Research
JAMA Psychiatry | Original Investigation
Association of Ambient Temperature With the Prevalence
of Intimate Partner Violence Among Partnered Women
in Low- and Middle-Income South Asian Countries
Yixiang Zhu, MS; Cheng He, PhD; Michelle Bell, PhD; Yuqiang Zhang, PhD; Zafar Fatmi, PhD; Ying Zhang, PhD;
Maryam Zaid, PhD; Jovine Bachwenkizi, PhD; Cong Liu, PhD; Lu Zhou, MS; Renjie Chen, PhD; Haidong Kan, PhD
Supplemental content
IMPORTANCE Intimate partner violence (IPV), including physical, sexual, and emotional
violence, constitutes a critical public health problem, particularly in low- and middle-income
countries. While climate change could escalate violent events, data quantifying its possible
association with IPV are scant.
OBJECTIVE To evaluate the association of ambient temperature with the prevalence of IPV
among partnered women in low- and middle-income countries in South Asia, and to estimate
the association of future climate warming with IPV.
DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from
the Demographic and Health Survey and included 194 871 ever-partnered women aged 15
to 49 years from 3 South Asian countries (India, Nepal, and Pakistan). The study applied the
mixed-effect multivariable logistic regression model to investigate the association of ambient
temperature with IPV prevalence. The study further modeled the change in IPV prevalence
under various future climate change scenarios. The data included in the analyses were
collected from October 1, 2010, to April 30, 2018, and the current analyses were performed
from January 2, 2022, to July 11, 2022.
EXPOSURE Annual ambient temperature exposure for each woman, estimated based
on an atmospheric reanalysis model of the global climate.
MAIN OUTCOMES AND MEASURES The prevalence of IPV and its types (physical, sexual, and
emotional violence) were assessed based on self-reported questionnaires from October 1,
2010, to April 30, 2018, and the changes in the prevalence with climate changes were
estimated through the 2090s.
RESULTS The study included 194 871 ever-partnered women aged 15 to 49 years
(mean [SD] age, 35.4 [7.6] years; overall IPV prevalence, 27.0%) from 3 South Asian countries.
The prevalence of physical violence was highest (23.0%), followed by emotional (12.5%),
and sexual violence (9.5%). The annual temperature ranges were mostly between 20 °C
and 30 °C. A significant association was found between high ambient temperature and the
prevalence of IPV against women, with each 1 °C increase in the annual mean temperature
associated with a mean increase in IPV prevalence of 4.49% (95% CI, 4.20%-4.78%).
According to the study’s projections under the unlimited emissions scenarios (SSPs [shared
socioeconomic pathways], as defined by the Intergovernmental Panel on Climate Change]
5-8.5), IPV prevalence would increase by 21.0% by the end of the 21st century, while it would
only moderately increase under increasingly stricter scenarios (SSP2-4.5 [9.8%] and SSP1-2.6
[5.8%]). In addition, the projected increases in the prevalence of physical (28.3%) and sexual
(26.1%) violence were greater than that of emotional violence (8.9%). In the 2090s,
India was estimated to experience the highest IPV prevalence increase (23.5%) among
the 3 countries, compared with Nepal (14.8%) and Pakistan (5.9%).
CONCLUSIONS AND RELEVANCE This cross-sectional, multicountry study provides ample
epidemiological evidence to support that high ambient temperature may be associated with
the risk of IPV against women. These findings highlight the vulnerabilities and inequalities of
women experiencing IPV in low- and middle-income countries in the context of global
climate warming.
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2023.1958
Published online June 28, 2023.
Author Affiliations: Author
affiliations are listed at the end of this
article.
Corresponding Author: Renjie Chen,
PhD (chenrenjie@fudan.edu.cn) and
Haidong Kan, PhD (kanh@fudan.edu.
cn), Department of Environmental
Health, School of Public Health,
Fudan University, No. 130 Dong An
Road, Shanghai 200032, China.
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Research Original Investigation
Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
I
ntimate partner violence (IPV) is a critical public health issue that threatens women’s human rights and undermines the achievement of the United Nations Sustainable
Development Goals.1,2 Estimates3,4 suggest that up to 30% of
ever-partnered women have experienced either physical or
sexual violence or both, in their lifetime, with notably higher
incidences in low- and middle-income countries (LMICs). Intimate partner violence can lead to multiple severe health
consequences for women, including mental health problems, physical injury, adverse birth outcomes, and even
death.5,6 Interrelated risk factors, which can interact in complex ways with legal, economic, and cultural systems, are
contributing factors to IPV.
Climate factors have been suggested as possible contributors to violence. The heat-aggression hypothesis proposes that
hot temperatures increase violent behaviors through various
biological and psychological processes,7 such as triggering
angry feelings, aggressive thoughts, and physiological arousal,8
or modifying daily activities to create more social interaction
situations.9 Additionally, proximity to the equator is associated with a quicker life pace, and lower focus on self-control,
which may lead to greater aggressiveness. 10 Mounting
evidence11,12 linking ambient temperature and violence supports that heat exposure has the potential to increase the risk
of IPV. However, few studies have quantitatively explored
the role of ambient temperature in IPV risk.
Climate change has been increasingly portrayed as the
greatest public health threat to human society in the 21st century. Growing evidence11,13,14 suggests that climate change
has strong causal influences on various types of violence.
Climate change may limit agricultural productivity and economic development, inducing family financial crises and violent events.15,16 Also, hot weather events can aggravate certain mental disorders (eg, anxiety, schizophrenia), and increase
people’s aggressive tendencies.17 Therefore, it could be reasonably hypothesized that further climate change may exacerbate the burden of IPV. However, to our knowledge, no previous studies have quantified such possible associations.
Given the higher prevalence of IPV in South Asia compared with that at the global level, and the region’s history of
more frequent and intense heat waves in the last 30 years,3,18
this study was designed to evaluate the association of ambient temperature with the prevalence of IPV and its types (physical, sexual, and emotional violence) among partnered women.
Additionally, the study aimed to project the association of
future warming with IPV prevalence under different climate
scenarios in South Asia.
Methods
Data Sources
This cross-sectional study used data from the Demographic and
Health Surveys (DHS)19 that were georeferenced and available for domestic violence in 3 LMICs in South Asia (India, Nepal, and Pakistan) from 2000 to 2018. The DHS were routinely conducted (3- to 5-year intervals) in more than 90 LMICs
worldwide, collecting health and sociodemographic informaE2
Key Points
Question What is the association of ambient temperature
with the prevalence of intimate partner violence (IPV) among
partnered women in 3 low- and middle-income countries in
South Asia (India, Nepal, and Pakistan)?
Findings This cross-sectional study of 194 871 ever-partnered
women aged 15 to 49 years from 3 South Asian countries found an
increase in IPV prevalence with higher annual mean temperature,
with a 1 °C increase in the annual mean temperature associated
with a 4.5% increase in IPV prevalence. By the end of the 21st
century, the prevalence of IPV was estimated to increase
substantially as temperatures increase, particularly under
an unlimited carbon emissions scenario.
Meaning The findings of this study suggest a need for sustainable
climate change mitigation and adaptation strategies, along with public
healthprograms,toaddresstheissueofIPVinclimate-sensitiveregions.
tion at the household level (details of the surveys and variables are given in the eAppendix in Supplement 1).
Data on domestic violence were derived from the DHS
module of questionnaires about IPV, including physical, sexual,
and emotional violence. With the respondents’ consent, all
ever-partnered women aged 15 to 49 years were interviewed
by trained fieldwork staff about their experience of IPV in the
past 12 months. The interview questions are given in the eAppendix in Supplement 1, and the data inclusion and exclusion
processes are summarized in eFigure 1 in Supplement 1. This
analysis included 4 DHS from the 3 South Asian countries
(eTable 1 in Supplement 1). The publicly available population
data used in this study have been reviewed and approved by
the Institutional Review Board of ICF International Inc. Written consent was obtained from the participants. The study followed the Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) reporting guideline for
cross-sectional studies.
Historical Meteorological Parameters, Population,
and Economic Data
In this study, the historical meteorological parameters were
obtained from the ERA5 (the fifth-generation ECMWF [European Centre for Medium-Range Weather Forecasts] atmospheric reanalysis of the global climate).20 Land variables, including 2m temperature (temperature of air at 2 m above the
surface of land) and total precipitation, with latitudelongitude grids at 0.25° × 0.25° (28 km × 28 km) resolution
and time frequency over 1 hour were provided in the database. We calculated the daily mean temperature and daily cumulative precipitation from January 1, 2009, to December 31,
2018, and matched the data to the geocoded addresses of clusters where the women’s households were located. A cluster is
defined in the DHS as a group of adjacent households, which
serves as the primary sampling unit for field work efficiency
in the 2-stage cluster sampling procedure. Finally, daily-level
parameters were aggregated into annual mean (for temperatures) or annual cumulative (for precipitations) over the year
prior to the interview day. Although data were collected
from October 1, 2000, to April 30, 2018, only surveys from
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Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
October 1, 2010, on were analyzed because data on IPV experience in the past year were not collected before then.
The current analyses were performed from January 2, 2022,
to July 11, 2022.
The population of reproductive women aged 15 to 49 years
was derived from WorldPop21 at a resolution of 1 km and was
aggregated into city and country levels. The gross domestic
product (GDP) per capita with a resolution of 30 arc seconds
was obtained from a gridded global data set for GDP.22
Future Meteorological Parameters and Population Data
The predicted daily mean temperature series under different
climate scenarios were obtained from the Coupled Model Intercomparison Project sixth phase.23 We extracted daily mean
temperature series from 10 global climate model data sets for
the baseline (January 1, 1985-December 31, 2014) and future
(January 1, 2015-December 31, 2099) periods under scenarios
(shared socioeconomic pathways [SSPs]) as defined by the
Intergovernmental Panel on Climate Change.23 The SSPs correspond to the increasing trajectories of atmospheric greenhouse gas (GHG) concentrations and characterize a range of
warming in global climate from mild to extreme.23 For this
study we used 3 SSPs, categorized as strict (SSP1-2.6; lowest
projected change), medium (SSP2-4.5), and unrestricted (SSP58.5; highest projected change) GHG emissions,23 with SSP58.5 implying unlimited energy consumption, GHG emissions, and population growth. The process of converting
gridded temperature to the city level and detailed information of the future population are given in the eAppendix in
Supplement 1.
Statistical Analysis
Temperature-IPV Association
We applied a multivariable mixed-effects logistic regression
model to quantitatively assess the association of annual mean
temperature with the prevalence of IPV and its 3 types (physical, sexual, and emotional) in the past 12 months under a linear association assumption. The associations were adjusted
by sociodemographic factors (residence type, woman’s and
partner’s age, and marital status), socioeconomic status (woman’s and partner’s educational levels, floor material, roof
material, household wealth status), and cluster-level (population density, GDP per capita, and annual cumulative precipitation) variables. To further account for location-specific factors and better isolate the temperature effect, we included a
random-effect term of cluster in the main model. The association was presented as a percentage change of IPV prevalence and its 95% CI per a 1 °C increment in the annual mean
temperature. We also checked the linearity of temperatureIPV association by comparing the linear and nonlinear models. Detailed information for covariates, effect estimation, and
linear assumption testing are provided in the eAppendix in
Supplement 1.
We conducted several stratified analyses to explore how
the association of annual temperatures with IPV prevalence
differed by region, wealth level, floor material, roof material,
marital status, ages of the women and their partners, and educational level. To examine the robustness of the associations,
jamapsychiatry.com
Original Investigation Research
we performed several sensitivity analyses, including the use
of varied model covariates, mean temperature during the hottest 3 consecutive months as the exposure, and future population change in the projection. Details of stratified analyses
and sensitivity analyses are described in the eAppendix in
Supplement 1.
Projection of Changes in IPV Prevalence
Associated with Climate Warming
Assuming a linear association between annual temperatures
and IPV prevalence, we calculated the excess cases of IPV
associated with nonoptimum temperature in each city as
follows:
Excess Casesci = Popci × Rateco × ERCco × ΔT,
where Excess casesci indicates the IPV cases in relation to the
annual temperature increase at the city level, Popci is the city
population size of women aged 15 to 49 years at baseline, Rateco
means the baseline IPV prevalence in the corresponding country, ERCco denotes the percentage change of IPV prevalence
along with change in annual temperature increment in the
specific country, and ΔT represents the change in future temperature compared with the baseline period (1985-2014). We
aggregated the gridded population and projected temperature series at the city level. Finally, we calculated the percentage change of IPV prevalence associated with future climate
warming for each country as follows:
ΔPrevalencecs% = [Excess Casesco / (Popco × Prevalenceco)]
× 100%,
where Excess Casescs denotes the projected excess IPV cases
associated with the annual temperature increase in each country under various emission scenarios, Popco represents the
country-specific population size of women aged 15 to 49 years
aggregated by gridded population data, and Prevalenceco
means IPV prevalence for each country at baseline. To quantify the uncertainty in estimating the exposure-response (E-R)
association and temperature variability for each climate model,
we calculated the empirical 95% CIs through 1000 Monte
Carlo simulations.24,25 We further added the gridded future
population of women aged 15 to 49 years in the projection of
IPV prevalence.
We performed all statistical analyses in R, version 4.0.5
(R Foundation for Statistical Computing). The packages lme4
and hyfo were applied to fit the mixed-effects logistic regression model and conduct bias-correction processes, respectively. A 2-tailed P < .05 indicated statistical significance.
Results
Descriptive Data
The analysis included 194 871 ever-partnered women aged
15 to 49 years (mean [SD] age, 35.4 [7.6] years; overall IPV prevalence, 27.0%) from 3 South Asian countries from 2010 to 2018.
The prevalence of physical violence was highest (23.0%),
followed by emotional (12.5%) and sexual (9.5%) violence
(eTable 2 in Supplement 1). Women who experienced IPV
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Research Original Investigation
Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
Figure 1. Annual Mean Temperatures for the Studied Clusters in South Asia, 2010-2018
A Geographic locations and annual mean temperatures in the clusters
B
Distribution of annual mean temperatures of the clusters across
the 3 countries (India, Nepal, and Pakistan)
40°N
3000
35
2500
30
20
Annual mean temperature, °C
25
20°N
2000
No. of clusters
30°N
1500
1000
10°N
15
500
0°E
60°E
0
10
70°E
80°E
90°E
100°E
–5
0
5
10
15
20
25
30
Annual mean temperature, °C
Clusters refer to groups of adjacent households, which serve as the primary sampling unit for field work efficiency in a 2-stage cluster sampling procedure in
Demographic and Health Surveys.
(n = 52 567) had significantly different characteristics from
those who had not experienced it (n = 142 304) (eTable 3 in
Supplement 1). For example, the proportion of women living
in rural areas was significantly higher among those who experienced IPV (74.6%) compared to those without this experience (69.6%). There is a higher proportion of women without education among those (55.0%) who experienced IPV
compared with women without this experience (43.8%). In
Pakistan, India, and Nepal, 31.9%, 27.6%, and 17.7%, respectively, of women reported IPV experience within the past 12
months (from 2010 to 2018). Most of the studied clusters in
South Asia had an annual mean temperature of more than 25 °C
(Figure 1A), and the annual temperature ranges were mostly
between 20 °C and 30 °C (Figure 1B). During 2011 to 2018,
women in India were exposed to higher mean (SD) annual temperatures (23.7 [6.2] °C) than women in Pakistan (14.2 [11.9]
°C) and Nepal (9.7 [11.8] °C) (eTable 4 in Supplement 1).
The Spearman correlations between individual and household variables are given in eTable 5 in Supplement 1.
E4
Figure 2. Percentage Change in Intimate Partner Violence (IPV) Prevalence
per 1 °C Increase in Annual Mean Temperature in 3 South Asian Countries
IVP type
Change in IPV
prevalence, %
(95% CI)
Total IPV
All 3 countries
4.49 (4.20-4.78)
India
6.23 (5.84-6.63)
Nepal
2.72 (1.61-3.85)
Pakistan
1.25 (0.78-1.73)
Physical violence
All 3 countries
6.55 (6.21-6.90)
India
8.06 (7.61-8.52)
Nepal
3.52 (2.30-4.76)
Pakistan
3.25 (2.65-3.85)
Sexual violence
All 3 countries
6.21 (5.69-6.74)
India
7.29 (6.60-7.99)
Nepal
4.70 (2.93-6.50)
Pakistan
3.47 (2.59-4.37)
Emotional violence
All 3 countries
1.39 (1.04-1.73)
Associations of Historical Temperature With IPV
India
2.53 (2.02-3.03)
For all 3 countries together, each 1 °C increase in the annual
mean temperature was associated with a mean increase in the
prevalence of IPV of 4.49% (95% CI, 4.20%-4.78%) (Figure 2).
Furthermore, a greater increase in the prevalence of physical
violence (mean increase, 6.55%; 95% CI, 6.21%-6.90%) and
sexual violence (mean increase, 6.21%; 95% CI, 5.69%6.74%) was observed compared with emotional violence (mean
increase, 1.39%; 95% CI, 1.04%-1.73%) for every 1 °C increase.
The percentages of physical and sexual violence were higher
in India than in Nepal and Pakistan (Figure 2).
We flexibly plotted the E-R curves for the associations
between annual temperature and IPV prevalence. The odds of
Nepal
2.62 (1.23-4.03)
Pakistan
1.20 (0.68-1.73)
0
2
4
6
8
10
Percentage change
Error bars represent 95% CIs.
IPV prevalence increased consistently with higher temperatures over most temperature ranges (eFigure 2 in Supplement 1). The overall shape of the E-R curves for total IPV and
the 3 subtypes was approximately linear according to an F test
(eTable 6 in Supplement 1), although there was a plateau for
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Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
Original Investigation Research
Figure 3. Effect Estimates for the Association Between Annual Mean Temperatures
and Intimate Partner Violence (IPV) Prevalence in Various Subgroups
Observations
Change in IPV
prevalence, %
(95% CI)
Urban
13 350
3.68 (3.07-4.29)
Rural
39 217
4.54 (4.21-4.88)
Low wealth level
30 539
5.09 (4.66-5.53)
High wealth level
22 028
3.38 (2.99-3.78)
Not finished
27 697
5.30 (4.88-5.73)
Finished
24 870
3.73 (3.33-4.14)
Not finished
10 737
4.95 (4.62-5.28)
Finished
41 830
2.52 (1.88-3.16)
Married
50 653
4.49 (4.20-4.78)
Not married
1914
3.08 (1.45-4.73)
Young
28 828
4.68 (4.09-5.28)
Old
23 739
4.42 (4.09-4.75)
Low
37 451
5.51 (5.05-5.97)
High
15 116
3.88 (3.50-4.26)
Young
29 462
4.82 (4.40-5.24)
Old
21 195
4.08 (2.75-5.42)
Low
27 248
5.50 (5.14-5.86)
High
25 137
4.08 (2.75-5.42)
Variable
Region
Wealth level
Floor material
Roof material
Marital status
Women's age
Women's education
Partners' age
Partners' education
0
2
4
6
8
10
Percentage change
the association for a specific IPV type or a specific country at
high temperatures.
In stratified analyses, we found significant associations
between temperature and IPV among women living in rural
(mean increase, 4.54%; 95% CI, 4.21%-4.88%) vs urban
(mean increase, 3.68%; 95% CI, 3.07%-4.29%) areas, in
households with middle wealth level and lower (mean
increase, 5.09%; 95% CI, 4.66%-5.53%) vs high wealth level
(mean increase, 3.38%; 95% CI, 2.99%-3.78%), and in houses
with an unfinished floor (mean increase, 5.30%; 95% CI,
4.88%-5.73%) or roof (mean increase, 4.95%; 95% CI, 4.62%5.28%) (Figure 3). Furthermore, women or their partners
below the mean age or with primary education levels and
lower may have higher odds of IPV prevalence in association
with high temperature. The temperature-IPV associations
were robust in all sensitivity analyses, as shown in eTable 7
and the results of the sensitivity analysis in the eAppendix in
Supplement 1. Compared with the main model estimate
using the annual mean temperature, the analysis found an
association between the mean temperature in the hottest 3
months and IPV prevalence (odds ratio, 1.06; 95% CI, 1.051.06). However, the model fit was slightly worse than in the
main analysis, except for emotional violence in Nepal
(eTable 8 in Supplement 1).
jamapsychiatry.com
Low wealth level refers to the wealth
level of the poorer or poorest
individuals; high wealth level refers to
individuals with middle wealth level
or higher; not finished refers to
natural, rudimentary, or other
materials; not married refers to
individuals living with a partner,
widowed, divorced, or separated;
young or old refers to women or their
partner under and over the mean
age; low educational level refers to
individuals with primary education or
lower; and high educational level
refers to secondary education or
higher. Error bars represent 95% CIs.
Spatial and Temporal Trends In Future Temperature Changes
eFigure 3 in Supplement 1 depicts the changes in the modeled ambient temperatures during the projection period
(2015-2099) compared with those in the baseline period
(1985-2014) under 3 emission scenarios. After the 2050s,
larger increases in the annual temperature were estimated
under the unlimited emission scenario (SSP5-8.5), while
the increasing trends would be moderate under the stricter
scenario (SSP2-4.5) and leveled off under the strictest
emission scenario (SSP1-2.6). Almost all cities (the secondlevel administrative area in a country) exhibited a consistent
increasing trend, with the most significant increase in
the Himalayas region. Specifically, temperatures in South
Asia were estimated to increase by 1.3 °C (95% CI, 1.1 °C1.5 °C), 2.4 °C (95% CI, 2.2 °C-2.7 °C), and 4.7 °C (95% CI,
4.2 °C-5.4 °C) under the SSP1-2.6, SSP2-4.5, and SSP5-8.5
scenarios, respectively, by the 2090s (eTable 9 in Supplement 1).
The Projected Changes in IPV Prevalence
Associated With Climate Warming
As shown in Figure 4, IPV prevalence was estimated to
increase more at higher altitudes under climate warming
scenarios in the 2090s compared with that in the baseline
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Research Original Investigation
Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
Figure 4. Spatial Distributions of City-Level Percentage Changes in Intimate Partner Violence (IPV) Prevalence
Associated With Climate Warming From the Baseline Period (1985-2014) in South Asia Under Different Climate Scenarios
A SSP1-2.6
B
C
SSP2-4.5
SSP5-8.5
40
40°N
30
30°N
25
20
20°N
15
10
10°N
5
Percentage change in IPV prevalence, %
35
0
60°E
70°E
80°E
90°E
60°E
70°E
80°E
90°E
60°E
70°E
80°E
90°E
The SSPs (shared socioeconomic pathways), as defined by the Intergovernmental Panel on Climate Change, correspond to the increasing trajectories of atmospheric
greenhouse gas (GHG) concentrations and characterize a range of warming in global climate from mild to extreme; for this study, 3 SSPs were used, categorized as
strict (SSP1-2.6; lowest projected change), medium (SSP2-4.5), and unrestricted (SSP5-8.5; highest projected change) GHG emissions.
period. The spatial distributions for the prevalence changes
were similar in the 3 climate scenarios, but the magnitude
varied, with the largest changes under the SSP5-8.5 scenario.
As shown in Figure 5, the IPV prevalence would increase by
21.0% (95% CI, 19.4%-22.6%) by the 2090s under SSP5-8.5,
while the increases would be smaller under SSP2-4.5 (9.8%;
95% CI, 9.0%-10.5%), and SSP1-2.6 (5.8%; 95% CI, 5.3%6.2%). The projected change in IPV prevalence would also
vary by country, with the largest change in India (23.5%;
95% CI, 22.0%-24.9%), followed by Nepal (14.8%; 95% CI,
8.7%-20.8%) and Pakistan (5.9%; 95% CI, 3.5%-8.2%).
(eTable 10 in Supplement 1).
Figure 5 shows the prevalence of each type of IPV in
South Asia was estimated to significantly increase in the
2090s compared with that in the baseline period, except for
the emotional violence prevalence in Pakistan (with nearly
no change). We estimated larger increases of prevalence of
physical violence (28.3%, 95% CI, 26.6%-30.1%) and sexual
violence (26.1%, 95% CI, 23.4%-28.8%) than emotional violence (8.9%; 95% CI, 6.8%-11.0%) (eTable 11 in Supplement 1). India is estimated to experience a larger increase in
the prevalence of physical and sexual violence (29.8%;
95% CI, 28.3%-31.4% and 27.2%; 95% CI, 24.7%-29.6%,
respectively) associated with climate warming than both
Pakistan (14.9%; 95% CI, 12.0%-17.7% and 15.9%; 95% CI,
11.6%-20.1%, respectively) and Nepal (18.9%; 95% CI, 12.4%25.4% and 25.0%; 95% CI, 15.6%-34.1%, respectively).
When gridded future population of women aged 15 to 49
years was included in the projection of IPV prevalence, the percentage increase in IPV prevalence associated with climate
change was not significantly different compared with the
projection under the assumption of no population change
(eFigure 4, eFigure 6, eTable 12, and eTable 13 in Supplement 1), although the trend of excess IPV cases differed (eFigure 5 and eFigure 7 in Supplement 1).
E6
Discussion
This cross-sectional study, using data from a multicountry
survey in South Asia, found increases in IPV prevalence associated with higher annual mean temperature between 2010
and 2018. We also estimated significant increases in IPV prevalence associated with increasing temperatures by the 2090s,
particularly under the unlimited emissions scenario (SSP58.5). To our knowledge, our investigation provides the first
evidence on the association of ambient temperature with IPV
prevalence from a multicountry perspective, as well as on the
projections of future IPV prevalence associated with climate
change.
The associations between high temperature and IPV in
this study coincide with the broader findings of the associations of high temperatures with violence. In Kenya, women
who experienced severe weather events, such as heat waves,
had 60% higher odds of reporting IPV.26 Similarly, a heat wave
in Madrid was associated with a 40% increase in the risk of intimate partner femicides.27 Moreover, high temperature was
associated with multiple manifestations of violence such as
intentional homicide, collective violence, and even regional
conflicts.11,13,28 Global data29 suggested that the risks of interpersonal violence and intergroup conflicts increased by 2.3%
and 13.2%, respectively, with a standard deviation increase in
local temperature. Collectively, these findings support our
findings on the increased risks of IPV associated with heat
exposure.
Our results are theoretically reasonable and supported by
the heat-aggression hypothesis, which suggests that global
warming is likely to increase violent behaviors through both
direct and indirect pathways.7 Acute heat exposure was associated with increased adrenaline production, which could
heighten physiological arousal and activate high aggression
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Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
Original Investigation Research
Figure 5. Estimated Percentage Changes in Prevalence of Intimate Partner Violence (IPV) and its Types (Physical, Sexual, and Emotional)
Associated With Climate Warming From the Baseline Period (1985-2014) in 3 South Asian Countries Under Different Climate Scenarios
IPV
Physical violence
Sexual violence
Emotional violence
A All 3 countries
SSP1-2.6
SSP2-4.5
SSP5-8.5
Change in IPV prevalence, %
40
30
20
10
0
2010s
B
2030s
2050s
2070s
2090s
2010s
2030s
2050s
2070s
2090s
2010s
2030s
2050s
Decade
Decade
Decade
SSP1-2.6
SSP2-4.5
SSP5-8.5
2070s
2090s
2070s
2090s
2070s
2090s
2070s
2090s
India
Change in IPV prevalence, %
40
30
20
10
0
2010s
C
2030s
2050s
2070s
2090s
2010s
2030s
2050s
2070s
2090s
2010s
2030s
2050s
Decade
Decade
Decade
SSP1-2.6
SSP2-4.5
SSP5-8.5
Nepal
Change in IPV prevalence, %
40
30
20
10
0
2010s
2030s
2050s
2070s
2090s
2010s
2030s
2050s
2070s
2090s
2010s
2030s
2050s
Decade
Decade
Decade
SSP1-2.6
SSP2-4.5
SSP5-8.5
D Pakistan
Change in IPV prevalence, %
40
30
20
10
0
2010s
2030s
2050s
Decade
2070s
2090s
2010s
2030s
2050s
2070s
2090s
2010s
Decade
2030s
2050s
Decade
The SSPs (shared socioeconomic pathways), as defined by the Intergovernmental Panel on Climate Change, correspond to the increasing trajectories of atmospheric
greenhouse gas (GHG) concentrations and characterize a range of warming in global climate from mild to extreme; for this study, 3 SSPs were used, categorized as
strict (SSP1-2.6; lowest projected change), medium (SSP2-4.5), and unrestricted (SSP5-8.5; highest projected change) GHG emissions. Whiskers represent
95% empirical CIs.
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Research Original Investigation
Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
under certain conditions (eg, provocation).30-32 Extreme heat
could also directly activate the brain areas associated with thermoregulation and emotion regulation.33 In addition, heatrelated events may contribute to a range of adverse mental
health outcomes, including anxiety, acute stress disorder, and
posttraumatic stress disorder,34 which potentially increase
IPV risk. On the other hand, high ambient temperature could
decrease agricultural production and labor efficiency, consequently exacerbating household economic circumstances
and further aggravating the issue of IPV.16,35 Finally, more frequent and intense extreme weather events, such as heat waves,
may cause substantial damage to infrastructure and social orders, creating a deteriorating living environment that increases life stressors, weakens law enforcement, and worsens gender inequality.36,37
Our stratified analyses found higher heat-associated IPV
prevalence among women with partners who were younger
or had a lower educational level or lower income. To address
these vulnerabilities, governments may need to offer greater
access to education and vocational training for both partners
and improve economic stability by reducing financial stress.38
These measures would be helpful in reducing incidents of domestic violence. Additionally, mental health services are also
necessary for younger partners with less social experience and
higher psychological pressure, particularly during hot seasons. These services can contribute to decreasing IPV prevalence and help both survivors and perpetrators of IPV to cope
with the challenges of a changing climate.5
The projected changes in IPV prevalence associated with
climate warming were associated with different emissions scenarios. The SSP5-8.5 scenario, characterized by unlimited energy consumption, GHG emissions, and population growth,
would result in a dramatic increase in IPV prevalence. Our projections were generally consistent with previous estimations
of violence associated with future climate warming. For instance, armed conflict incidence in Africa was projected to increase by 54% in Africa by 2030 under the representative concentration pathways (RCPs) 8.5 scenario (highest greenhouse
gas concentration scenarios).39 Individuals who have experienced domestic violence are more likely to exhibit depressive symptoms or comorbidity with posttraumatic stress
disorder and have a higher risk of engaging in self-harm.40
A study41 projected a 1.4% increase in suicide rates in the United
States and 2.3% in Mexico by 2050 under the RCP8.5 scenario. Our projections enrich the knowledge of how high temperature in the future may be associated with human violence
and add further impetus to implement more rigorous policies
in mitigating future climate warming and reducing IPV.
This study suggests that India may suffer a much higher
burden of IPV associated with climate warming than Nepal and
Pakistan. The heterogeneity may be attributed to India’s higher
annual temperatures compared with those of Nepal and Pakistan. Moreover, heat waves in India are becoming more frequent and severe than in other South Asian countries, which
ARTICLE INFORMATION
Accepted for Publication: April 24, 2023.
E8
could aggravate the issue of IPV in the region.18 The high baseline prevalence of IPV and other social factors may also contribute to the vulnerability of Indian women to the effects of
climate warming. India has a high prevalence of IPV among
ever-partnered women (32.8%) and acceptability of marital violence compared with other regions of the world.42,43 Thus, the
Indian government should adopt more stringent policies to reduce anthropogenic GHG emissions and address the issue of
IPV. Existing laws and policies that protect women’s rights
need to be reinforced, and sufficient resources should be allocated to promote education and healthy associations to foster positive and healthy partner relationships in schools and
communities to adapt to the rapidly changing climate.
Limitations
This study has several limitations. First, the temperature-IPV
associations were estimated using a cross-sectional design. Although this design was most commonly adopted in epidemiological studies of IPV due to the limitation of data collection,
compilation, and sharing, any causal associations could not be
inferred.44,45 Second, self-reported outcomes are subject to
memory biases, but we assume a weak association with ambient temperature, which would not significantly confound the
results. Third, historical meteorological data were derived from
atmospheric reanalysis products rather than observations,
but previous studies46 showed that this kind of association
can be minimal. Reanalysis data have been proven to be a valid
alternative source of exposure variables in epidemiological
analyses, particularly in assessing temperature-associated
risks.47 Fourth, projections of future changes in IPV prevalence associated with climate warming were based on the
assumption of no changes in E-R associations, socioeconomic status, or climatic adaptation, and further research is
needed to define their associations with the projections.
Fifth, the DHS data set applied in this study included data
from only 3 South Asian countries, and thus the results
could not be easily extrapolated to other regions. Additional
potential sources of bias are detailed in the eAppendix
in Supplement 1.
Conclusion
In this cross-sectional study in 3 countries in South Asia,
high ambient temperatures were associated with an
increased prevalence of IPV against women. These findings
highlight the additional vulnerabilities and inequalities
faced by women experiencing IPV in LMICs during climate
changes. The projected increase in IPV prevalence, particularly under the unlimited emissions scenario, highlights
the necessity for sustainable climate change mitigation
and adaptation strategies, as well as public health programs,
to address the IPV issue in climate-sensitive regions or
subgroups.
Published Online: June 28, 2023.
doi:10.1001/jamapsychiatry.2023.1958
Author Affiliations: School of Public Health, Key
Laboratory of Public Health Safety of the Ministry
of Education, and National Health Commission Key
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Ambient Temperatures and the Prevalence of Intimate Partner Violence Among Women in South Asia
Laboratory of Health Technology Assessment,
Fudan University, Shanghai, China (Zhu, He, Zaid,
Liu, Zhou, Chen, Kan); IRDR ICoE on Risk
Interconnectivity and Governance on Weather/
Climate Extremes Impact and Public Health, Fudan
University, Shanghai, China (He, Liu, Chen, Kan);
Helmholtz Zentrum München-German Research
Center for Environmental Health (GmbH), Institute
of Epidemiology, Neuherberg, Germany (He);
School of Forestry and Environmental Studies, Yale
University, New Haven, Connecticut (Bell); Gillings
School of Global Public Health, University of North
Carolina at Chapel Hill, Durham (Yuqiang Zhang);
Department of Community Health Sciences, Aga
Khan University, Karachi, Pakistan (Fatmi); School
of Public Health, University of Sydney, Sydney, New
South Wales, Australia (Ying Zhang); Department of
Environmental and Occupational Health, Muhimbili
University of Health and Allied Sciences, Dar es
Salaam, Tanzania (Bachwenkizi); Children’s Hospital
of Fudan University, National Children’s Medical
Center, Shanghai, China (Kan).
Author Contributions: Drs Chen and Kan had full
access to all of the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis. Mr Zhu and Dr He
contributed equally to this work.
Concept and design: Zhu, He, Bell, Yuqiang Zhang,
Fatmi, Zhou, Chen, Kan.
Acquisition, analysis, or interpretation of data: Zhu,
He, Fatmi, Ying Zhang, Zaid, Bachwenkizi, Liu,
Zhou, Chen, Kan.
Drafting of the manuscript: Zhu, He, Yuqiang Zhang,
Bachwenkizi.
Critical revision of the manuscript for important
intellectual content: He, Bell, Yuqiang Zhang, Fatmi,
Ying Zhang, Zaid, Liu, Zhou, Chen, Kan.
Statistical analysis: Zhu, He, Ying Zhang, Liu.
Obtained funding: He, Chen, Kan.
Administrative, technical, or material support: Zhu,
He, Zaid, Bachwenkizi, Liu, Zhou, Chen, Kan.
Supervision: Zhu, He, Bell, Yuqiang Zhang, Liu,
Chen, Kan.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by
National Natural Science Foundation of China grant
92043301 (Drs Chen and Kan), National Key
Research and Development Program grant
2022YFC3702701 (Dr Chen), Shanghai Committee
of Science and Technology grant 21TQ015
(Drs Chen and Kan), Shanghai International Science
and Technology Partnership Project 21230780200
(Drs Chen and Kan), and a grant from the Alexander
von Humboldt Foundation for the Humboldt
Research Fellowship (Dr He).
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Data Sharing Statement: See Supplement 2.
Additional Contributions: We thank the US
Agency for International Development (USAID) for
its contributions in data collection, cleaning, and
management.
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