In an important and well-crafted study appearing in this month’s issue of Pediatrics, Jeong et al1 investigate the impact of intimate partner violence (IPV) and of maternal and paternal intellectual and social stimulation on early child development in 11 low- and middle-income countries (LMICs). The study includes data on >18 000 children drawn from the Demographic and Health Surveys (DHS), which are nationally representative household surveys that collect health and population data in >90 countries.2 The DHS include a core survey used in all countries and optional modules on a range of topics that each country may select. This remarkable study using routinely collected data was made possible by the simultaneous inclusion of both the Early Child Development Index (ECDI) module and the domestic violence module in the DHS in these 11 forward-thinking countries.
In their study, Jeong et al1 provide important national and regional estimates on the contribution of IPV to a low ECDI in children in LMICs. They make use of questions on the nature of parental interactions with the child, allowing a nuanced study of whether differences in paternal or maternal stimulation partially account for the impact of IPV; although ultimately, parental stimulation explained only a small proportion of the relationship between IPV and child development. This article complements the sparse published research on the impact of IPV on child development in LMICs. Previously, Durand et al3 leveraged Brazilian data from a multicountry study of domestic violence by the World Health Organization4 to demonstrate that physical and sexual IPV was associated with child behavior difficulties and school problems. Chander et al5 documented that the impact of IPV on preschool-aged child behavior in the South African Asenze cohort remained after adjusting for caregiver mental health and binge drinking. IPV has been included as a component in measures of the cumulative effect of adverse childhood experiences in LMICs, but these studies assess the cumulative effect of multiple stressors and cannot isolate the effects of IPV.6,7
Why did Jeong et al1 only find 11 countries to include in their analysis? Sadly, only these 11 countries have included both the domestic violence module and the ECDI in the DHS. The domestic violence module was introduced in the late 1990s, but uptake has been slow: of 93 DHS countries,8 only 9 had used the module in a 2004 report,9 and as of 2019, only 25 counties included the module.10 The ECDI, more frequently included in national surveys, has been available as an optional DHS module since 2011 and as a module in the United Nations Children’s Fund Multiple Indicator Cluster Surveys (MICS) since 2009.1,11,12
Additionally, improvements to the implementation of the DHS domestic violence module are important. Until January 2020, the majority of its questions were asked only of women who had been married or cohabited with a man, thus excluding many single mothers, and it is still only given to one randomly selected woman per household.13 Additionally, research in high-income countries has revealed that women living with a partner who is not the father of their children are more likely to experience IPV.14–17 If the DHS added a question to the domestic violence module about the partner’s relationship to the respondent’s children, this would provide another important piece of information about IPV risk to the woman and her children.
Jeong et al1 have moved our understanding forward, but we need to know more: is there co-occurring child abuse or neglect, as is frequently found in both high-income countries and LMICs,18–21 and does the child witness the violence? In some countries, DHS surveys include the MICS questions on child discipline, which ask whether the respondent or any other adult in the household has used a range of physical and verbal abusive behaviors toward a child in the household.22 However, as with IPV and the ECDI, this is an optional module and not part of the standard DHS questionnaire, so the data have not been collected in most countries. Additionally, no module addresses whether a child has witnessed violence in the home. This knowledge, which is essential to plan effective intervention and provide protection for children globally, will have to be answered through de novo research studies.
The article by Jeong et al1 demonstrates that rigorous analyses can be applied to DHS and MICS data to investigate important hypotheses in addition to establishing a baseline and tracking prevalence at the national, regional, and global levels over time. There is still a need for well-designed prospective population-based research, preferably in longitudinal studies that investigate the direct and indirect impact of IPV, including child victimization by parental violence and witnessing violence. Demographic planners around the world would do well to adopt the ECDI, the child discipline module, and the domestic violence module of the DHS to inform needed early intervention. Jeong et al1 set the scene to challenge researchers globally to take on this agenda.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: Supported by the Fogarty International Center, National Institutes of Health (NIH), Office of Behavioral and Social Sciences Research, and Office of Disease Prevention of the NIH (award R01 TW011228). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2955.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.