**3. Methodology**

This chapter discusses the impacts of VAWG and its health, social and economic effects on the families and communities of the survivors. We argue that the impact of VAWG goes beyond individual health effects. VAWG affects individual women and girls, their families, their communities and larger societal and economic structures (See **Figure 1** for the conceptual framework of the study). Using this framework, this study measures the impact of intimate partner violence (IPV) and sexual violence by non-intimate partner (NPSV) on the health and wellbeing of the women and girls who experience violence. It also estimates the social and economic costs of VAWG by analysing the direct and indirect tangible and intangible costs by looking at the impact on both the individual and society.

For this, a mixed method study consisting of both quantitative surveys with women and with households and qualitative interviews was implemented. For the quantitative study, the team used a household questionnaire to collect data about the general household and individuals within the household and a women's questionnaire applied only to women between 18 and 60 years of age. A multidisciplinary team surveyed 2002 women and 1917 households in 10 regions in Ghana.

The surveyors requested consent to a follow up qualitative interview to all participants in the women's survey. The team selected women and men to participate in in-depth interviews (IDIs), key informant interviews (KIIs) and focus group discussions (FGDs) conducted in Ga and Twi. The team conducted 28 IDIs and 8 FGDs with between 6 and 10 women and men and 10 KIIs (**Table 1**).

**205**

mental health.

**Table 1.**

the last 12 months.

**4. Findings and discussion**

violence up to five times in past 12 months.

*The Health and Economic Costs of Violence against Women and Girls on Survivors…*

Researchers used Stata and/or SPSS for the quantitative analysis and NVivo to analyse qualitative data. During the analysis, the team created quality of life measures to establish health effects of IPV on the woman involved, her partner and her children. The authors used econometric modelling to establish implications, including economic, social and health, of experiences of violence. The analysis included violence at the household level and at the workplace, educational institutes and in public spaces. At the household level, the analysis included the type and nature of injuries suffered, and the impact of IPV on reproductive, physical and

Quantitative survey (female) 1046 956 2002 In-depth interviews (female) 15 13 28 Focus group discussions (male, 6–10 participants in each group) 15 13 28 Focus group discussions (female, 6–10 participants in each group) 16 19 35 Key informant interviews (female/male) 5 5 10

**Urban areas**

**Rural areas**

**Total**

The study found, in-line with previous studies, that violence is a common experience for women in Ghana. An estimated 46% of the respondents of the women's survey reported having experienced physical, psychological, sexual or economic violence in the home, workplace, educational institution, or public space in the past 12 months. In the case of IPV, 43% of partnered women had suffered IPV in

Incidents of violence ranged in severity. In relation to IPV, the study found that 38% of IPV survivors reported suffering severe violence. This means that they experienced economic or psychological violence in a frequency greater than 10 times, physical violence greater than three times and/or sexual violence during the last 12 months. Twenty-five percent of women reported moderate violence, defined as physical violence once or twice and economic and psychological violence 6–10 times. Finally 36% reported low violence, defined as economic or psychological

Additionally, women reported VAWG in a range of locations, and violence by different types of perpetrators, not just their partners or relatives. About 4% of the total sample in this study reported experiencing violence in educational institutions. About 18% of female respondents reported having suffered some form of violence in a public space, such as the market, on public transportation or on streets. About 43% of female respondents who are married or have a partner and 47% of female respondents who are staying with other family members reported IPV and violence by other family members respectively. Twenty four percent of

The evidence indicates that women in Ghana experience violence from a range of actors and locations. Notably, while violence occurs in workplaces, public spaces and in educational institutes, the home was identified as the place women are most likely to experience violence. The impact of these incidents of violence, on both physical

female respondents who were working reported workplace violence.

*DOI: http://dx.doi.org/10.5772/intechopen.88690*

*Number of participants by type of data collection activity.*

#### **Figure 1.** *Conceptual framework of social and economic impacts of VAWG and economic loss.*

*The Health and Economic Costs of Violence against Women and Girls on Survivors… DOI: http://dx.doi.org/10.5772/intechopen.88690*


**Table 1.**

*Public Health in Developing Countries - Challenges and Opportunities*

looking at the impact on both the individual and society.

FGDs with between 6 and 10 women and men and 10 KIIs (**Table 1**).

*Conceptual framework of social and economic impacts of VAWG and economic loss.*

understanding and addressing VAWG in Ghana.

**3. Methodology**

where possible, the costs of violence is thus an important contribution towards

This chapter discusses the impacts of VAWG and its health, social and economic effects on the families and communities of the survivors. We argue that the impact of VAWG goes beyond individual health effects. VAWG affects individual women and girls, their families, their communities and larger societal and economic structures (See **Figure 1** for the conceptual framework of the study). Using this framework, this study measures the impact of intimate partner violence (IPV) and sexual violence by non-intimate partner (NPSV) on the health and wellbeing of the women and girls who experience violence. It also estimates the social and economic costs of VAWG by analysing the direct and indirect tangible and intangible costs by

For this, a mixed method study consisting of both quantitative surveys with women and with households and qualitative interviews was implemented. For the quantitative study, the team used a household questionnaire to collect data about the general household and individuals within the household and a women's questionnaire applied only to women between 18 and 60 years of age. A multidisciplinary team surveyed 2002 women and 1917 households in 10 regions in Ghana. The surveyors requested consent to a follow up qualitative interview to all participants in the women's survey. The team selected women and men to participate in in-depth interviews (IDIs), key informant interviews (KIIs) and focus group discussions (FGDs) conducted in Ga and Twi. The team conducted 28 IDIs and 8

**204**

**Figure 1.**

*Number of participants by type of data collection activity.*

Researchers used Stata and/or SPSS for the quantitative analysis and NVivo to analyse qualitative data. During the analysis, the team created quality of life measures to establish health effects of IPV on the woman involved, her partner and her children. The authors used econometric modelling to establish implications, including economic, social and health, of experiences of violence. The analysis included violence at the household level and at the workplace, educational institutes and in public spaces. At the household level, the analysis included the type and nature of injuries suffered, and the impact of IPV on reproductive, physical and mental health.

### **4. Findings and discussion**

The study found, in-line with previous studies, that violence is a common experience for women in Ghana. An estimated 46% of the respondents of the women's survey reported having experienced physical, psychological, sexual or economic violence in the home, workplace, educational institution, or public space in the past 12 months. In the case of IPV, 43% of partnered women had suffered IPV in the last 12 months.

Incidents of violence ranged in severity. In relation to IPV, the study found that 38% of IPV survivors reported suffering severe violence. This means that they experienced economic or psychological violence in a frequency greater than 10 times, physical violence greater than three times and/or sexual violence during the last 12 months. Twenty-five percent of women reported moderate violence, defined as physical violence once or twice and economic and psychological violence 6–10 times. Finally 36% reported low violence, defined as economic or psychological violence up to five times in past 12 months.

Additionally, women reported VAWG in a range of locations, and violence by different types of perpetrators, not just their partners or relatives. About 4% of the total sample in this study reported experiencing violence in educational institutions. About 18% of female respondents reported having suffered some form of violence in a public space, such as the market, on public transportation or on streets. About 43% of female respondents who are married or have a partner and 47% of female respondents who are staying with other family members reported IPV and violence by other family members respectively. Twenty four percent of female respondents who were working reported workplace violence.

The evidence indicates that women in Ghana experience violence from a range of actors and locations. Notably, while violence occurs in workplaces, public spaces and in educational institutes, the home was identified as the place women are most likely to experience violence. The impact of these incidents of violence, on both physical

and psychological well-being and on women's capabilities is critical to assess to gain a deeper understanding of the scope and depth of the problem of VAWG in Ghana.

#### **4.1 Impacts on women's health, well-being, and capabilities**

Impacts of VAWG can occur in a myriad of ways, often indirect, hence difficult to fully capture in a single study. However, the negative impact of VAWG on the health and well-being of survivors is clear. As is explored below, these impacts often have far-reaching consequences that go beyond the immediate injuries (whether physical or psychological) to constrain women's capabilities in relation to a number of functions, including working, learning, and socialising.

#### *4.1.1 Physical, mental health, and reproductive impacts of IPV*

In line with the literature, participants in this survey and qualitative study identified a number of different negative impacts due to VAWG. These included physical, reproductive, and mental health impacts, discussed further below.

Many participants highlighted physical injuries, chronic pain, and disability as a result of beating, hitting, slapping, or other physically violent acts. Drawing from data from the women's survey, a set of scores were constructed, including disability, illness, and depression scores, to identify the strength and significance of the relationship between these health outcomes and experience of IPV, the most commonly experienced form of VAWG in the study. The disability score was calculated based on the following elements: visual, auditory, mobility, cognitive, and articulation difficulties. The score was computed by summing up the level of difficulty of these elements as experienced by respondents. There was a weak but statistically significant relationship between experience of physical and/or sexual IPV and higher disability score.

Similarly, an acute illness score was constructed that identified particularly strong relationships between higher scores on the scale and experience of any form of IPV. The acute illness score was calculated based on: acute health problem, acute impairment, acute pain, consulting any health care worker, headache, loss of appetite, poor sleep, anxiety, difficulty in thinking clearly, mood, crying, loss of enjoyment, difficulty in making decisions, loss of productivity, loss of interest, worthlessness, and tiredness in past 4 weeks. The acute illness score was statistically significantly higher among women who experienced any of the forms of IPV considered (*P*-value <0.001).

Participants reported insomnia, feelings of anxiety, and varying degrees of depression. Women reported chronic fear after being raped; that fear was described as turning into intense and persistent worry that some women said "could lead one to lose [their] sanity". A depression score, calculated based on suicidal thoughts, loss of interest, mood, poor sleep, tiredness, loss of appetite, worthlessness, and difficulty in thinking clearly, found that women who had experienced any form of IPV scored statistically significantly higher than women who had not experienced IPV (*P* value <0.001) (**Table 2**).

Out of the total sample of 2002 women, about 52% of women who had experienced health problems in the last 4 weeks also reported experiencing IPV in the last 12 months. Nineteen percent of women who experienced IPV reported having had suicidal thoughts. Out of this number, 63% attempted suicide.

The survey data was used to identify sexual and reproductive health impacts of physical and sexual violence (PSV). The proportion of women who had miscarried and had suffered PSV (15%) is higher than the proportion of women who have miscarried and have not suffered PSV (14%). We did not find significant differences between women who had suffered PSV and those who had not suffered PSV in terms of abortions and still births.

**207**

*The Health and Economic Costs of Violence against Women and Girls on Survivors…*

0.359; 0.614

10.460; 11.914

> 2.515; 3.013

*Physical and mental health outcome scores among partnered women in past 12 months [20].*

**Economic Psychological Physical Sexual Yes No Yes No Yes No Yes No**

**0.09 0.05 0.24 0.34**

3.02 3.1 2.86 5.50

1.6 1.2 1.31 2.20

0.445; 0.845

10.550; 12.308

2.670; 3.361

0.324; 0.486

8.040; 9.097

1.575; 1.847 0.440; 1.094

12.989; 15.331

3.404; 4.561

0.348; 0.503

8.195; 9.119

1.652; 1.908

Mean 0.52 0.43 0.49 0.44 0.65 0.41 0.77 0.43

*P* value **0.293 0.554 0.012 0.011**

*P* value **0.000 0.000 0.000 0.000**

Mean 3.2 1.6 2.8 1.6 3.02 1.71 3.98 1.78

1.423; 1.715

Mean 11.31 8.29 11.19 8.09 11.43 8.57 14.16 8.66

7.536; 8.643

0.343; 0.534

IDI and FGD participants discussed the link between physical violence and sexual abuse and miscarriages and bleeding, and some mentioned contracting infectious diseases such as HIV and other STIs. Many participants linked VAWG experiences to fatal consequences indirectly as they discussed that depression could lead to suicide or fatal complications of unsafe abortions. Respondents discussed several instances of women who died, or were severely ill, from injuries suffered as

*P* value **0.000 0.000 0.000 0.000**

Notably, some participants also distinguished between acceptable and unacceptable levels of physical violence, based on the degree of harm to the victim, as

*"…There are different kinds of beating; there is love beating and a beating which can lead to death. There are times your husband will beat, but that is love beating… This small one will not hurt you [reference to love beating]. Wicked beating can* 

The mental and physical health effects of VAWG can have secondary affects that impact on women's capabilities. Participants described how violence could impact women's mobility, as well as cause them to miss work and school due to physical injuries or psychological distress. VAWG can also create barriers to women's social

*lead to death…" - Urban In-Depth Interview, Female*

*DOI: http://dx.doi.org/10.5772/intechopen.88690*

Disability score

95% CI 0.366;

Acute illness score

95% CI 10.539;

95% CI 2.928;

Depression score

0.682

12.081

3.495

0.344; 0.518

7.746; 8.835

1.415; 1.689

Mean difference

Mean difference

Mean difference

**Table 2.**

a result of VAWG or unsafe abortions.

*4.1.2 Impacts on capabilities due to VAWG*

explained by a participant below:


*The Health and Economic Costs of Violence against Women and Girls on Survivors… DOI: http://dx.doi.org/10.5772/intechopen.88690*

#### **Table 2.**

*Public Health in Developing Countries - Challenges and Opportunities*

**4.1 Impacts on women's health, well-being, and capabilities**

of functions, including working, learning, and socialising.

*4.1.1 Physical, mental health, and reproductive impacts of IPV*

and psychological well-being and on women's capabilities is critical to assess to gain a deeper understanding of the scope and depth of the problem of VAWG in Ghana.

Impacts of VAWG can occur in a myriad of ways, often indirect, hence difficult to fully capture in a single study. However, the negative impact of VAWG on the health and well-being of survivors is clear. As is explored below, these impacts often have far-reaching consequences that go beyond the immediate injuries (whether physical or psychological) to constrain women's capabilities in relation to a number

In line with the literature, participants in this survey and qualitative study identified a number of different negative impacts due to VAWG. These included physical, reproductive, and mental health impacts, discussed further below.

Many participants highlighted physical injuries, chronic pain, and disability as a result of beating, hitting, slapping, or other physically violent acts. Drawing from data from the women's survey, a set of scores were constructed, including disability, illness, and depression scores, to identify the strength and significance of the relationship between these health outcomes and experience of IPV, the most commonly experienced form of VAWG in the study. The disability score was calculated based on the following elements: visual, auditory, mobility, cognitive, and articulation difficulties. The score was computed by summing up the level of difficulty of these elements as experienced by respondents. There was a weak but statistically significant relationship between experience of physical and/or sexual IPV and higher disability score. Similarly, an acute illness score was constructed that identified particularly strong relationships between higher scores on the scale and experience of any form of IPV. The acute illness score was calculated based on: acute health problem, acute impairment, acute pain, consulting any health care worker, headache, loss of appetite, poor sleep, anxiety, difficulty in thinking clearly, mood, crying, loss of enjoyment, difficulty in making decisions, loss of productivity, loss of interest, worthlessness, and tiredness in past 4 weeks. The acute illness score was statistically significantly higher among women who experienced any of the forms of IPV considered (*P*-value <0.001). Participants reported insomnia, feelings of anxiety, and varying degrees of depression. Women reported chronic fear after being raped; that fear was described as turning into intense and persistent worry that some women said "could lead one to lose [their] sanity". A depression score, calculated based on suicidal thoughts, loss of interest, mood, poor sleep, tiredness, loss of appetite, worthlessness, and difficulty in thinking clearly, found that women who had experienced any form of IPV scored statistically significantly higher than women who had not experienced

Out of the total sample of 2002 women, about 52% of women who had experienced health problems in the last 4 weeks also reported experiencing IPV in the last 12 months. Nineteen percent of women who experienced IPV reported having had

The survey data was used to identify sexual and reproductive health impacts of physical and sexual violence (PSV). The proportion of women who had miscarried and had suffered PSV (15%) is higher than the proportion of women who have miscarried and have not suffered PSV (14%). We did not find significant differences between women who had suffered PSV and those who had not suffered PSV

suicidal thoughts. Out of this number, 63% attempted suicide.

**206**

IPV (*P* value <0.001) (**Table 2**).

in terms of abortions and still births.

*Physical and mental health outcome scores among partnered women in past 12 months [20].*

IDI and FGD participants discussed the link between physical violence and sexual abuse and miscarriages and bleeding, and some mentioned contracting infectious diseases such as HIV and other STIs. Many participants linked VAWG experiences to fatal consequences indirectly as they discussed that depression could lead to suicide or fatal complications of unsafe abortions. Respondents discussed several instances of women who died, or were severely ill, from injuries suffered as a result of VAWG or unsafe abortions.

Notably, some participants also distinguished between acceptable and unacceptable levels of physical violence, based on the degree of harm to the victim, as explained by a participant below:

*"…There are different kinds of beating; there is love beating and a beating which can lead to death. There are times your husband will beat, but that is love beating… This small one will not hurt you [reference to love beating]. Wicked beating can lead to death…" - Urban In-Depth Interview, Female*

#### *4.1.2 Impacts on capabilities due to VAWG*

The mental and physical health effects of VAWG can have secondary affects that impact on women's capabilities. Participants described how violence could impact women's mobility, as well as cause them to miss work and school due to physical injuries or psychological distress. VAWG can also create barriers to women's social

and political participation as well as economic agency. Rural participants discussed feelings of shame, fear, and embarrassment associated with having experienced VAWG that kept them from going out in their community to do chores or do attend social events. Participants also discussed remaining at home out of fear of encountering their perpetrator(s) while out in public.

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

Women also reported missing work and being unable to conduct other daily activities given the physical and mental health effects, social stigma and reduced mobility that may result of experiencing VAWG. The women's survey asked respondents about missed work and schooling due to VAWG. The results show that about 6% of women experiencing IPV missed on an average 11 days of work from their economic activity in the prior 12 months. Approximately 4% of women experiencing another form of violence reported missing about 10 days of work in the 12 months. About 8% of women living with school going children reported children missing about 3 days annually due to IPV.

The withdrawal from social and work spaces due to VAWG places a constraint on women's capabilities that may translate over time to reduced social status and position, isolation and further vulnerabilities. Missed work is likely to result in lost wages and carries with it a significant opportunity cost. These impacts further expose women to poverty, itself a risk-factor for violence. Thus, VAWG significantly undermines women's potential—an impact that may be passed on to other family members and the next generation.

#### **4.2 Impacts to households**

Individual women survivors of VAWG are not the only ones affected by the experience of violence. Family members, including children, are also likely to suffer a range of costs due to VAWG. Below, we discuss the findings of the impacts of VAWG on the health and finances of the relatives of survivors and the impact on the children of survivors.

#### *4.2.1 Health effects on the relatives of survivors*

Participants identified several mental health effects of VAWG on relatives of survivors. Among these effects, they discussed depression and feelings of guilt. They also discussed anxiety caused by threats from the perpetrator, social stigma and isolation. This anxiety may affect direct victims but also their relatives, including parents or children of the women and girls affected by VAWG. Further, participants in the qualitative research described that victims of VAWG whose capacity to carry out chores and household duties was reduced, relied on family members for assistance. The time-burden of taking on such extra workloads by the relatives of survivors also contributes to a loss to households.

#### *4.2.2 Economic costs*

Families may experience increased expenses and/or loss of income or productivity due to VAWG. The lack of shelters and public support for VAWG survivors

**209**

future potential.

violence.

*The Health and Economic Costs of Violence against Women and Girls on Survivors…*

create financial hardship that may lead to household dissolution or homelessness in extreme cases. Some participants emphasised that these financial burdens fall onto the woman's family because there is a lack of formal social support for affected women and their families. Women described economic worries and concerns about their ability to take care of their children as a barrier to escaping VAWG. Families are burdened by hospital bills when survivors require medical care for physical injuries, pregnancies, STIs, or mental health care as a result of VAWG, in addition to the cost of caring for children of women who are no longer able to care for their

The study also identified out of pocket expenditures incurred on health care, police, court, shelter and replacing property. For example, a participant described:

*"…I was speaking to a woman about this yesterday, and she said when her husband gets angry at her, he just destroys things that belong to her…when she came back he had disconnected the light and spoilt her kettle…" - Rural In-Depth Interview,* 

To estimate these economic costs to households of VAWG an accounting methodology was employed whereby costs were calculated for specific categories and added to calculate the total cost to households and/or society [21]. Tangible costs can be grouped into direct, from the use of goods and services and indirect, calculated using imputed monetary value such as lost income and reduced profits [22].

The calculations based on the accounting methodology described above were applied to the survey data. It was found that, on average, almost 11% of women experiencing IPV incurred costs of GH¢275.62 due to IPV. Among women experiencing any form of violence, 11% of women reported out of pocket expenditures equivalent to US\$53 in the last 12 months, including on health-related expenditures, filing police reports, or replacement of furniture; this amount is equivalent to 10% of the annual per capita expenditure on non-food consumption in Ghana. This economic loss to households has the potential to result in further vulnerability, including poverty, or to the re-direction of funds away from long-term planning, such as children's education or building a business, towards immediate survival.

IPV does not only affect the victims' physical and psychological health and social wellbeing, but also the children in the home. Participants discussed direct effects on children, such as fear, anxiety, stigma, and pain; they also discussed how VAWG can lead to the loss of school days when homes are dissolved as a result of

Evidence from the women's survey provides further support that children are negatively affected by the violence experienced by their mothers. Twenty-one percent of participants in the survey noted that their children felt scared after witnessing IPV. About 18% of them said their children felt confused and 14% reported that their children asked a lot of questions about the incident. An important finding was the children of women who experienced violence were more likely to miss school, due to their mother's being unable to bring them, or having to help care for their mothers after an incident. It was found that 3 days of school were lost on average per year, among those women with children who reported violence and responded to the question. When extrapolated to the national level, this indicates that nearly 300,000 school days are lost to children in Ghana annually—a significant drain on

This approach was used to estimate the costs to households due to VAWG.

*DOI: http://dx.doi.org/10.5772/intechopen.88690*

children due to death or long-term injury.

*4.2.3 Impacts on the children of survivors*

*Female*

#### *The Health and Economic Costs of Violence against Women and Girls on Survivors… DOI: http://dx.doi.org/10.5772/intechopen.88690*

create financial hardship that may lead to household dissolution or homelessness in extreme cases. Some participants emphasised that these financial burdens fall onto the woman's family because there is a lack of formal social support for affected women and their families. Women described economic worries and concerns about their ability to take care of their children as a barrier to escaping VAWG. Families are burdened by hospital bills when survivors require medical care for physical injuries, pregnancies, STIs, or mental health care as a result of VAWG, in addition to the cost of caring for children of women who are no longer able to care for their children due to death or long-term injury.

The study also identified out of pocket expenditures incurred on health care, police, court, shelter and replacing property. For example, a participant described:

*"…I was speaking to a woman about this yesterday, and she said when her husband gets angry at her, he just destroys things that belong to her…when she came back he had disconnected the light and spoilt her kettle…" - Rural In-Depth Interview, Female*

To estimate these economic costs to households of VAWG an accounting methodology was employed whereby costs were calculated for specific categories and added to calculate the total cost to households and/or society [21]. Tangible costs can be grouped into direct, from the use of goods and services and indirect, calculated using imputed monetary value such as lost income and reduced profits [22]. This approach was used to estimate the costs to households due to VAWG.

The calculations based on the accounting methodology described above were applied to the survey data. It was found that, on average, almost 11% of women experiencing IPV incurred costs of GH¢275.62 due to IPV. Among women experiencing any form of violence, 11% of women reported out of pocket expenditures equivalent to US\$53 in the last 12 months, including on health-related expenditures, filing police reports, or replacement of furniture; this amount is equivalent to 10% of the annual per capita expenditure on non-food consumption in Ghana. This economic loss to households has the potential to result in further vulnerability, including poverty, or to the re-direction of funds away from long-term planning, such as children's education or building a business, towards immediate survival.

#### *4.2.3 Impacts on the children of survivors*

IPV does not only affect the victims' physical and psychological health and social wellbeing, but also the children in the home. Participants discussed direct effects on children, such as fear, anxiety, stigma, and pain; they also discussed how VAWG can lead to the loss of school days when homes are dissolved as a result of violence.

Evidence from the women's survey provides further support that children are negatively affected by the violence experienced by their mothers. Twenty-one percent of participants in the survey noted that their children felt scared after witnessing IPV. About 18% of them said their children felt confused and 14% reported that their children asked a lot of questions about the incident. An important finding was the children of women who experienced violence were more likely to miss school, due to their mother's being unable to bring them, or having to help care for their mothers after an incident. It was found that 3 days of school were lost on average per year, among those women with children who reported violence and responded to the question. When extrapolated to the national level, this indicates that nearly 300,000 school days are lost to children in Ghana annually—a significant drain on future potential.

*Public Health in Developing Countries - Challenges and Opportunities*

*send someone..." - Rural In-Depth Interview, Female*

tering their perpetrator(s) while out in public.

missing about 3 days annually due to IPV.

family members and the next generation.

*4.2.1 Health effects on the relatives of survivors*

survivors also contributes to a loss to households.

**4.2 Impacts to households**

children of survivors.

*4.2.2 Economic costs*

and political participation as well as economic agency. Rural participants discussed feelings of shame, fear, and embarrassment associated with having experienced VAWG that kept them from going out in their community to do chores or do attend social events. Participants also discussed remaining at home out of fear of encoun-

*"…She will not be able to go there [market]. She will fear that the man will show up over there to disgrace her. It is a market where a lot of people are found. If he shows up over there, the woman will feel bad so she will not go there, so that she will save herself of the disgrace. If she wants something from the market, she will* 

Women also reported missing work and being unable to conduct other daily activities given the physical and mental health effects, social stigma and reduced mobility that may result of experiencing VAWG. The women's survey asked respondents about missed work and schooling due to VAWG. The results show that about 6% of women experiencing IPV missed on an average 11 days of work from their economic activity in the prior 12 months. Approximately 4% of women experiencing another form of violence reported missing about 10 days of work in the 12 months. About 8% of women living with school going children reported children

The withdrawal from social and work spaces due to VAWG places a constraint on women's capabilities that may translate over time to reduced social status and position, isolation and further vulnerabilities. Missed work is likely to result in lost wages and carries with it a significant opportunity cost. These impacts further expose women to poverty, itself a risk-factor for violence. Thus, VAWG significantly undermines women's potential—an impact that may be passed on to other

Individual women survivors of VAWG are not the only ones affected by the experience of violence. Family members, including children, are also likely to suffer a range of costs due to VAWG. Below, we discuss the findings of the impacts of VAWG on the health and finances of the relatives of survivors and the impact on the

Participants identified several mental health effects of VAWG on relatives of survivors. Among these effects, they discussed depression and feelings of guilt. They also discussed anxiety caused by threats from the perpetrator, social stigma and isolation. This anxiety may affect direct victims but also their relatives, including parents or children of the women and girls affected by VAWG. Further, participants in the qualitative research described that victims of VAWG whose capacity to carry out chores and household duties was reduced, relied on family members for assistance. The time-burden of taking on such extra workloads by the relatives of

Families may experience increased expenses and/or loss of income or productivity due to VAWG. The lack of shelters and public support for VAWG survivors

**208**

Participants and key informants mentioned that VAWG may become normalised among children who witness it in the household. They were especially concerned about how witnessing violence could lead to male children perpetuating violence in the future and female children accepting violence as a normal part of relationships. While this intangible impact cannot be immediately monetized, the long-term cost to society would be immense and would ultimately translate into economic costs.

It is clear that the cost VAWG is not only an issue for the survivor. It has impacts that ripple beyond the individual to their children and other relatives. Indeed, as is explored below, they also affect whole communities.

#### **4.3 Impacts to community and participation**

#### *4.3.1 Help-seeking behaviour and service usage*

Studies suggest that the rate of help seeking for VAWG, and IPV in particular, is generally low. Stigma, fear and challenges in availability and access all create barriers to help-seeking. Our survey shows that only 3% of survivors of IPV reported any of the incidents to the police.

Among those who did seek help, participants mentioned seeking help from the Department of Social Welfare, police, and assemblymen as a source of legal aid and punishment for perpetrators; others sought help from local chiefs, traditional community elders, family elders, and religious leaders. However, many participants reported that women were unlikely to seek formal help, such as from police or legal institutions, preferring to seek advice from community or church elders, family members, or close friends, or to keep the issue secret. Reasons for this included normalisation ("this is just how marriage is"), that IPV is a personal issue, and love for their partners. One participant went further, to say that women who did report their husbands would be disparaged by the community:

*"People insulted the woman that she was stupid and a foolish. How could she report a man who was the father of her children? Why did she not forgive the man for the sake of her children?" - Rural In-Depth Interview, Female*

The evidence suggests that family unity and even community cohesion were deemed as more important than individual wellbeing. Thus, reporting violence was seen as either a failure of the woman to maintain a peaceful household or a selfish act that sacrificed her family's reputation or wellbeing for her own interests. In such contexts, reporting of IPV is unlikely to occur, potentially reinforcing existing stigma against women who experience violence.

#### *4.3.2 Women's participation in the community and leadership*

Respondents discussed how experiencing VAWG impacted women's participation in community events and decision-making. They explained that a leader who experiences any type of VAWG would no longer be seen as having "the qualities of a leader" or as being "qualified" to give her opinion on issues in the community, as she would no longer be deemed a good role model. This affects the ability of survivors to take and keep leadership positions in their community. In communities where VAWG is common, the fear of experiencing violence may have an effect on women's and girls' mobility and leadership undermining their potential. Women and girls in the community who have not experienced violence themselves may reduce their mobility and participation in order to avoid the violence they have heard that others have experienced.

**211**

**Table 3.**

*The Health and Economic Costs of Violence against Women and Girls on Survivors…*

*encing from her partner…" - Urban In-Depth Interview, Female*

*"… It depends. People may decide to vote against her, or ask her to step down because they think she might not be a good example to the younger ones. At other times too, they may decide to help her fight against the violence she may be experi-*

When women reduce their participation and involvement, communities experience a loss of input that undermines genuine democratic functioning. Considering the high proportion of women in Ghana who experience violence, the potential consequences of even a small percentage of them reducing leadership activities and

The economic implications of VAWG at individual, household and community levels impact the overall economy via productivity loss. Productivity loss emerged as an impact that women and households experience and discussed within the qualitative research. A participant in a focus group with young urban women

*"[A woman who is abused by her husband] will not be able to focus on her work so her income level will reduce. If you are working for someone, and you always have a divided attention, you will not be able to meet your set target." -Urban Focus* 

In the quantitative survey, productivity loss was probed through measuring absenteeism (missing work), tardiness (being late or leaving early by an hour), and presenteeism (being less productive or having less focus, low concentration, working slowly, stopping work or having an accident). The estimates of productivity loss due to IPV and VAWG more broadly were derived as the difference in means between working women experiencing violence and those not experiencing violence. For women who experience IPV, the productivity loss was equivalent to 12 working days per woman in the past 12 months; nearly two-thirds of this loss is due to being less productive at work and the remaining one third is due to absenteeism (see **Table 3**). For women experiencing any form of violence across various locations, the total days of lost productivity is 26 days per woman in the past 12 months. This translates into nearly 65 million days at the national level or equivalent to 216,000 employed women not working, assuming women work 300 days in the year. Overall, the economy is estimated to lose output equivalent to 5% of its female

**Category Due to partner violence Due to any violence**

*-The weighted IPV prevalence rate among working women = 24.13% (based on study survey). -The weighted any violence prevalence rate among working women = 51.47% (based on study survey).*

*-Used the employment rate of women 15+ 2016 = 64.6% (Ghana Labour Force Survey).*

Absenteeism 4.1 4,714,811 15.14 37,042,551 Presenteeism 7.49 8,601,655 11.27 27,789,032 **Total 11.59 13,316,465 26.41 64,831,583**

*-Used estimated number of women aged 18–60 in Ghana as of 2016 = 7,377,138 (Ghana Statistical Service—GSS).*

**Mean days lost Total days lost Mean days lost Total days lost**

*DOI: http://dx.doi.org/10.5772/intechopen.88690*

participation, is substantial.

**4.4 Impacts on the economy**

*Group Discussion, Female*

workforce not working annually due to VAWG.

*Notes for calculation of mean and total days lost:*

*National estimate of productivity loss due to violence [20].*

remarked:

*The Health and Economic Costs of Violence against Women and Girls on Survivors… DOI: http://dx.doi.org/10.5772/intechopen.88690*

*"… It depends. People may decide to vote against her, or ask her to step down because they think she might not be a good example to the younger ones. At other times too, they may decide to help her fight against the violence she may be experiencing from her partner…" - Urban In-Depth Interview, Female*

When women reduce their participation and involvement, communities experience a loss of input that undermines genuine democratic functioning. Considering the high proportion of women in Ghana who experience violence, the potential consequences of even a small percentage of them reducing leadership activities and participation, is substantial.

#### **4.4 Impacts on the economy**

*Public Health in Developing Countries - Challenges and Opportunities*

explored below, they also affect whole communities.

their husbands would be disparaged by the community:

stigma against women who experience violence.

*4.3.2 Women's participation in the community and leadership*

*sake of her children?" - Rural In-Depth Interview, Female*

**4.3 Impacts to community and participation**

*4.3.1 Help-seeking behaviour and service usage*

of the incidents to the police.

Participants and key informants mentioned that VAWG may become normalised among children who witness it in the household. They were especially concerned about how witnessing violence could lead to male children perpetuating violence in the future and female children accepting violence as a normal part of relationships. While this intangible impact cannot be immediately monetized, the long-term cost to society would be immense and would ultimately translate into economic costs. It is clear that the cost VAWG is not only an issue for the survivor. It has impacts that ripple beyond the individual to their children and other relatives. Indeed, as is

Studies suggest that the rate of help seeking for VAWG, and IPV in particular, is generally low. Stigma, fear and challenges in availability and access all create barriers to help-seeking. Our survey shows that only 3% of survivors of IPV reported any

Among those who did seek help, participants mentioned seeking help from the Department of Social Welfare, police, and assemblymen as a source of legal aid and punishment for perpetrators; others sought help from local chiefs, traditional community elders, family elders, and religious leaders. However, many participants reported that women were unlikely to seek formal help, such as from police or legal institutions, preferring to seek advice from community or church elders, family members, or close friends, or to keep the issue secret. Reasons for this included normalisation ("this is just how marriage is"), that IPV is a personal issue, and love for their partners. One participant went further, to say that women who did report

*"People insulted the woman that she was stupid and a foolish. How could she report a man who was the father of her children? Why did she not forgive the man for the* 

The evidence suggests that family unity and even community cohesion were deemed as more important than individual wellbeing. Thus, reporting violence was seen as either a failure of the woman to maintain a peaceful household or a selfish act that sacrificed her family's reputation or wellbeing for her own interests. In such contexts, reporting of IPV is unlikely to occur, potentially reinforcing existing

Respondents discussed how experiencing VAWG impacted women's participation in community events and decision-making. They explained that a leader who experiences any type of VAWG would no longer be seen as having "the qualities of a leader" or as being "qualified" to give her opinion on issues in the community, as she would no longer be deemed a good role model. This affects the ability of survivors to take and keep leadership positions in their community. In communities where VAWG is common, the fear of experiencing violence may have an effect on women's and girls' mobility and leadership undermining their potential. Women and girls in the community who have not experienced violence themselves may reduce their mobility and participation in order to avoid the violence they have heard that others

**210**

have experienced.

The economic implications of VAWG at individual, household and community levels impact the overall economy via productivity loss. Productivity loss emerged as an impact that women and households experience and discussed within the qualitative research. A participant in a focus group with young urban women remarked:

*"[A woman who is abused by her husband] will not be able to focus on her work so her income level will reduce. If you are working for someone, and you always have a divided attention, you will not be able to meet your set target." -Urban Focus Group Discussion, Female*

In the quantitative survey, productivity loss was probed through measuring absenteeism (missing work), tardiness (being late or leaving early by an hour), and presenteeism (being less productive or having less focus, low concentration, working slowly, stopping work or having an accident). The estimates of productivity loss due to IPV and VAWG more broadly were derived as the difference in means between working women experiencing violence and those not experiencing violence.

For women who experience IPV, the productivity loss was equivalent to 12 working days per woman in the past 12 months; nearly two-thirds of this loss is due to being less productive at work and the remaining one third is due to absenteeism (see **Table 3**). For women experiencing any form of violence across various locations, the total days of lost productivity is 26 days per woman in the past 12 months. This translates into nearly 65 million days at the national level or equivalent to 216,000 employed women not working, assuming women work 300 days in the year. Overall, the economy is estimated to lose output equivalent to 5% of its female workforce not working annually due to VAWG.


*Notes for calculation of mean and total days lost:*

*-The weighted IPV prevalence rate among working women = 24.13% (based on study survey).*

*-The weighted any violence prevalence rate among working women = 51.47% (based on study survey).*

*-Used estimated number of women aged 18–60 in Ghana as of 2016 = 7,377,138 (Ghana Statistical Service—GSS). -Used the employment rate of women 15+ 2016 = 64.6% (Ghana Labour Force Survey).*

#### **Table 3.**

*National estimate of productivity loss due to violence [20].*

The impact of annual loss of output combined with the ongoing negative consequences for the capability and participation of women establishes the systematic but unrecognised drain that violence against women and girls imposes on the economic prosperity and societal well-being of the nation.

### **5. Conclusion**

In this mixed methods study, we found that VAWG is a persistent public health problem that affects women and girls who experience it, as well as their families and communities. Almost half of the women who participated in the women's survey reported having experienced physical, psychological, sexual, or economic violence in the home, workplace, educational institution, or public space in the past 12 months. The violence women and girls experience varies in severity. It also varies by type of perpetrator and place of experience. Women reported experiencing violence in educational institutions, in public spaces, such as the market, on public transportation or on streets, in their work places, and at home. Nevertheless, it was also found that the home was the most dangerous place for women in Ghana.

This study also found that there are clear negative impacts on the health and wellbeing of survivors of VAWG. The effects that we identified have far-reaching consequences that go beyond immediate injuries (whether physical or psychological) to affect women's ability to work, learn, and socialise. Participants in the study identified physical, reproductive, and mental health impacts. The study also found a statistically significant correlation between an illness score, a depression score, and experiencing any form of IPV.

The effects of VAWG on the health of women who have experienced violence affect other areas of their lives, creating a complex net of effects that goes beyond their individual health and well-being to affect their livelihood, through the impact of VAWG on the women and girls' capabilities, with economic costs that have to be covered by women and girls and their families. Family members' health may also be affected by VAWG. More subtle and difficult to notice are the costs that VAWG brings to the communities and countries.

VAWG also affects community cohesion and, according to the participants in our study, is often underestimated given that women and girls hardly ever report VAWG to formal authorities. The overall economy of Ghana is impacted due to the productivity loss that results from VAWG.

The study highlights the importance of research on costs/impacts of violence that recognise the social embeddedness of individuals and their locations within broader ecological systems. Such approaches go beyond simplistic accounts of immediate injuries and impacts but rather recognize how negative impacts ripple outwards—both through social networks as well as through time—thus creating much more substantive impacts with consequences for societies, economies and generations. While this study focused on Ghana, similar effects have been identified in South Sudan [23] and are likely to be replicated throughout countries in Africa. Further studies on the costs of VAWG are recommended, particularly longitudinal studies that can produce robust evidence of the long-term consequences of VAWG on capabilities in developing countries.

This study identifies the serious and long-lasting costs of VAWG to individuals, households, communities and economy through assessment of data from Ghana. The evidence generated by this study can be used by advocates across developing, low-to-middle income countries in Africa to influence policy makers and stakeholders, showing them the importance of investing funds in sustainable actions to prevent VAWG. Given the lack of funding for shelters and treatment for women

**213**

*The Health and Economic Costs of Violence against Women and Girls on Survivors…*

health of populations and, ultimately, achieving development goals.

and girls who experience violence, the authors suggest increasing the funding for support services, treatment and prevention initiatives. Such investments are sure to yield high returns—reducing the human and financial losses that impact on the

The project that forms the basis for this chapter was made possible by funding from the UK Department for International Development through the What Works to Prevent Violence against Women and Girls programme. We would also like to acknowledge the contributions of Felix Asante, University of Ghana, who oversaw the project in Ghana, Carol Ballantine, National University of Ireland, for her assistance with the literature review, and Mrinal Chadha for his work on quantitative analysis. We would also like to acknowledge the research team in Ghana who undertook data collection.

We gratefully acknowledge the women who willingly gave their time to share

\*, Jennifer L. Mueller3

, Lila O'Brien-Milne3

,

their experiences and insights on the impacts of violence for them and their

2 Centre for Global Women's Studies, National University of Ireland Galway,

4 Institute of Statistical, Social and Economic Research, University of Ghana,

3 International Center for Research on Women, Washington, District of Columbia,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Stacey Scriver2

1 Landesa, Washington, District of Columbia, United States

\*Address all correspondence to: stacey.scriver@nuigalway.ie

provided the original work is properly cited.

and Nata Duvvury2

*DOI: http://dx.doi.org/10.5772/intechopen.88690*

**Acknowledgements**

**Conflict of interest**

communities.

**Author details**

Ama P. Fenny4

Galway, Ireland

United States

Accra, Ghana

Gina Alvarado Merino1

The authors declare no conflict of interest.

**Notes/thanks/other declarations**

*The Health and Economic Costs of Violence against Women and Girls on Survivors… DOI: http://dx.doi.org/10.5772/intechopen.88690*

and girls who experience violence, the authors suggest increasing the funding for support services, treatment and prevention initiatives. Such investments are sure to yield high returns—reducing the human and financial losses that impact on the health of populations and, ultimately, achieving development goals.
