Author's School

Brown School

Author's Department

Social Work

Language

English (en)

Date of Award

8-13-2024

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Chair and Committee

Lindsay Stark

Abstract

Syndemic theory highlights that epidemics do not occur in isolation. Due to harmful political inequalities, epidemics can co-occur and interact with one another to magnify the overall burden of disease. Certain contexts and populations are more prone to syndemic vulnerabilities. Gender based violence (GBV) has been labeled as an epidemic in low- and middle-income countries (LMICs). Epidemiological evidence has demonstrated that GBV co-occurs alongside other epidemics such as HIV and substance use. This dissertation extends the application of syndemic theory to GBV in LMIC for the purpose of improving methodological and analytical approaches as well as global health applications. Three research aims scaffold this overall goal. In Aim 1, I conducted a systematic review of quantitative research that tested syndemic theories involving GBV the context of LMICs. The following research questions guided the systematic review: (1) How has GBV been integrated into syndemic theories tested in LMICs? (2) Where are the methodological, empirical, and theoretical gaps concerning the testing/application of GBV syndemics LMIC contexts? (3) What are good research practices concerning the integration of GBV syndemic theories in LMIC contexts. Using the 2022 nationally representative Demographic and Health Survey from Nepal, in Aim 2 I quantitatively tested an originally developed intergenerational mother–child syndemic model, using additive and multiplicative interaction analysis. The model posits that mothers from the most economically disadvantaged households experience the clustering of intimate partner violence, depression, and inadequate dietary iron intake, which interact synergistically to magnify the probability of child health disparities (in this case, diarrheal disease). In Aim 3, I drew on a synthesis of qualitative and quantitative GBV syndemics literature from LMICs and consulted with GBV syndemics researchers to develop a mixed-methods framework. The framework proposed provides guidance and examples on how to strategically integrate qualitative and quantitative methods to more holistically test syndemic theory’s tenets. Overall, this dissertation expands the application of syndemic theory to GBV in LMIC in three ways. The Aim 1 systematic review of 45 articles identified greater empirical attention is needed to investigate GBV syndemics involving GBV perpetration as an outcome, during the pregnancy/prenatal period, and in postconflict, conflict-affected and humanitarian settings. Future research should also focus on integrating the political context investigations of syndemic clustering and context and robustly estimating the population prevalence of syndemic clustering to improve the public health utility of the evidence. Aim 2 demonstrated that harmful interactions involving the co-occurrence of intimate partner violence, depression, and inadequate dietary iron intake among mothers magnified the probability of diarrhea among children under 5 only in Nepal’s most disadvantaged households. This interaction offers evidence for intergenerational syndemics and provides impetus for integrating GBV in syndemic theory. Second, the findings suggest that intervening in one of the maternal syndemic epidemics in disadvantaged households can disrupt the synergies in child diarrhea, an important risk factor for under-5 child mortality and stunting. Last, Aim 3 developed the first mixed methods framework on how to leverage qualitative and quantitative methods when testing GBV syndemics in LMICs. This framework has the potential to strengthen the existing mixed-methods evidence base, which does not currently explain the benefit of integrating methods vis-à-vis syndemic theory.

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