data show that wives are often in charge of decisions that reect nancial management (buying

10% 0% 0 1 2 3 4 5 6 7 8 9 10 11 Panel C: Number of Decisions Made Jointly

Fig. 1. Percentage of wives experiencing IPV by the couples decision-making patterns. Error bars indicate the upper limit of the 95% condence intervals.

shoes, clothes, and gifts for relatives), which is similar to other studies. For all of the decision-making variables, the association with abuse is generally U-shaped with both

M.J. Hindin, L.S. Adair / Social Science & Medicine 55 (2002) 13851399 Table 2 Distribution of household decision-making and percentage of women experiencing IPV by household decision-making, Cebu Variable: who has nal say over Wife buying shoes Husband Couple Wife Buying childrens clothes Husband Couple Wife Childrens schooling Husband Couple Wife Taking children to doctor Husband Couple Wife Gifts for relatives Husband Couple Wife Major purchases Husband Couple Wife Buying/selling land Husband Couple Wife The wife working Husband Couple Wife The wife traveling outside Cebu Husband Couple Wife Using family planning Husband Couple Wife Family planning method choice Husband Couple Wife
a

1393

Total no. (%) 135 (6.6) 158 (7.7) 1752 (85.7)

% experiencing IPVa 14.8 7.0 13.4

95 (4.7) 368 (18.1) 1569 (77.2)

20.0 ** 8.7 13.6

186 (9.2) 1411 (70.0) 420 (20.8)

17.7 *** 10.8 17.9

109 (5.3) 872 (42.7) 1062 (52.5)

19.3* 11.5 13.7

181 (8.9) 870 (42.7) 983 (48.3)

18.7* 11.0 13.4

281 (14.4) 1495 (74.4) 234 (11.6)

21.3*** 10.9 14.5

231 (12.1) 1580 (82.5) 103 (5.4)

21.2*** 11.1 20.4

398 (19.5) 669 (32.8) 973 (47.7)

12.1*** 9.0 16.1

607 (30.0) 837 (41.3) 582 (28.7)

15.6 *** 8.8 16.5

138 (6.8) 1233 (60.6) 663 (32.6)

13.8 *** 9.3 19.4

128 (6.3) 1236 (61.2) 654 (32.4)

10.9 *** 9.7 19.3

Signicance levels determined by overall w2 test. ***Po0:001; **Po0:01; *Po0:05:

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Table 3 Summary scores of household decision-making Variable No. of major decisions dominated by husband No. of major decisions dominated by wifea No. of decisions made jointlyb
a a

Items 7 7 11

N 1856 1856 1829

Mean score (SD) 0.9 (1.3) 1.5 (1.5) 5.5 (2.8)

The seven items included are decisions about major purchases, buying or selling land, womens working, women traveling outside Cebu, family planning use, and family planning method choice. b All eleven decision-making items are included.

husbands dominating and wives dominating being associated with higher levels of IPV while joint decision-making is associated with the lowest levels of abuse. All of the associations are statistically signicant at the 0.10 level, and seven of the eleven are signicant at p0.001 level. This pattern clearly suggests that for couples who make major decisions jointly, women are less likely to experience IPV. As compared to jointly made decisions, IPV is signicantly more common if husbands have the nal say over decisions in the following six domains: buying the children clothes, choosing the childrens school, taking the child to the doctor, gifts for relatives, major purchases, buying or selling land, and the wife traveling outside Cebu. As compared to jointly made decisions, IPV is signicantly more common when the wives have the nal say in the following seven domains: buying the childrens clothes, choosing the childrens school, buying or selling land, whether or not she works outside the home, traveling outside Cebu, and use and method choice in family planning. Table 3 shows the distribution of the household decision-making indices. The means for domination by husbands and wives show that on average, women dominate more decisions than men. Fig. 1 shows the associations of IPV with the number of major decisions dominated by the husband (Panel A), the wife (Panel B) and the number of all decisions made jointly (Panel C). The higher the number of decisions that either the wife or the husband dominate, the higher the percentage of women who report IPV. The strongest association is the relationship between joint decisionmaking and abuse. Among couple who make none of the household decisions jointly, 25% report IPV in contrast to couples who make all of the decisions jointly, where IPV is 6% (p-trend o0.001). Mutivariate analysis of factors associated with household decision-making We consider whether the socio-demographics, household income allocation, and relationship issue variables are associated with patterns of household decision-

making using the decision indices as the outcomes for three separate OLS regression models (Table 4). Husbands dominate more major household decisions when the couple lives in an urban area, the household has a lower household wealth, the wife is younger, the husband completed grades of education, and when the wife is unemployed. Husbands also dominate more decisions when their wives contribute o50% of the household income, when they do not turn over all or their income, when their wives believe they earn enough income for household expenditures, and when some of the household weekly expenditures include alcohol. Women dominate more major decisions in urban households, when their husbands are relatively older, are unemployed, and when husbands attend church less frequently. The women also dominate more decisions when their husbands do not turn over all their income, and when some of the household money is spent on alcohol. Women who report ever having used a modern method of contraception are also more likely to dominate major household decisions. Couples who make more decisions jointly are more likely to be rural, and are characterized by wives being older relative to their husbands, and husbands who attend church more frequently than their wives. Couples also make more joint decisions when husbands turn over all their earnings to their wives and there are no weekly expenditures on alcohol.

Multivariate analysis of factors associated with IPV Table 5 shows the results of ve multiple logistic regression models reported as odds of reporting IPV associated with each group of risk factors. Urban residence is associated with nearly three-fold higher odds of IPV. IPV is less likely with more household assets, and more frequent church attendance by the husband. Looking across the models, the addition of each new set of factors to the model does not substantially aect the signicance or magnitude of husbands church attendance or household wealth, but

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Table 4 Multiple linear regression models of number of decisions dominated by the husband, wife, or made jointly on household characteristicsa Husband dominates major decisions (N 1836) Socio-demographics Urban Household wealth, items Wifes age, years Husbands age, years Wifes grades completed Husbands grades completed Wife works for pay Husband works for pay Wifes church attendance Husbands church attendance Household income distribution Wife earns >50% of income Husband turns over all income Husband earns enough Any weekly expenses on alcohol Relationship issues Had sex in last week Ever used modern FP Adjusted R2
a

Wife dominates major decisions (N 1836) 0.09*** 0.05 0.05 0.07* 0.0 0.03 0.03 0.05* 0.04 0.07*

Decisions made jointly (N 1809) 0.11*** 0.05 0.11*** 0.09 ** 0.02 0.02 0.01 0.04 0.06* 0.06*

0.06* 0.08* 0.10 ** 0.02 0.03 0.10*** 0.09*** 0.01 0.02 0.01

0.05 0.06 0.05 0.05

* ** * *

0.03 0.13*** 0.03 0.05 *

0.02 0.16*** 0.02 0.07**

0.0 0.03 0.04***

0.02 0.08*** 0.05***

0.02 0.03 0.06***

Notes: Standardized betas are reported. ***Po0:001; **Po0:01; *Po0:05:

does lower the magnitude of the eects of urban residence. Of the household income distribution variables, the only signicant association is with whether the husband turns over all of his income. When husbands turn over all of their income, the women are 0.52 times less likely to experience IPV. The other variables are in the expected direction. When any amount of money is spent on alcohol, there is trend that shows women are somewhat more likely to report experiencing IPV (p 0:09 in Model 2) but this relationship is not statistically signicant in this or in later models. When they report that their husband earns enough money, women are somewhat less likely to experience IPV but this relationship does not reach statistical signicance in Models 4 and 5. In terms of relationship issues, having sexual relations in the past week and ever use of a modern family planning method are positively associated with women experiencing IPV. The household decision-making variables are strong predictors of IPV, even after adjustment for all the variables in Table 5. When either men or women dominate all major household decisions, womens risk of experiencing IPV was 2.72 and 3.82 times greater,

respectively, than when neither member of the couple dominated any major household decisions. In couples who made all decisions jointly, women reported signicantly less IPV compared to couples where none of the decisions were made jointly (OR=0.25). When testing the linearity of the decision-making indices, only the index measuring the wifes domination of decisionmaking signicantly deviates from linear. When a quadratic term is added to for the non-linearity of the wife dominating decisions, the quadratic term is signicant, consistent with the plateauing eect seen in Fig. 1B, but the results from other variables in Model 4 are not signicantly dierent. In contrast to couples who had arguments that include violence, the data from Table 5 shows that joint decision-making is protective. A 33 year-old rural woman who was married at age 15 describes how she and her spouse settle arguments: Interviewer: How do you solve arguments? Respondent: Oh, we talk about it. He would say that even if we have problems, we shouldnt be arguing because it can only worsen the situation. He said that if we have problems, we should just nd a solution and talk things through. He does not like to argue.

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Table 5 Multiple logistic regression models of socio-demographics, household income distribution, relationship issues, and decision-making on IPVa Model 1 Socio-demographics Urban residence Household wealth, items Wifes age, years Husbands age, years Wifes grades completed Husbands grades completed Wife works for pay Husband works for pay Wifes church attendance Husbands church attendance Income distribution Wife earns >50% of income Husband turns over all income Husband earns enough Any weekly expenses on alcohol Relationship issues Had sex in last week Ever used modern FP Indices of decision-making Husband dominates major decisionsb Wife dominates major decisionsb Couple makes decisions jointlyb N w2 from log likelihood ratio testc Degrees of freedom
a b

Model 2 2.64*** 0.92** 0.97 1.00 1.00 0.96 1.05 0.76 1.03 0.75***

Model 3 2.51*** 0.91*** 0.98 1.00 1.00 0.96 1.04 0.80 1.03 0.74***

Model 4 2.13*** 0.93* 0.98 0.99 0.99 0.96 1.00 0.74 1.03 0.75***

Model 5 2.23*** 0.91** 0.98 0.99 1.00 0.96 1.01 0.78 1.02 0.74***

2.93*** 0.91*** 0.98 0.99 1.01 0.97 1.17 0.72 1.03 0.71***

1.21 0.51*** 0.79 1.28

1.24 0.53*** 0.79 1.24

1.24 0.63** 0.75 1.10

1.29 0.61** 0.75 1.11

1.28 1.68**

1.35* 1.68**

1.34 1.69**

2.72** 3.82*** 0.25*** 2050 F F 2050 23.54*** 4 2023 12.061** 2 1836 23.28*** 2 1809 21.30***d 1

***Po:001; **Po:01; *Po:05: Coecients based on standardized indices (01) calculated as the number of decisions of a give type divided by the total number of items in the index. c Compared to the previous model constrained to have the same number of observations as Model 5 (N 1809). d Compared to Model 3.

Discussion As in most areas of the world, IPV is an important problem in marital relationships in the Philippines. Even with the known problems of under-reporting of IPV, more than one in ten married women report physical abuse by their spouses. At the same time, women in Cebu have substantial input into the nal say of most household decisions showing that women have a substantial degree of power in the household. The contrast between high levels of autonomy for women and high levels of abuse make Cebu an interesting and valuable case study. In this paper, we demonstrate that household decision-making autonomy and IPV are related. Not

surprisingly, the more domains of decision-making men dominate, the more likely they are to dominate their wives in terms of physical abuse. More surprising, however, is that when women dominate more household decisions, they are also more likely to experience IPV. More encouraging data are revealed when we look at how well women fare when the decisions are made jointly. Looking across eleven domains, when couples make decisions together (both major and minor decisions), fewer women experience IPV. Although the way husbands and wives negotiate decisions is clearly related to IPV, the relationship is largely independent of the factors that determine how men and women negotiate decisions. Patterns of decision-making are consistently related to urban versus

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rural residence, age or relative age dierences, whether or not the husband turns over all his income, and whether the household spends any money on alcohol. In a society where husbands turning over all their income is socially expected so that women can manage the budgets, our analyses show that deviations from this expectation is one of the strongest predictors of decision-making. Husbands who keep some of their income and do not give it to their wives are less likely to make joint decisions, which explains some of their higher rates of abuse. While economic factors are often implicated in the cycle of violence in households, this paper only lends modest support to this notion. Employment status and relative earnings do not predict IPV in these data. Even when considering the relationship between employed women and unemployed spouse, which should be related to power imbalances in the marriage, there were no signicant ndings. Household wealth, a measure of overall economic success, is associated with a lower likelihood of IPV. Rural women are less likely to experience IPV than urban women. In fact, further analysis shows that women who live in the most remote rural areas are at the lowest risk of IPV. At the same time, these rural households have lower household wealthFa risk factor for abuse. This combination of results may have important implications for how men and women cope with urban life and what factors in the process of urbanization could be modied to decrease stress-induced violence. Alcohol use, a key reason stated as a reason for violence in other studies (Grisso et al., 1999; Kyriacou et al., 1999; Rao, 1997) is modestly associated with IPV. This modest association may be due, in part, to our measure of alcohol use, which is limited to weekly expenditures. Alcohol use may predict incident abuse, which is not measured in this study. We do nd, however, that alcohol expenditures are associated with patterns of decision-making. Another key factor commonly implicated in IPV is womens employment; however we nd no signicant associations between womens employment and IPV in our study. Recentness of sexual relations is somewhat associated with IPV in our study. While not a very robust result, it does warrant some consideration. It is possible that women who experience IPV are also unable to refuse sexual relations. In addition, conict over sexual relations may lead to violence. Another possibility is that after an incident of violence, the batterer may want to make up for the violent altercation. We would need more data on timing of violence to better sort out this relationship. Ever use of modern contraceptives is associated with an increased likelihood of IPV in our study. These results need to be interpreted with caution since we are unable to sort out the timing of the contraceptive use and violence. Despite this limitation, the results are

provocative. In some settings, contraceptive use is a marker for progressive couples who are more likely to communicate about decisions. However, in the Philippines, there is evidence to suggest that for women, procreation is a measure of status (see Alcantara, 1994) and, at the same time, men often dominate decisions about family planning use (see David, 1994). If modern methods are being used and are associated with women having more power in the household, this may, in fact, produce conict leading to violence. On the other hand, women who have experienced abuse may want to limit their childbearing, to protect their children from potential abuse. The qualitative data clearly illustrate the complexity of studying IPV. Our data point to the fact that men and children experience violence as well. In addition, the threat of violence emerges in the in-depth interviews as a prominent issue of concern. This paper points to the need for further studies of threatened violence and why women become physically abusive. The qualitative data also point to the benets of focusing on household dynamics as a source of violence and some of the diculties in assessing the motivations and rationales for violence. Although the observed relationships are quite strong, knowing both the long-term dynamics between husbands and wives and a longer history of abuse, may indicate other important factors that underlie patterns of abuse such as abuse in childhood or a family history of IPV. In addition, it would be important to know the causal ordering of the observed relationships, which requires longitudinal data. It is possible, for example, that some women who are abused by their spouses, allow their spouses to make major decisions in order to avoid conict. At the same time, it is of central importance to understand what it is about women who dominate decision-making that puts them at a higher for violence. This study has several methodological limitations. At this point, we only have cross-sectional data on decisionmaking and abuse. In addition, generalizability to other areas of the Philippines should be made with caution. For example, the CHLNS cohort is older than the average married woman in Cebu. However, additional data from a sample of 220 married women ages 1925 in Cebu show that 15% (33) of these younger married women report having been physically hurt by their spouses, suggesting that the estimates based on the older sample of women used for this study are not substantially higher than those in younger women. Our measures of IPV for this study rely on womens selfreported data. It is unlikely that women would report IPV wihout experiencing it, but it is more likely that some women may not report experiencing abuse. If IPV is under-reported in this sample, it may change the observed relationships but random under-reporting

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M.J. Hindin, L.S. Adair / Social Science & Medicine 55 (2002) 13851399 R. Jerey, & A. M. Basu (Eds.), Girls schooling, womens autonomy, and fertility change in South East Asia (pp. 48 71). Thousand Oakes, CA: Sage Publications Inc.. Blood, R. O., & Wolfe, D. M. (1965). Husbands and wives: The dynamics of family living. New York: The Free Press. Blumberg, R. L. (1991). Income under female versus male control: Hypotheses from a theory of gender stratication and data from the Third World. In R. L. Blumberg (Ed.), Gender, family, and economy: The triple overlap (pp. 97 127). Newbury Park: Sage Publiations. Cebu Study Team. (1991). Underlying and proximate determinants of child health: The Cebu longitudinal health and nutrition study. American Journal of Epidemiology, 133,185201. Cebu Study Team. (1992). A child health production function estimated from longitudinal data. Journal of Development Economics, 38, 323351. David, F. P. (1994). The roles of husbands and wives in household decision-making. Philippine Sociological Review, 42, 7894. David, F. P., Chin, F. P., & Herradura, E. S. (1998). Family planning: Its economic and psychosocial inuences on the lives of women in Western Visayas. Summary of Final Report Prepared for the Womens Studies Project: Family Health International. Desai, S., & Saltzman, L. E. (2001). Measurement issues for violence against women. In C. M. Renzetti, J. L. Edleson, & R. K. Bergen (Eds.), Sourcebook on violence against women (pp. 3552). Thousand Oaks, CA: Sage Publications. Dobash, R. E., & Dobash, R. P. (1998). Cross-border encounters: Challenges and opportunities. In R. E. Dobash, & R. P. Dobash (Eds.), Rethinking violence against women (pp. 121). Thousand Oaks, CA: Sage Publications. Dwyer, D., & Bruce, J. (1988). A home divided: Women and income in the Third World. Stanford: Stanford University Press. Feliciano, M. S. (1994). Law, gender and the family in the Philippines. Law and Society Review, 28, 547560. Grisso, J. A., Schwarz, D. F., Hirschinger, N., Sammel, M., Brensinger, C., Santanna, J., Lowe, R. A., Anderson, E., Shaw, L. E., Bethel, C. A., & Teeple, L. (1999). Violent injuries among women in an urban area. New England Journal of Medicine, 341, 18991905. Gwako, E. L. M. (1997). Conjugal power in rural Kenyan families: Its inuence on womens decisions about family size and family planning practices. Sex Roles, 36, 127147. Heise, L., Ellsberg, M., & Gottemoeller, M. (1999). Ending violence against women. Population Reports, Series L, No. 11. Baltimore: Johns Hopkins University School of Public Health, Population Information Program. Hindin, M. J. (2000a). Womens power and anthropometric status in Zimbabwe. Social Science and Medicine, 51, 15171528. Hindin, M. J. (2000b). Womens autonomy, womens status, and fertility-related behavior in Zimbabwe. Population Research and Policy Review, 19, 255282. Jejeebhoy, S. J. (1995). Womens education, autonomy, and reproductive behavioural experiences from developing countries. Oxford: Clarendon Press.

would only weaken the observed associations. The CHLNS is limited to physical abuse by the spouse, though sexual abuse, an important measure of IPV in marriage (Martin, Tsui, Maitra, & Marinshaw, 1999), should be studied since it may be determined by a dierent set of household dynamics. Despite limitations, this study has several key implications for health care professionals and policymakers. Finding additional activities, like attending church, where men might be receptive to messages that discourage IPV or that promote the value of communication may be useful. Health care providers who nd that their clients who report not discussing important issues with their partners may want to probe further for possible abuse. In addition, the paper provides evidence that promoting womens autonomy without the support of men in the community may put women at risk of IPV. Although we do not show causality, the idea that IPV could result from womens empowerment needs further consideration. It is also clear that a better understanding of IPV in marital relationships may require quantitative measures that look at the factors associated with violence as well as qualitative measures that capture the marital dynamic from both partners perspectives.

Acknowledgements The authors wish to thank the US Agency for International Development (USAID) and the National Institute for Child Health and Human Development (NICHD) for its generous support. The data collection for this study was funded by USAID under Cooperative Agreement USAID/CCP-3060-A-00-93-0021-05 to Family Health International (FHI). The analysis is supported by NICHD through a training grant to the Carolina Population Center (T32-HD07168-21). The conclusions expressed in this report do not necessarily reect the policies of FHI, USAID, or NICHD. We would like to thank Azot Derecho for her work in clarifying the in-depth interviews as well as providing a perspective for some of our results.

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