Brand Extension and its Impact on the Parental Brand

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Branding is the subsequent creation of a distinct identity of a product or service. Byung, Jongwon, & Robert (2007) argued that branding develops a product or service base within a market, which determines its success. However, they also acknowledge that branding is not the only determinant for a successful brand in the market. It has to incorporate other issues such as factors of production and distribution within the market. As part of re-branding, brand extension has come up and notably recognized by organizations as a strategy when venturing into the same or new markets. The entire process of brand extension is used mostly in many organizations as a way of developing uniqueness in a market and distancing the product or service from others. Park & Srinivasan (1994) was of the view that branding establishes particular perceptions among the consumers because it instils a certain level of knowledge for the product or service and helps them have to establish a comparison with other products in the market. Marketing concepts have been advanced in the consumer market, which are linked to the entire process of branding. One of the major concepts is brand extension, which plays an important role in the market place. Reddy, Holak, & Bhat (1994, pp.276 – 285) asserted that effective brand extension is a great solution especially when establishing strategies for improving sales. In the international market, maintaining quality is the big issue. Therefore, it is important to understand how the entire issue can be handled. Of particular interest is the change expected among the customers. It is known that consumers change in terms of preferences, feelings and tastes (Pina, Martinez, De Chernatony, & Drury 2006, pp. 174-197). Therefore, the main issue is to ensure that the brand changes to fit the customers’ expectations. Chiefly, there is no better way to change brands other than brand extension. Therefore, organizations should work towards knowing issues that relate to brand extension and how best to carry out the practice. However, changing the quality means that the organization should have adequate knowledge of its customers and should have conducted an appropriate assessment in readiness to explore the market and introduce appropriate change to its customers.

Chiefly, it is realizable that the topic for brand extension is well studied. Scholars have detailed a lot in terms of concepts, issues and practices that are related to brand extension. However, these studied have one thing in common which is recommending for further study in the same field. They assert that understanding the brand extension phenomenon is critical for survival of brands in the market.This study will evaluate two fast moving consumer goods in the market including Colgate and Dettol. The two products have been ranked in the as having a reputable history in the market and having succeeded greatly from brand extensions. The main problem identified for the study is that within the market, there is huge competition particularly among products. FMCG have therefore sought strategies that could be of value in winning the competitive advantage and maximizing their profits from the vast population by being the preferred brand in the market. However, it is clear that not all strategies succeed and this is a risk to major companies within the market. Therefore, companies are desperate to understand the concept of brand extensions in an effort to succeed in the competitive market. The study will be aiming at analyzing three hypotheses. They include:

H1: high quality perceptions of the parent brand leads to positive attitude towards the extended brand extension

H 2: high quality perceptions of the parent brand contribute to the high reputation of the parent brand.

H3: high similarity in the process of product extension increases the possibility of brand extension

The study will be relevant for the marketers within organizations because they will develop an understanding of the impact of brand extension on the parent brand. It will also be valuable to the consumers in helping them realize the process of brand extension and elements that they need to look into. Byung, Jongwon, & Robert (2007) noted that achieving the first priority of the consumers is a huge change for organizations particularly in terms of their selection criteria to purchases. Understanding brand extension is therefore equally challenging and should be handled as an activity which enables the organisations to create effective marketing strategies.

brand extension sample by academic writing services

Background of the Problem

Competition in the global market has increased and more stakeholders continue to join the market. With the high level of competition, competitive advantage has been established as a major issue that needs to be accounted for within any organization. In this case there are many ways of winning the competitive advantage, which an organization can apply. These are strategies that will enhance the uniqueness of an organization and win the loyalty of customers. The common market strategies have been challenged because many organizations have capitalized on the including gifts, offers and promotions (Reddy, Holak, & Bhat 1994, pp.276 – 285). Therefore, it has become excessively difficult to change the strategies as well as approaches used in winning the customers’ loyalty. Pina, Martinez, De Chernatony, & Drury (2006, pp. 174-197) were among the scholars who noted that the only strategy that is still working in the modern market to win the competitive advantage of consumers is brand extension. In this case, other strategies as noted earlier have been so common among organizations and their applications are the same. Kwon & Leslie (2010, pp.276 – 285) noted that brand extension is ideal as one of the strategies because of its diverse nature. Brand extension is unique to the product or service, to the market and to the target audience. Therefore, it is the only way to ensure a successful strategy in the modern day as compared to other strategies. However, Pina, Martinez, De Chernatony, & Drury (2006, pp. 174-197) also noted that organizations have been challenged in the process of brand extension. This is because they do not have the proper knowledge of facilitating the entire process and they lack proper planning in establishing successful brand extension practices (Reddy, Holak, & Bhat 1994, pp.276 – 285). Reddy, Holak, & Bhat (1994, pp.276 – 285) emphasized that there is a wide range of literature on this issue but of major importance is to conduct a study that will facilitate adequate data collection on the brand extension practice.

Literature Review on Brand Extension:

The literature review for this study will be specifically aiming at answering the question for brand extension and its impact on the parental brand. This study will be based mainly on seven studies that investigated the topic identified for this study. Völckner & Sattler (2007, pp. 149-162) are some of the scholars whose studies will provide a base for this study. They looked specifically at the negative impact of brand extensions. In this case, they concentrated on how the parent brand is affected negatively by the extension process basically assessing and criticizing the process of extension as used by different organizations. The general approach from their study is how consumers evaluate brand extensions. From their study, we develop the knowledge of what needs to be done in order to establish appropriate brand extensions which are successful and beneficial to the parent brand. The ideal approach would be appropriate in addressing the main challenges associated with brand extensions and strategizing towards the increased productivity and profitability of a company. Other major scholars that will be a basis for this research include Pina, Martinez, De Chernatony, & Drury (2006, pp. 174-197). Their works was an empirical study which necessitated a model developed to establish an explanation on brand extension.

However, they were also concerned particularly with the service brand and how the extension process affects their position in the global market.Their study is a major contribution on the knowledge required to understand the topic better. From their study, information on brand familiarity, brand equity and other brand terms can be outsourced with proper definitions and explanations making it most relevant for the present study.Pina, Martinez, De Chernatony, & Drury (2006, pp. 174-197) argued that it is important for any brand to establish consistency particularly when venturing into the market. In this case, their efforts were to explain brand extensions and the changes they bring within the market. They highlight the negative changes but also show the positive side of the process in facilitating sales within the market. They also evaluate some of the concepts involved in brand extension practices such as honesty and integrity and the need to have them in place when conducting brand extension. From their works, they also affirm how the extension process needs to be strategized to avoid failure and how organizations can benefit from the entire process.Their works were supported by Kapferer (2004) framework which of the same view arguing that “…identity expresses the brand’s tangible and intangible characteristics – everything that makes the brand what it is, and without which it would be something different” (p. 67). In his framework he aims at explaining brand relations in relations to the heritage of the parent brand and establishing the relationship between the two.

Other scholars whose work will be a basis for this study will be Roedder-John, Loken, & Joiner (1998, pp.276 – 285). The scholars conducted a number of studies, which were related to the topic for brand extension. In their study, they were of the view that risk reduction should be considered as an important aspect in practising brand extension. In this case, risk reduction is particularly considered as a process targeting the reduction of sales for a given product or service brought about by market challenges including competition and level of quality. In risk reduction, the scholars come up with an argument on the need to have a better strategy in shifting from the parent brand to ensure that consumers are happy with the new product. However, they also necessitate the argument that not every extension process is successful and thus every organization needs to know its way of facilitating the extension process to achieve success and benefit from the same.

From their study, we also establish that further study is necessary particular to cover the gaps of knowledge identified in relations to the topic at hand.Martinez & Chernatony (2004, pp. 426 – 432) were other scholars who noted that extension is either a success or failure depending on the strategy established by an organization. However, they also note that in most cases, extensions are successful because the organizations normally strategize in detail and they plan way ahead of time to venture into the market with the new product. However, they also argue that nor all extension strategies are successful and thus there is need to conduct a study that can provide a discussion on the challenges and difficulties that lead to failure of brand extension strategies.Therefore, they also recommend further study in order to establish a better understand of the brand extension practice.

From the works of Chung & Anne (1996, pp.24 – 37), this study draws information on types of extensions which may be relevant for companies in different ways. Their works explain the use of horizontal brand extension. In their discussion, they assess the successful and the failed brand extension strategies to facilitate a better understanding of what happens in the entire process. Their study will be relevant in helping understand horizontal extension. In horizontal extension, a parent brand shares identity with the new brand in an effort to establish their relations. However, it is not clear as to how the relations affect both particularly because of the sharing of identity. Therefore, in their recommendations, they argue that it is important to conduct other studies and link them to this discussion in an effort to establish a deeper understanding of the topic at hand.Chung & Anne (1996, pp.24 – 37) further provide descriptions of vertical brand extension, which is also relevant information for this study. They argue that for vertical brand extension, it involves a firm facilitating a launch in a new or the same market for a new brand. However, they argued that in most cases, the launch involves a new product particularly of different quality. Their argument is that reduced popularity of a particular product provokes the need for brand extension. This is in an effort to renew the product and enhance its market prominence. Once the brand is well-established, the extension targets the increase in sales, which is important for the growth and development of a given company.Therefore, the information obtained from the study will be relevant in understand the topic for this study better.

However Kwon & Leslie (2010, pp.276 – 285) were among the scholars who criticize the need for brand extensions.In this case, their study their argument is that in most of the extension practices, the parent brand is weakened. Therefore, they establish the argument that this is a huge risk that organization cannot afford to take if they are to survive in the vast market. Their study is therefore important in understanding the perceived risk of brand extensions and how to avoid them when practicing. One of the elements they observe as a weakness for brand extensions is the negative perceptions that emanate from the extensions. They argue that in most case, consumers are comfortable with the parent bran. Therefore, any change in the parent brand has negative impacts, which are not desired for a given organization. They are also of the view that it is not necessarily that brand extension fails. The main issue is that a brand extension may succeed but the beliefs and perceptions of the consumers change negatively. Since the consumers are the main target for the extension, such a strategy can be accounted a having failed. However, they are acknowledge that proper planning and strategizing is critical for ensuring that organizations succeed in any given brand extension strategy.

In general, seven studies will be mainly used as the basis for this study. However, the study will also incorporate other studies from other scholars who have also provided results and findings related to this topic. Additionally, this research will be based on the conceptual-theoretical research method. Among the topics that will be covered in this study include role of brand extension, horizontal brand extension, vertical brand extension, brand extensions benefits, risks associated to brand extensions, and impact of brand extension on the parent brand.


Research Design

This study will use both secondary and primary research methods. The two methods have been used in other studies and they have been successful in proving the research hypothesis and meeting the research objectives, which is why they are verified as applicable for this study.Secondary research will be aiming at looking the previous works of other scholars. The main aim will be to assess what has been done to identify what needs to be done. Primary research will also be necessary after the gaps of knowledge have been identified. This will be in an effort to conduct a study and establish a better understanding of the identified topic. The main aim will be to identify and support the research objectives for the study.A survey will be used in this study to evaluate the people perceptions on brand extension and the impact it has on the parent brand.

A survey will be preferred for this study because it will help the researcher to generally build a holistic research study in a natural setting. This will also be valuable because the research will secure data directly from the consumers who have used the identified products including Dettol and Colgate and have different perceptions regarding brand extensions of the same products. Diversity of perceptions will also be relevant in providing data to be used as a basis in future study.

Research Approach

To test the above-mentioned hypotheses, two fast moving consumer goods (FMCG) brands will be chosen for this study. The choice of the FMCG for this study will be based on the success of previous studies that have also used them to evaluate cases of brand extensions. To identify the brands to use in this study, secondary data will be used. The brands will be purposively selected based on previous data provided by publications in the vast UK market. Of great importance will be surveys that have been conducted in the market on the most trusted brands in UK. Therefore, the information from these publications including the Economic Times and business news daily will be valuable in understanding the brand to choose for this study.

Of particular interest will be columns published between 2004 and 2011, which contained most of the information including fast moving consumer goods reports. The reportswill provide information from over 7000 people across UK regarding the FMCG in the market, which makes it immensely valuable for this study. It is also relevant because information was sought from diverse socio-economic class, age groups, income levels and geographical areas. Therefore, the information is a representation of the perceptions of the entire UK population. Times Intelligence Group which conducted the study ranked the most trusted brands in UK based on different attributes including: price premium, high level of quality, popularity for many years as a brand, evokes confidence and pride among the consumers and has a strong bran recall. Therefore, the brands chosen are definitely appropriate for this study. The two brands chosen in the FMCG category will be Colgate (ranked 1) and Dettol (Ranked 4). They are also great brand used regularly by almost everyone across UK, which makes data collection easier for the study.

Population and Sampling


The vast population for this study will be students within the UK market mainly in institutions of learning. In this case, university students will be identified for the research because it engages participants who are readily available. The population will also be relevant for this study because it integrates all the relevant demographics for the study. Some of the important demographics include age, gender, and education level.


Simple random sampling will be used in this study. The method has been identified as valuable for this study because of the nature of the required participants. Simple random sampling is critical because it gives everyone within the target population a better and equal chance of taking part in the study. Therefore, the method allows for diversity and equality in the research, which are important in collecting reliable and valid data for the study.In conducting huge research studies Creswell (2003, pp. 78 – 81) argued that simple random sampling is better because it is representative of everyone within such a population. Another major reason of using this method is to enhance the selection of unbiased sample. A total of 50 participants have been identified as ideal for this study to represent the entire population of the UK market.

However, the sample will also be divided into demographics of age, gender and education level. These demographics have been identified as important because they will ensure that the sample is representative of diverse views from the different social and economic classes. For age, the diversity is important in ensuring that the range of experience is included in the data provided. Gender equality will also be a key issue that will be relevant in enhancing equal representation of views and perceptions relating to the identified topic. For the education level, this is important in enhancing a greater representation of diverse experiences in marketing particularly in relation to the topic for brand extension.

Data Collection

A structured questionnaire has been proposed for this study. Creswell (2003, pp. 43 – 52) defined a structured questionnaire as an instrument that includes a set of questions, which are standardized in a way that the research respondent only provided direct responses without explanations. In this case, the questionnaire will be in form of choice provided for each question for the study. The respondent will only have to make a selection for the choice that he or she thinks that it matches his or her response. The structured questionnaire has been preferred for this study because it is straight to the point and it generates reliable and valid data for any study. This is because before the questionnaire is used; the questions are set based on the research objectives. Therefore, the researcher is sure that every question set is relevant for the study and that everything will aim at developing data that is critical in answering the research question.

In this study, separate questionnaires for all the two brands including Dettol and Colgate will be developed. Standardized constructs for the structured questionnaire will be used to measure the perceived risk, brand reputation, service quality, similarity fit, and overall brand extension. The questionnaire will incorporate questions on brand satisfaction, consumer attitude and brand reputation. This will be linking the perceptions of the consumers for both the parent brand as well as the extended brand. To enhance validity and reliability of the instrument identified for this study, they will be sent to professionals including my supervisor to ascertain that the questions asked are valid and will be relevant in answering the research questions for this study.

Data analysis

This study will develop the Central Limit Theorem as the basis of analysing the collected data. The theorem explains that parametric research is important for any study that exceeds 0 participants in the selected sample. Therefore, with the sample for this study being 50 participants, this is the ideal method to apply in the analysis process. The study will involve manual calculations for the responses to the questionnaires. Manual calculations will include establishing the frequency of particular responses to the questions and noting them done. Later, percentages will be calculated in an effort to simplify the data analysis process for this study. Figures, charts and graphs will be developed after the analysis to present the data in an easy to understand way. In general a quantitative analysis will be thenature for this study to enhance easy discussion and presentation of data.

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Chung K. K., & Anne, M. L 1996, ‘Vertical brand extensions: current research and managerial implications’, Journal of Product & Brand Management, 5(6), pp.24 – 37

Creswell, J. W 2003, Research Design: Quantitative, Qualitative, and Mixed Methods Approaches, SAGE: Thousand Oaks. USA.

Kapferer, J. N 2004, The New Strategic Brand Management: Creating and Sustaining brand equity Long term, Kogan Page, London, U.K.

Kwon, J. & Leslie, T 2010, ‘Searching for boundary conditions for successful brand extensions’, Journal of Product & Brand Management, 19(4), pp.276 – 285.

Leedy, P. D. & Ormrod, J 2001, Practical Research: Planning and Design (7th Ed.), Upper Saddle River, NJ: Merrill Prentice Hall

Martinez, E. & Pina, J. M 2003, ‘The negative impact of brand extensions on parent brand image/executive summary’, The Journal of Product and Brand Management, 12 (6/7) pp. 426 – 432

Pina, J. M., Martinez, E., De Chernatony, L., & Drury, S 2006, ‘The effect of service brand extensions on corporate image’, European Journal of Marketing, 40 (1/2), pp. 174-197

Roedder-John, D., Loken, B. & Joiner, C 1998, ‘the negative impact of extensions: can flagship products be diluted’, Journal of Marketing, 62(1), pp. 19-32

Völckner, F., & Sattler, H 2007, ‘Empirical generalizability of consumer evaluations of brand extensions’, International Journal of Research in Marketing, 24(2), pp. 149-162

Domestic Violence in Nigeria

Overview of Domestic Violence

Violence against women has attracted international attention due to its alarming increase and has, thus, been recognized as a human rights violation. It violates and nullifies the fundamental human rights of women throughout the world. Violence against women results from social (practical), religious and cultural ideologies that accord to the male gender supremacy and domination over the women.

The United Nations General Assembly recognized violence against women to be a “manifestation of the historically unequal power relations between men and women”, which ultimately results in discrimination against women. It passed the Declaration on the Elimination of Violence Against Women. Despite the ratification of the Convention as well as the popular enthusiasm for it in many nations, the declaration remains merely a declaration, in many African countries, including Nigeria. This act of non-compliance with the provisions of the Convention has further lead to adverse discrimination against women.

The failure of state interventions in Nigeria to address domestic violence in policy and legal terms has meant the neglect of the plight of women as a population. This phenomenon derives not only from historically unequal structural relationships between men and women, but also from its relationship with the entire edifice and mentality of governance. Understanding this relationship requires unmasking and analyzing the interaction between historical and prevailing mentalities of governance, and the governance of women as a population and the problem of domestic violence. In other words, given that domestic violence has been a major problem affecting women over the years, how have the regulatory practices changed? What are the forms, contents, contexts, and constitutionality of these regulatory practices? These issues motivate this study. Addressing these questions will clarify the legal framework and principles that guide these regulatory practices. Advocacy and legal reforms demand this clarification and require, first, appreciation of the extent and scope of domestic violence in Nigeria.

domestic voilance

Statement of the Problem

In Nigeria the family unit is regarded as sacred it is the woman’s duty to preserve the home, at all cost. Any act of violence meted out to her is often endured for fear of social ridicule, or she would be taken to have failed in her duties. The man is to use any amount of control to check his wife, and any restraint by him would be taken as an indication of weakness. Nigerian Laws entrench this cultural stereotype.

Domestic violence is an area where women’s rights are routinely abused and where women have little legal recourse. In most African societies such abuse manifests itself in forms of female genital mutilation, child marriages and labor, rape of women and girls, child slavery, suppression of dissent in the family, wife battering, and widowhood rituals. This study restricts to battering relationships. This issue lacks adequate recognition in Nigeria despite its implication for human rights. According to Omorodion (1992), cases of domestic violence increased by 100% between 1982 and 1988. Lack of published data on domestic violence tends to mask the reality of its scope, rate, intensity and incidence in Nigeria.

Yet, public opinion, media attention and increasing attention of state government, judges it that, domestic violence is alarming in Nigeria. More importantly, in a statistic released, the Canadian and United State Immigration departments report that, most African women applying for refugee status and asylum do so on grounds of domestic violence and the absence of effective legal protection from it. As a result, domestic violence has induced migration of women from Africa thereby exposing them to uncertainties despite the potency of grassroots’ advocacy and legal instruments in some democratic countries in Africa. This phenomenon places enormous responsibility on the legal system to have laws at protecting women more adequate. Still, no enabling law protects women from violence. For instance, Section 55 of the Penal Code of Northern Nigeria exacerbates matters by placing the discipline of women and children in the hands of husbands, thereby encouraging women to suffer in silence. Asserting their legal rights in the face of naked provision to protect them would definitely be detrimental to them. What does the Matrimonial Property Act offer a woman who leaves an abusive relationship after slaving in her home? This depends on the form of marriage contracted: either under English or Customary law.

Nigeria being a developing country, a greater section of the populace are uneducated and dwell in poverty. Education is important for the issue of violence against women in Nigeria, since it generally raises their awareness of legal and constitutional rights. Some women have made considerable individual progress in academic and business world, but women remain discriminated against in their access to education for social and economic reasons. In Northern Nigeria, Muslim communities favor boys over girls in deciding which child to enroll in schools. In the South, economic hardship also restricts many families’ ability to send girls to school; instead they are directed to commercial activities such as trading and street merchandising.

More importantly, presently, only one shelter exists in Lagos (Western Nigeria) for victims of domestic violence and their children. Many factors are responsible for this, including lack of sponsorship, lack of trained personnel, and the need to protect family privacy. If however, the government decided to treat this crime as a grievous offence, then facilities to deal with it would receive funding. The family unit is one which deserves much attention. In Nigeria, it is held in high esteem, and if all is done to protect it, this would go far to reduce crime in the nation. The government needs to be sensitized and motivated to enact and promote both the law and the policy reforms that would create an awareness of the offence of domestic violence and thereafter deter it.

Poor or no awareness of the crime of domestic violence has resulted in the lack of adequate data on the incidence of domestic violence. The attitude of law enforcement agents and sometimes the victims has resulted in little or no prosecution of the offence: it is considered a mere matrimonial dispute, to be resolved between the parties.

Asserting their rights due to the “codified and uncodified” norms work against women. This situation, however, does not mean that some women have kept silent about this injustice. Many non-government organization (hereinafter called NGO) in Nigeria have brought this violation of women’s rights to light, this has had little impact in the Nigerian society. The mentality of the people still remains. The women are not bold enough to assert their rights and they shy away from reporting to the law enforcement agents. Some women due to their economic dependency on the men, perceive wife battering as acceptable discipline. In some cases, where there has been grievous assault, which often leads to a criminal prosecution, women often plead for leniency on behalf of their husband, in order to prevent the men from being incarcerated. Other suitable methods ought to be examined since a criminal charge might not be effective.

dissertation service ukObjective of the Study

The objectives of this study are threefold: to examine the incidence of domestic violence in Nigeria, to unravel further the legal framework and policy alternatives around domestic violence in Nigeria, and lastly, to examine the mentality or ideologies behind the legal framework. To achieve these objectives, the legal and policy thrusts of Canada are reviewed in the Nigerian context, so as to offer adequate reforms to the Nigerian government.

However, for a proper appreciation and understanding of this research, it is important to recall the history of Nigeria and its culture.

Introduction to Nigeria

Nigeria covers 913,072.64 kilometers in West Africa, located on the gulf of Guinea; it shares its western border with Benin, its eastern border with Cameron, with Niger to its North and Chad in the North-East. The local currency is Naira. With a population estimated, 130 million, Nigeria is the most populous country in Africa and has over 400 ethnic groups, with each having their own peculiar form of cultural organization in terms of language and dialect, social customs and beliefs. Nigeria is also Africa’s leasing oil producer. The capital is the Federal Capital Territory Abuja; its major cities include Lagos (the commercial capital), Ibadan, Kano, Ogbomosho, Abeokuta, Ilorin and Port Harcourt. English is the official language in Nigeria; however, over 250 other languages are spoken including Hausa, Yoruba, and Ibo. The major ethnic groups are the Hausa, Igbo and Yoruba. No single tribe encompasses a majority of the population. In Africa, Nigeria seems to stand on her own due to her size, diverseness of language, the development of resources both human and material and the vast increase in the population of the people.  In this research references will be made to the major ethnic groups in Nigeria, it is therefore necessary to state a brief introduction to the Nigerian culture.

The Yorubas

The term “Yoruba” refers to the people, the language spoken by this tribe, and can also be used to refer to the geographical location of this tribe commonly referred to as “Yoruba Land”. The Yoruba’s are mainly found in the South-Western part of Nigeria, which includes Lagos, Ogun, Ekiti, Ondo state and the South-Eastern parts of Kwara state J.S. Eades, (1980).

The various tribes in Yoruba land trace their origin from Oduduwa, the father of Yoruba land and the founder of Ile-Ife whence Yoruba civilization emerged I.A. Akinjogbin, B. Adediran, (1985). Thus Ile-Ife is regarded not only as the cradle of Yoruba people, but also where the religion common to them originated, since Oduduwa was the sacred king from whom Yoruba civilization began J.A. Atanda, (1980). His seven sons are believed to have founded the other Yoruba kingdoms.

The Igbos

The word “Igbo” refers to the “speaker of the language, their area of occupation and the language spoken by this group of people”. The Igbo’s are mostly found in the Eastern part of Nigeria, and occupy a total of 15,800 square miles. The Igbo people have been found to be mobile (but not nomadic) and are seen in almost every part of Nigeria, African and some countries abroad due to the preference to trade: hence they are referred to as the “go – and – get people”. Structurally, the Igbo culture has an egalitarian social pattern, but practice does not conform to it, within the family, authority is vested in the first son usually referred to as “Opara”. Elders in the Igbo community are respected and honored.

The Hausas

The Hausa’s are made up of Sudanese people whose fusion form an area occupied by Hausa people now referred to as Hausaland S Rakow, “Ethnicity in Nigeria”. Thirty-eight percent of all Hausas are in the North and North-West regions of Nigeria. This region extends from Nigeria’s western boundary eastward to Borno state and into much of the territory of southern Niger. Although English is recognized as Nigeria’s official language, Hausa, is rapidly becoming the chief language of Northern Nigeria. Only about half of the population are literate. Women usually do not work in fields, but are responsible for preparing meals at home. Many Hausa women are confined to their homes, except for visits to relatives, ceremonies and the workplace, and seldom receive access to western education.

The governorship of Sir. Frederick Lugard lead to the creation of Nigeria in 1914 with the amalgamation of the protectorates of Northern and Southern Nigeria Reuben K. Udo, (1970). This administration further divided Nigeria into three unequal political regions: the North, being the largest and most populous where the Muslim Hausa and Fulani are mostly found; the West, which presently is dominated by the Yoruba, and the East, where 60% of the Christian Igbo form the largest groups United Nations High Commissioner for Regugees, (2000).

Nigeria gained independence in 1960. As a result of this, a new federal structure was adopted in 1968 which led to the creation of 12 states which was further increased to 19 in 1976 M.A. Kwamena-poh, (1985). A Federal Capital Territory was established in 1979, and, by 1996, the number of states increased to 36, as obtains presently. Independence freed Nigeria from colonial rule, but still had its disappointments. Firstly, the unfair trading terms adopted during the colonial period between Nigeria and other developed Western European countries were not altered after independence, this slowed the pace of Nigeria’s economic progress. Secondly, Nigeria and her neighbors disputed borders, thirdly, Nigeria was weakened both by the Biafran civil war of 1967-70, in which various infrastructure were destroyed and. also by successive military coups.

Nigeria became a republic in 1963, with its first president late Dr. Nnamdi Azikiwe. Since then, the nation has suffered from series of military coups; in the thirty-one years of military rule, human rights violation took various forms

Nigeria is a transitional state, having emerged from military rule to a democratic government. During the regime of General Sani Abacha president from 1993-1998, many Nigerians suffered human rights violations. His sudden death changed the political landscape, and led Nigeria into democratic rule. General Adusalam Abubakar, replaced General Abacha, and handed over power to a democratically elected president, General Olusegun Obasanjo in May 1999 (a former military ruler, who had handed over power to an elected president in 1979).

Domestic Violence in Nigeria


Mojubaolu Olufunke Okome (Assistant Professor Department of Political Science, Brooklyn College, New York) characterizes African women as “juridical minors” who are under the care of their fathers during the early stages of their lives; this duty of care is then transferred to their husbands after marriage N Sudarkasa, (1996). Traditionally, they are property of the father of birth, and of the husband on the payment of dowry; and are made to feel inferior to men. Despite the prevalence of this tradition, other writers still note the independence of African women, especially in trade. Others have stated that the roles played by both African men and women as complementary D Paulme, (1963). Yet the classification of the characterized role of African women depends on the era in question. Much attention has recently been directed to the liberation of African women from their cultural ties.

Domestic violence in Sub-Saharan African countries has its roots, amongst other factors, in the cultural traditions of the people. Nigeria is blessed with a rich culture with over 400 ethnic groups each possessing its own peculiar beliefs and traditions. Unfortunately, some of these traditions are discriminatory towards women, and account for the persistent domestic violence against them. The women might not perceive these discriminatory traditional practices as violence, but rather as part of the tradition that must be fulfilled. Nigeria is basically a patrilineal society. Amongst the various cultural groups in Nigeria, descent and inheritance pass to the male side of the family only. A matrilineal system is found amongst the Yako in Cross River State and amongst the Ohafia in Imo State, under which “inheritance passes through the female side of the family” O.Y. Oyeneye, (1985).

In contemporary Nigeria some women have made considerable individual progress in all sectors of the society. Despite this, a greater percentage of women are still being discriminated against in areas such as the acquisition of land (in some traditional societies), leasing of properties (single women are believed not to be credit-worthy), politics and marriage (in some cultures girls are not given the right to consent in their choice of partners, husbands are chosen for them and occasionally, older men). The discrimination suffered by the Nigerian woman over land acquisition runs counter to their fundamental human rights guaranteed by the Nigerian constitution, which states that

“Subject to the provision of this constitution, every citizen of Nigeria, shall have the right to acquire and own immovable property anywhere in Nigeria” Constitution of the Federal Republic of Nigeria, (1999).

This section has no qualification, rather, it confers on every citizen the right to acquire immovable property. Traditional societies have, however, imputed customary limitations into this section. In a liberal society, where the rule of law reigns, the law seeks to protect all classes of individuals in the state and does not reserve rights to a particular class. The Nigerian Constitution expressly states that

“everyone is entitled to freedom from discrimination on the grounds of sex, ethnic groups, place of origin…”.

The rights of women in the family are central to their rights as individuals. Violence in the family has been ignored for too long in Nigeria, as is evidenced by the laxity with which the law, courts, law enforcement agents, and the society in general view this issue. The home is the seat of violence for most Nigerian women as revealed in the media. This violence has received less attention and made less of a structural impact on the government and Nigerian society at large. Basic stereotypical cultural barriers prevent it from being viewed as a violation of women’s rights.

Violence against women according to the United Nations official definition, includes

“Any act of gender-based violence that results in physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life”.

Domestic violence related to violence within but not limited to the family. Within the family context, the manifestation of domestic violence is not only seen as physical assault, which is the common stereotype associated with it, but includes instances of sexual, psychological and emotional abuse, which affects the health of the victims R. Bird, (1997).

This section is an introduction to domestic violence in Nigeria. What is perceived as domestic violence in Nigeria? It will also examine the scope and dimensions of domestic violence in Nigeria. This examination is essential in order to offer adequate solutions to this problem in ways that would be embraced by Nigerian society and would not be offensive to any particular cultural group since each tribe guards the issue of tradition jealously. To further this examination, the origin of violence against women will be addressed. A historical analysis of violence against women, through the lens of colonialism, provides vital basis for understanding the genesis of violence in the Nigerian society and will reveal the impact of colonialism on this issue in Nigeria.

professional assignment writersTheories of Domestic Violence

Theorists have explained the causes of domestic violence from different perspectives. Among these, exchange, resource control, culture of violence, patriarchal, ecological, and social learning theories are widely used (Levinson 1989). My research explores linkages among global economy, gender inequality, and domestic violence at the cross-national level. I have not discussed theories that have included the following issues: cost- benefit (exchange theory), status inconsistencies among the people, ambiguous norms of the society, material as well as non-material resources (resource control theory), or personal behavior that people learn from the family (social learning theory) (Levinson 1989). I utilize only two theories, patriarchal and ecological theory. Patriarchal theory has explored the association between gender inequalities in access to resources and domestic violence both at the micro and macro levels but has not explored the causes of gender inequality using development variables. Ecological theory has emphasized combining structural, cultural, institutional, and individual level variables to explore the causes and aspects of domestic violence.

Patriarchal Theory

Patriarchal theorists focus on patriarchal ideologies, which refer to systems of belief, values and ideas that support men’s domination over women and depict that domination as natural (Hartmann 1990; Hayward 2000; Websdale and Chesney-Lind 1998). This theory argues that men have dominated most of the societies in this world in different phases of development. Conversely, men have classified women as subordinate to them, while norms and laws support husbands’ control over their wives. As a result, violent behavior becomes a means of controlling women (Mies 1986; Zaman 1998).

While patriarchal theory resembles resource theory, this theory emphasizes forces that operate at the societal level. These include control over women’s sexuality, marriage and reproduction, preferences for a male child, and differential access to food and formal education (Zaman 1998).

Patriarchal theorists have also identified the social construction of production and reproduction as the basis of domestic violence and have focused on the social relations of gender and work (Zaman 1998). Women’s housework must be examined with greater importance, as it has implications for the abuse of women, both within the household and in the current global production process (Mies 1986). Patriarchal theorists argue that unequal access to economic resources and political power is the main reason for domestic violence. However, patriarchal theorists overlook the effects of the global economy on the gender inequality. They have also ignored that levels of gender inequality are not the same for all societies, which may be an important reason for variations in domestic violence rates.

Ecological Perspective

The ecological perspective emphasizes the social contexts of family violence (Levinson 1989). Several researchers have applied the framework to analyze child abuse, wife battering and violence against women (Heise 1998; Shrader 2000). This model seeks to demonstrate that one level or one set of variables cannot be the only determinants in explaining violence in a given society or across societies. Several levels or sets of variables combined together capture a situation that can explain the causes of violent behavior in a group of people. This framework consists of four levels of analysis, best visualized as four concentric circles. The inner circle consists of personal or individual factors that each individual contributes to yield violent behavior. The next circle consists of micro-system factors that contribute to the immediate context in which violence may take place. The exo-system level encompasses both formal and informal institutions and social structures. The final level, the macro system, represents the general structural or cultural ethos that condones violence as a means to settle interpersonal disputes (Heise 1998). There are two limitations of this model. First it has not incorporated the global economy or development factors, so the variations in the economic development of different societies remain unexplored. Second, the model also has failed to examine the variations of nation-states’ locations in the global economy. Further, the current ecological framework does not acknowledge any level that may incorporate nation-states’ location in the global economy.

Domestic Violence: Cultural or Structural Problem Of Globalization?

Evidence suggests that domestic violence exists at different levels in all societies around the world (Bergen 1995; Hartmann 1990). Such violence is condoned and even explicitly legalized as an acceptable way for husbands to discipline their wives. Several studies have found that power relations between husbands and wives, occurring as the result of either economic conditions or the patriarchal nature of the society, or both, are the cause of domestic violence (Kalmuss and Straus 1982; Websdale and Chesney-Lind 1998).

Levels of wife beating are highest when the family norms are the most patriarchal (Hayward 2000). In a study among 604 Toronto women, Smith (1990) found that men who adhere to patriarchal ideologies are more likely to abuse their wives or partners. In societies where the state, legal system, and other institutions uphold patriarchal notions, wife beating is high, even when wives hold high positions in the workplace (Smith 1990; Websdale and Chesney-Lind 1998; Yllo and Straus 1984). Although almost all societies possess some form of patriarchy, patriarchal relations may vary by culture, as do women’s economic opportunities (Websdale and Chesney-Lind 1998). Quoting Kate Miller (1969), Smith (1990) argues that different forms of patriarchy are reinforced by the acts of different agencies, including the state and other various economic organizations. These social and economic organizations act as energy sources for patriarchal domination (Smith 1990).

Some researchers have found that institutions such as the state, religious organizations, and legal systems refuse to acknowledge domestic violence and maintain men’s superiority over women (Ameen 2003; Osirim 2004). For example, a woman’s inferior status is reinforced by the patriarchal society, and revealed through the proud mother-in-law’s statement, “My son keeps his wife at the end of a stick,” and reinforced by religious institutions via some cliché, e.g. “The part beaten by (one’s) husband would go to heaven” (Ameen 2003).

Law enforcement agencies also uphold patriarchal values by treating wife-killing as less serious than other forms of violence. Such negligence is observed in countries that do not have any laws on domestic violence. Countries where there are no laws against domestic violence and where these crimes are considered under the laws against common assault, fines for such crimes are often a very small amount of money, failing to deter such crimes (Ameen 2003; Osirim 2004; Wing 2000). Within the states both decision-making regarding the legal and the economic system and enforcement of such decisions are substantially in men’s hands. Ghana does not have any specific legislation on domestic violence. Subsequently, men feel that abusing their wives is their legal right (King 2000). In Palestine, almost 50% of husbands believe that it is their fundamental right to beat their wives if they think their wives are not performing their wifely duties (Wing 2000). Even though women are considered equals to men under their constitution, in reality, the absence of domestic violence laws provide men some right to physically abuse their wives.

Some researchers have argued that domestic violence is linked with the global economy (Bowman 2003). For example, African societies are in transition from traditional cultures to modern and urbanized societies. Many violent quarrels have escalated because of social changes and men’s sense of threat. Quarrels erupt because of women’s growing independence as they take “second” jobs and interact with other men.

Women face difficulties in performing household work in traditionally expected ways when they also work in the cash economy (Bowman 2003). Moreover, traditional norms may now fail to control men’s behavior. In the past, although men controlled household resources, they were seen as collective resources to be used for the good of the other family members. Now, income and resources have become more individualized (wages, for example, rather than herds of cattle), and the man may see them as his alone (Bowman 2003).

Osirim (2004) describes how the Economic Structural Program (ESAP) adopted in 1990 by the Mugabe government in Zimbabwe has led to economic violence against women and perpetuated domestic violence. Under the ESAP program, the government has retrenched over 40,000 workers, most of them men. The Mugabe government has encouraged retrenched workers to look for alternative jobs in private entrepreneurships, or to work in the informal economy. The incomes are lower than in the formal sector, and as a result, the dependence on women’s incomes from subsistence crops or other sources has increased. In such situations men who have failed to fulfill their expected gender roles leave their families. As a direct result, female headed households have increased up to 31% in 1990 (Osirim 2004). However, not all men can migrate, and as a result, physical abuse increases as men take out their frustration on their partners. The Musasa Project, an NGO that has provided counseling services to survivors of domestic violence, reported that 42% of the women who received counseling between 1988 and 1998 suffered from domestic violence resulting from economic violence (Osirim 2004).

Studies on the effects of women’s formal work on women’s status indicate that the mobile nature of the MNCs has a negative impact on women’s lives. Garment factories as well as agricultural plantations are constantly shifting from Caribbean countries to Asia, and Asia to Caribbean countries. Women who work in these factories lose jobs after working for some time; such loss of jobs has a negative impact on women, because economic crises at the household level negatively affect gender relations and women become the victims of spousal abuse (Ward and Pyle 1995). Qualitative studies conducted in Mexico, Ecuador, and some other Latin American countries reveal that domestic violence becomes high when women cease working outside the home (Oropesa 1997; Pickup, Williams, and Sweetman 2001). Studies also noted that when garment workers became unemployed in Bangladesh, dowry demands and dowry-related abuse at home increased (Akhter and Ward 2004; Ward, Rahman, Islam, Akhter, and Kamal2004). Dowry is a social practice where grooms demand cash or goods from brides’ families. Researchers have found several restrictions in women’s upward mobility affecting domestic violence rates (lack of access to formal work or productive assets, weak bargaining power compared to their male partners in economic transactions, and limited access to institutional credit) without improving their status at home (Bowman 2003; Mannan 2002; Pyle and Ward 2003; Schuler, Hashemi, Riley, and Akhter 1996; Ward, Rahman, Islam, Akhter, and Kamal 2004).

In summary, domestic violence has multidimensional aspects: structural, cultural, economic, social, and individual. Until now most studies on domestic violence have focused on either resource constraints, laws, or social constructions of masculinity and feminity. Few researchers have discussed the effects of global economy policies on women and men’s life at the household level (Bowman 2003; Osirim 2004; Ward and Pyle 1995). Theorists have not yet explored at the macro level how gender inequality shapes the context for domestic violence. In this research I combine components of the global economy, culture, and gender inequality to find out how these factors jointly make women subject to domestic violence. In the next section, I propose a model that explores linkages among the global economy, gender inequality, and domestic violence.

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History of Gender Violence in Nigeria


The structure of the Nigerian society during the pre-colonial days was patrilineal, which is still a common feature in most African societies. Hence, women married into “a Yoruba or Igbo patrilineage or a Hausa gandu” C. Dennis, (1987). The gandu is

“a voluntary, mutually advantageous, agreement between father and married son in which the son works in a subordinate capacity on his father’s farms in return for a variety of benefits including a share of the food supplies” C. Gore, (“Social Exclusion and Africa South of Sahara: A review of Literature”).

Typically, women lived in seclusion, but engaged in private trade from their homes. The Islamic religion restricted Hausa women to their household. This practice is called purdah. Women in Purdah were forbidden to be seen by other men excluding their husbands, and were therefore kept in seclusion. However, some women still have to earn a source of livelihood for their families due to the limited earnings of their husbands. This seclusion was not the case in all Nigerian communities, as oral tradition recalls female oba’s (kings). In Pre-colonial Nigeria, tribal culture dictated, the role women played in the society. Women contributed to the political affairs in their various communities through power obtained by inheritance (in cases where the matrilineal structure of inheritance was practiced, or where only females were born into a family) or by being married into ruling families M. Rojas.

The Yoruba riverain Igbo women had the prosperity to acquire more wealth than their male counterparts due to their unilateral control of trade and profits made in this was invested into further trade N.E. Mba, (1982). However, the women in the inland areas (a less developed area) did not have this advantage, rather they used the profits to feed their families. In other societies, such as the Ibibio, where each sex had specific roles, the women formed strong organizations and had political influence on the basis of collective strength. Another avenue through which women exercised political power, in areas that lacked political organizations such as among the Efik, Edo, Kalabari, Ijo and Itsekiri women was either through the office of the queen mother who was seen as a female ruler or through relationships with male rulers as the queen. As a rule, pre-colonial women attained some forms of power, either politically, socially, or structurally, that can be seen as being complementary to that held by men.

A system of judicial mediation was in place before the advent of colonialism. Cases brought to these courts were basically trade disputes A O. Obilade, (1979). Disputes within the family were settled by the family head, usually the eldest person in the family. The eldest son in the family who is usually the family head inherits the parents’ property; this is usually referred to as the rule of “primogeniture” N. Nzewunwa, (1985). Most Nigerian families are structured according to this rule. The term “family” is not restricted to the nuclear family, but includes the extended family system, a concept prevalent in Nigeria. The extended family is

“a group of closely related people known by a common name and consisting of a man and his wives and children, his son’s wives and children, his brothers and half brothers and their wives and children and probably his near relations” E I. Nwogugu, (1947).

Polygamy, an essential aspect of the family system, was a customary law institution and still obtains today. Men married more than one wife in order to have children to help in farm work and also to show affluence. The worth of a woman was valued in traditional communities due to the power often associated with child bearing, since children were regarded as economic assets. Where a woman was infertile, she could marry a wife for her husband and bear children through her.

Although women were visible in the society during this period, their roles were still restricted to farming, trading, cutting trees, and constructing houses Justice A. P. Anyebe, (1985). The role of women in the public was limited. They were restricted to their household, with the duty of catering for the family needs. Although women in pre-colonial Nigeria had powers complementary to men, this did not alter the superiority role men exercised over women. Socially, women had a status, which is presently recognized by many religions in Nigeria, as being bearers of fertility; hence the creation of “gods of fertility and social peace”. Amongst the Yoruba’s of Western Nigeria, the traditional religion recognizes “Ymoja” a “river goddess that rules over women and children”. In spite of this respect disposed to women, accusations of witchcraft were made against them, which the men envisaged as a threat, of women acquiring a source of power which they had no control over. As a result, these women were treated as outcast in their communities. These accusations were made duet to the progress made by women traders, leading to a vast increase in the number of women in trade as a result of them leaving their traditional chores to explore other profitable source of living elsewhere. In order to prevent women from dominating trade, their male counterparts formed the Atinga cult movement, to prosecute women who practiced witchcraft, which the male traders identified as their source of power, of making profit in trade. The women accused of this practice were forced to succumb to dehumanizing acts, which the male traders believed would cleanse them from the evil associated with this practice. In contrast, the witchdoctors recognized by the community were usually men. There was actually no significant difference between the evil practiced by them and the female witches, the only difference being the acknowledgement by the community of the practice of the witchdoctor, which can sometimes be used for a good course such as curing the sick.

Although subordinate to men, pre-colonial women had their own roles in the community that were not interfered with by the men. They were content with their way of living, submitting to the authority of their man and at the same time jealousy guarding their positions in the community, which were complementary to the men.


The traditional role played by African women in the community was adversely disrupted by colonial penetration in the 19th and 20th centuries. F.C. Steady, (1996). Prior to colonialism, African women experienced minimal exercise of inequality by men. Colonialism further re-enforced discrimination against women through the machinery of the state, by introducing a society that was more stratified and emphasizing racial segregation.

The initial contact between the British and Nigerians began with trade relations. Trade disputes led to the establishment of consular courts. Through this medium British law filtered into Nigeria, and eventually led to the establishment of British governance over Nigeria in 1862.

The colonizers came with a patriarchal civilization. European women also suffered a similar dilemma of gender discrimination as African women. Spousal abuse was undisputedly accepted in the society, and perpetrators’ actions were justified since most went unpunished. Hon. Madam Justice Mclachlin, (1991).

This was due to the predominant belief of the husband’s ownership of his wife and he could exercise an undue amount of authority over his property. This was the situation of women in the 18th and 19th century Europe, which was reflected in the administration of colonial subjects. A. Mama, (1997). This had an adverse implication on African women as they experienced violence at home and from the Europeans. Inter-racial relations were forbidden between the British and the Nigerian women; the “1909 Concubinage Circular” punished those who were found guilty of this act. Sequel to this, Sir Frederick Lugard, in 1914, enacted the “Secret Circular B”. Through this law miscegenation and bestiality were viewed as the same offence, but it never came into operation due to its unfeasibility and the potential danger its applicability envisaged. H. Callaway, (1987). Nevertheless, the colonizers still satisfied themselves with the local women, by engaging them in prostitution services with their troops whilst still maintain their legal and social status by outlawing legal marriages between the local women and white men. Some women were even marked as whiter men’s favorites. These women received beatings from potential or actual husbands or from their fathers as punishment for their illicit relationships with white men, – actions they simply did not have control over.

In Nigeria today, women still remain under the control of men, and are devalued by them. In marriage, they become possessions and get little respect from their husbands. A woman usually does not receive any inheritance and is blamed if she cannot have children. Recently, education is beginning to be valued by women. Hopefully, over time women will use this education they are being offered to regain their independence.

However, the gains of colonialism to Africa women cannot be ignored. It gave them free choice in Christian monogamous marriage, the opening of schools, the introduction of modern medicine and hygiene, and also the suppression of some barbaric practices such as killing of twins in Calabar by a Scottish missionary, Mary Slessor.

Post-Colonial Period

Traces of patriarchal form of governance introduced by the colonizers still exist in Nigerian society today, even after independence, as is evidenced by Nigeria’s sexist laws in the nation. The various post-colonial regimes exhibited a high tolerance for domestic violence. The political crisis in post-colonial Africa, followed decline in the economy, resulting in the dependence of women on men, which therefore led to an exercise in vengeance against women. Through struggles by many feminist activists the plight of women came to the limelight. They provided great advocacy of women’s rights. From the 1960’s violence against women has been found to occur mostly in the home regardless of the family type T.O. Pearce, (1992).

Successive military rule (1966-1979, 1983-1998) led to the suspension of the Constitution which guaranteed the fundamental rights of all Nigerian citizens. The rights of many, especially women, were violated during this period. Violence against women also proliferated especially between the mid 80’s and early 90’s with the “War Against Indiscipline” a program set out to curb the indiscipline of the people since, the regime attributed the declining state of the country to indiscipline. This program resulted in many women being subjected to all various forms of abuse. Following this, the military governor of Kano state in 1986, promulgated and edict, whereby being single upon attaining marriageable age became a crime and further gave those women who fell within this category a three-month ultimatum to get married or be punished.

Feminists intensified their advocacy for women’s rights. Gradually, women became active participants in the economic activities of their community. This resulted in their independence and control of the markets. The Babangida regime (1985-1993) introduced “Better Life for Rural Women”, a program aimed at alleviating the plight of women at the grass-roots level. This program was to empower women politically and economically but became a program for the elites in the society, thereby co-opting women into the state as a subordinate and ineffectual part of the power structure. The tangible achievement of the program was very limited.

professional essay writing servicesManifestations of Domestic Violence in Nigeria

Various writers have identified varying manifestation of domestic violence, which encompasses bride price or dowry, widowhood rites, female genital mutilation, child marriage, and spouse battering.

Bride Price/Dowry

A distinction between dowry and bride price. Dowry is “a customary gift made by a husband to or in respect of a woman at or before the marriage”. Although defined as a gift, it is enforceable by a court of law. In traditional societies, the bride price is the amount paid by a potential husband to “purchase” his wife Hon.C. Oputa, (1998). This is otherwise referred to as the “commodification of women”. Nigerian society today has diverted from the original concept of bride price, a traditional practice that has existed for thousand of years; has withstood European colonialism in the late 1800’s and early 1900’s; and has survived until the present day. In the traditional society, this was the pride of a young girl which accorded her a lot of respect from her peers and in-laws.

In contemporary Nigeria, this practice varies amongst different cultures. Some have discontinued it, and in the alternative the wife receives gifts. However, this practice still obtains in parts of Nigeria and has been an avenue to demand outrageous amounts from the man. Society is dynamic, and traditions that are detrimental to a particular group of people should be modified or totally abolished for violating their fundamental human rights. In the campaign against domestic violence, the bride price system needs to be modified in traditional societies.

Widowhood Rites

A widow in Nigeria is forced to participate in various dehumanizing traditional practices by her in-laws, in order to lead her to confess to the murder of her husband, if she was responsible for it. Up until the present day, widows are put through gory rites to prove their innocence or in the name of mourning the dead. Such dehumanizing rites include:

“crying out loud, shaving of hair, being isolated, bating in the bush, sitting by the corpse, wife inheritance, eating from a broken unwashed plate, and sitting on the floor”

Wife inheritance means, inheritance of the widow by her in-laws. All these practices are peculiar to different communities, and according to myth, it shows that the wife loved and appreciated the man A.O Bassey, (1995).

The plight of widow has recently been addressed in Nigeria. Human rights organizations, such as Civil Liberties Organization, have through series of seminars and public lectures have educated the public of the evil of these practice, of the health hazard they pose to widows and, most importantly, of their infringement of the fundamental human rights of women to personal liberty and right to dignity of human person as guaranteed by the Nigerian Constitution. Though not all widows undergo these rites, those who escape have been economically empowered by their deceased husband. This harmful traditional practice has to be eliminated, and women should also strive to achieve a level of economic independence.

Female Genital Mutilation

This term generally referred to as “Female Circumcision” which describes the “traditional practice in which a person, often unskilled, cuts off parts or the whole organ of the vulva or stitches the vulva together” WOPED, (2000). The term “Female Circumcision” understates the severity of the act. According to Dr Irene Thomas,

“Female Genital Mutilation is now a universally accepted term used to describe any interference with the natural appearance of the female external genitalia using a balde, knife or any sharp instrument in order to bring about either a reduction in size of the clitoris or a complete removal of the vulva”.

Different forms of FGM in Nigeria are peculiar to different ethnic groups. “Sunna” (“religious duty” in Arabic) is the “excision of the clitoral hood, with the preservation of the clitoris itself and the labia minora”. This is practiced mainly in the south-east, south, and south-west of Nigeria. The “excision” or “clitoridectomy”, is “the excision of the prepuce and clitoris together with partial or total excision of the labia minora”. This is practiced in the North-West of Nigeria. “Infibulation” involves “the removal of the entire clitoris and the adjacent parts of the labia minora and the adjacent medical part of the interior labia minora”. The two sides of the vulva are then stitched together with thorns or thread, leaving only a tiny opening for the flow of urine and menstrual blood.

In Nigeria, the prime driving force behind this practice is tradition and the misguided belief that it prevents promiscuity. It has, however, no religious backing in the Bible or the Koran. In Edo State, the practice has been abolished and offenders fined or imprisoned. This law makes consent of the person mutilated irrelevant. The offenders are any of the persons listed below:

  1. “Any person that offers herself for genital mutilation
  2. Any person who coerces, entices, induces any person to undergo female genital mutilation.
  3. Any person who allows any female who is either the daughter or ward to be genitally mutilated.
  4. Any person who performs the operation of genital mutilation” Hon E. Jacobs, (2000).

Child Marriage

No consensus exists in Nigerian law on the official age for marriage. Many of the laws at the state and the federal level have varying stipulations for marriageable age. This non-coherence of the laws gives credence to the issue of ‘child brides’. This practice is rampant in Northern Nigeria, particularly in the “Orlu, Orsu, and Ideato local governemtn areas in Imo State”.

Under the Islamic legal system known as the Maliki school of law, a father has a right to choose a spouse for his virgin daughter regardless of her age; where he consults her, this gives her a right to choose. This is called the father’s right of ‘Ijbar’. However, he may lose this right if he gives his daughter a right to choose Alhaji Isa Basida v. Baiwa, (1971).

There have been reported cases of harm done to these girls by their husbands, following repeated and failed attempts to escape. Some of them end up killing their husbands or committing suicide. Hauwa Abubakar’s story is one such case. At the age of nine she was married off to a forty-year old man, in payment of a debt. She escaped repeatedly but was always returned by her father. In order to prevent her eventual escape, her husband chopped off her legs, and she died from excessive bleeding at the hospital. Her husband pleaded guilty and received life imprisonment. In response to the huge public outcry, the Military Governor of Bauchi issued an Edict to prosecute any parents who withdrew their children from school for marriage.

The Federal Government of Nigeria designed a new national policy on womanhood—the “Charter for Womanhood”. This policy inter alia bans the marriage of women under 18 years of age. This policy is intended to reduce the rate of school drop and eventually increase literacy in many parts of Nigeria.

Spouse Battering in Nigeria

This is the main focus of this research. Although a non-gender term is used, this does deviate from the fact that the term “spouse” in this research refers to the victim (she) and is not restricted to married couples but embraces co-habiting relationships. This, however, does not extinguish the fact that men are also victims, but this situation is an exception rather than the rule. It is a taboo for Nigerian men to report this, as he will not be seen as a ‘man’. Battering may also occur in same sex relationships. Nigerian society has not yet considered this issue, since it has yet to fully embrace the criminality of spousal violence in heterosexual relationships.

Most jurisdictions have acknowledged the gender nature of this problem. Some use gender terms, referring to the victim as “she” while those who use gender neutral terms still acknowledge gendered nature of the problem. The Law Reform Commission of Nova Scotia specifically referred to women being the victims of domestic violence and totally discarded the use of gender neutral terms. The Alberta Law Reform Institute applied a gender neutral term, though it recognized that a vast majority of victims are women

Spousal battering is “a pattern of abuse that involves verbal, emotional and psychological abuse, and physical and sexual violence, to terrorize, intimidate, hurt, victimize, and impose a batterer’s will on his spouse, ex-spouse or girlfriend”. This issue has been neglected in Nigeria because of the value of the violence, which is the home, and the relationship between the victim and the perpetrator. A basic characteristic of African families is the issue of internal sovereignty. Members of family have a duty to keep their affairs private and settle any arising dispute within the family. This regard for family sovereignty and privacy is the major factor affecting the responsibility rate of this crime and hence, the lack of adequate data on the incidence of spousal battering. Other factors in this regard includes the fear of irretrievable breakdown of the family, divorce; over-dependence on the batterer, and existence of discriminatory laws, which makes it difficult for women to come forward and assert their legal and fundamental rights, fearing triviality of their case. Women complainants may become ridicule in their neighborhood.

Modes of Spousal Battering

Psychological/Emotional Violence

The batterer uses this form of abuse to intimidate the victim. It can take the form of abusive language, making the victim feel worthless and shouting to create fear. BAOBAB-for Women’sHuman Rights, (2000). Threats can also be used to make them carry out wrong acts, such as prostitution. Psychological violence can also take the form of denying women the right to choose, freedom to express themselves, denial of emotional and economic support, and freedom of association. The causes of psychological violence include unresolved issues of male inferiority. Psychological violence results in tension in the home, unfriendly environment, distorted personality, and can also lead to death, as in Roseline’s case.

Sexual Violence

This is also an aspect of physical violence. It includes rape, prostitution, and procuring women to commit bestiality. Under Nigerian Law, rape is “sexual intercourse obtained by means of force, threat, blackmail, deceit or coercion on a girl or woman, without her consent” Criminal Code, (1990). Penetration is a constitutive element of rape. “Marital rape” is a term that is unrecognized in Nigerian Law. It is expectedly excluded under the Nigeria Criminal Code, which defines rape as

“….an unlawful carnal knowledge of a woman or girl, without her consent, or with her consent, if the consent is obtained by force or by means of threat or intimidation of any kind, or by fear of harm, or by means of false and fraudulent representation as to the nature of the act, or, in the case of a married woman, by impersonating her husband”.

Social Violence

In the Nigerian context, this is defined as “unhealthy or hostile interaction, practices and relationships between various members of the family”. This is closely linked to psychological violence. In an extended family there are more potential batterers other than the husband. The unreported case of Mrs. Fatima Ajiroba illustrates this form of violence; she was killed by her brother-in-law. He became envious of Fatima because her husband was buying her material things. Her brother-in-law preferred that his brother spend his money on other investments rather than on his own wife. After she sent his child on an errand, he beat her, and she died from the wounds. In other words, he murdered her.

Physical Violence

Physical violence is violence that causes harm to the physical body, and usually completes the cycle of destruction after all the other forms of violence such as emotional violence have taken place. Physical violence includes pushing, beating, slapping, macheting, clubbing, and murder. The Nigerian media also reports increasing cases of acid baths and ritual killings of women. In some parts of Nigeria it is the belief that some human organs generate quick money. This practice is fast gaining in Nigeria.

Causes of Spousal Battering

Various factors have been adduced as causes of spousal battering in Nigeria, these includes poverty, traditions, and laws.


Some authors have argued that poverty in Nigeria can be traced to the introduction of the Structural Adjustment Program in 1986 P. Williams, (1994). This program has resulted in the state perpetuating violence against Nigerians. Most Nigerians men often cast this anger on women on the slightest provocation. This program was created by World Bank in order to cause increase economic growth, and enable developing countries participate in the world trading system. This objective failed; rather it further pauperized the poor countries and increased the wealth of the rich ones.


Generally in a patriarchal society such as Nigeria, men are allowed to have control over women and their property, due to the premium placed on female subordination and inferiority. Customs and beliefs become imbued with this hierarchy, and women are eventually treated as second class citizens in the society and even in their homes. The object here is not to criticize the tradition the customs of Nigerian people, but to reveal the gender discrimination infused into these customs.


Laws are enacted to protect every life in Nigeria, regardless of sex. Moreover, the law preaches equality under the law regardless of age, sex, religion, but in reality this does not obtain. One can then assume that the claim of law to gender neutrality is a myth.

Chapter 3: Regulatory Practices and Governance of Domestic Violence in Nigeria


The Nigerian Constitution guarantees and protects the rights of women. The judiciary, being the instrument for the interpretation of these laws, has maintained its independence by carrying out the provisions of the Constitution and declaring laws inconsistent with the Constitutions void to the extent of their inconsistency and, thus, maintain and emphasizing the supremacy of the 1999 Constitution of the Federal Republic of Nigeria.

In addition to the domestic laws in Nigeria that protect women’s rights, there are also international laws that guarantee and enforce the rights of women. These laws are sufficient to protect the rights of women in a nation. Yet, despite the existence of these laws that protect women in Nigeria acting in consonance with some other laws and practices that condone the violation of the rights of women, what has the Nigerian government done to ensure the protection of the rights of women in society and in the family? How will proposed policies aid in the elimination of violence against women; and what is the implication of international laws for the protection of women’ rights in Nigeria? This chapter addresses these questions. The role and enforcement of international law in the protection of women’s rights in Nigeria will also be examined.

Nigerian Government Policies Protecting the Rights of Women

Various women’s human rights organizations and other NGO’s have put considerable pressure on the Nigerian government to enact laws to secure the protection of women’s rights and to abolish or reform discriminatory laws in order that the fundamental human rights or women will be actualized. Having identified the various practices that lead to violence against women in Nigeria, one of the basic causes that lead to this persistent crime is the discriminatory cultural and traditional practice against women. The Ministry of Women Affairs in Nigeria identified that this practice of female subordination is included in the female child from early childhood. Female children are separated from males. Some female children are withdrawn from school and given away in marriage or retained at home to do the house chores. These female children are further exposed to and become targets of sexual and domestic abuse T.U. Akumadu, (1998). Early marriage for young girls impedes their rate of self-development. They end up being liabilities on their husbands, and in the eventuality of a divorce, they become financially handicapped since most of them are too young, having little resource to education, and cannot generate revenue. This is usually the trend experienced by these young girls. There is usually a high rate of abuse recorded in such marriages since the men take advantage these young girls and expect them to carry out their orders. In recognizing this issue, the Nigerian government has made positive steps to deter such acts. The Gombe State government, acknowledging the prevalence of this practice in the State and Northern Nigeria, enunciated a policy, which became a law. This law punishes parents who withdraw their children from school for the purpose of marriage. It states:

“Any parent who withdraws his/her female ward from school for early marriage will be liable to imprisonment for six months or subject to a fine”.

According to the only female member of the State House of Assembly, Hajiya Maryam Abduladir, “this law is intended to encourage female wards to acquire western education”. Also in this line, it would eradicate V.V.F, which can also be caused by early marriage due to their under developed pelvic of these young girls. She further stated that these girls should be given out in marriage only upon attaining the age 18-19, when they have had substantial education such as completing high school and are considered matured to enter into a marriage contract.

Under customary law, although there is no age limit for betrothal, parental consent is required before the actual marriage of the minor E.I. Nwogugu, (1974). In some states such as the Eastern States; the age of betrothal has been laid down by the Age of Marriage Law 1956, which applies only to customary marriages. It states:

“A…promise or offer to marriage between or in respect of persons either of whom is under the age of 16 shall be void”.

Under Islamic law, parents can carry out a betrothal for a child from the day of birth.

There is no express provision in any Nigerian legislation for the age of marriage. The incidence of child brides mostly occur under customary laws, which, apart from Eastern Nigeria, does not state the age limit for marriage. How can we reconcile the provisions of this proposed legislation with this recurrent incidence in Nigerian law and practice? How then can the provisions of the Teenage Sexual Act apply to a man who has sexual contact with his teenage wife? As between strangers, the Teenage Sexual Act will apply without any difficulty. As an added complexity, the Criminal Code, Penal Code and customary law indicate marriage as an implied consent to sex, as a result, marital rape is not a crime under Nigerian statutes.

In resolution of the envisaged conflict, the Federal Government of Nigeria designed a new national policy on women called the “Charter for Womanhood”. This policy, inter alia, bans the marriage of women less than 18 years of age. This Charter when passed into law by the National Assembly stopped the incidence of child brides and will give female children the opportunity and the right to self development, and ultimately guarantee their fundamental human right to education and proper mental development. This Charter is all encompassing. It also intends to provide for mandatory health services, and to prevent other harmful traditional practices and domestic violence. It also embraces other issues such as inheritance as regards the discriminatory attitude towards women and children, especially female children.

Various human rights organizations are canvassing support for a bill on “Violence Against Women in Nigeria” Eliminating Violence Against Women, (2001). A conference organized by the International Human Rights Law Group in Nigeria, resolved on the establishment of a task force, aiming at drafting a bill on violence against women as other African countries such as Namibia, Kenya, Zimbabwe and South Africa have done. This committee will do all that is necessary in paving the way for the successful implementation of this bill.

A bill against trafficking in women, the Anti-Human Trafficking Bill, was presented to the National Assembly, by the wife of the Vice President and founder of an NGO called Women Trafficking and Child Labor Eradication Foundation.

Without these policies, Nigeria still has laws that guarantee the fundamental rights of women against violence, but such laws have not been adequately utilized in eradicating this violence. When these policies are passed into law, there in no guarantee that they will be properly utilized for the benefit of the object of their creation. As with many laws in Nigeria, there will be a selective observance of its requirements, except, proper monitoring bodies are set up to ensure that the policy serves its purpose. This is the situation of various international conventions that Nigeria has ratified. International law also protects the fundamental human rights of women. Nigeria has indirectly secured such relevant conventions, by the provision in the Constitution, which allows treaties to have the force of law only when enacted into law by the National Assembly. Nigeria has utilized this provision, by adopting the African Charter as a domestic law, having the force of law in Nigeria. Various international human rights conventions protecting the human rights are also incorporated in this Charter.

Nigerian Women’s Rights: An International Perspective

International Human Rights Law is that aspect of international law which deals with “the protection of individuals and groups, against violations by government of their internationally guaranteed rights” Dr. M.T. Ladan, (1999). Similarly, international humanitarian law, is to afford legal protection of human rights. Human rights of women are a matter of legitimate international concern and are appropriately a part of international law legal system. The Vienna Declaration states that:

“The Human rights of women and of the girl-children are an inalienable, integral and invisible part of universal human rights. The full and equal participation of women in political, civil, economic, social and cultural life, at the national, regional and international levels, and the eradication of all forms of discrimination on grounds of sex, are priority objectives of the international community”.

Human rights concerns are not simply within the exclusive domestic jurisdiction of a state though at the same time the principle of internal sovereignty of a state is respected. States have a national and international obligation to protect citizens; a violation of these rights is contrary to national and international laws, which would incur liability on the part of the state N.Pillay, (2000). The persistent violation of citizens fundamental human rights in some developing nations calls for international attention. This is the current situation in Nigeria on the death sentence that has been passed on Amina Lawal on charges of adultery which is a criminal offence under Sharia law. Various international human rights organizations protested against the violation of this woman’s human rights. Under international human rights law, the standard of proof for each state is basically objective. This disproves the theory of cultural relativism, since human rights are universal. However, some states that violate human rights, carry this out under the pretext of cultural relativism and internal sovereignty in order to prevent international intervention. These states are persistent violators of human rights and seek to avoid their responsibility to protect human rights. The whole essence of the United Nations Charter indicates the universality of human rights. Nigeria as a nation and a state party to various United Nations human rights conventions does not share in the theory of cultural relativism. This can be deduced from the positive efforts made to ratify various international human rights treaties. There are few effective channels to carry Nigerian women’s voices, concerns and interests into the human rights arena, thereby sidelining Nigerian women in the international sphere. However, as indicated earlier, it is only recently that NGO’s concerned with human rights have increased their pressure on the Nigerian government to recognize the particular disadvantages faced by Nigerian women. As a result, various policies are on the way to being enacted into law to protect the rights of women.

The Convention on the Elimination of All Forms Discrimination Against Women (CEDAW) can be referred to as the international bill of rights for women. This Convention enjoins “state parties to eliminate discrimination against women in order for them to fully enjoy their civil, political, economic, social, and cultural rights” CEDAW provides that

“state parties must pursue, by all appropriate means, measures to eliminate discrimination against women by any person, organization or enterprise”.

By this, a state that has ratified this Convention has a duty to prevent, prosecute, and do all that is necessary to prevent discrimination against women R.J. Cook, (1994). These states also have to ensure that women to do not have limited access to claim redress or compensation under the law. If they do not carry out this obligation, they will be seen as condoning these acts. A state can ‘therefore’ be held liable where there is evidence of lack of diligent prosecution of actions that violate women’ human rights and giving commensurate compensation for these violations. This act by the state additionally violate a woman’s fundamental human rights such as “right to life, freedom from torture, inhuman and degrading treatment and her right to equal treatment before the law” K.M. Culliton, (1993).

Domestic Implementation of International Conventions As Municipal Laws in Nigeria

Ratification of international women’s conventions impose an obligation on ratifying states to reflect these provisions in their laws. However, domestic implementation tends to pose a lot of difficulty, depending on the respective politics in these states and their lack of adequate resources to provide its full implementation. Some countries have made international law to have a force of authority under their own laws, and it can be applied as municipal law, which can be enforced in the local courts of law. International human rights are enforceable in national courts either directly or to aid in the interpretation of domestic laws K. Morvai, (2000).

Nigeria directly adopted the African Charter as a municipal law, and uses the other ratified international instruments as persuasive authorities. It is not until a state has made conventions part of domestic law that it can be obliged to apply them; but they can still influence the interpretations of its laws. Domestic compliance with international human rights agreements cannot be determined solely by how a state party has made them into law; this can be a legal compliance. Practical compliance can be achieved through “government, international institutions, and NGO’s, and through citizens” D.Matas, (1987).

Treaties form part of international law. If part of municipal law, treaties protecting and maintain women’s rights can be enforced in domestic courts. The mode of implementation of a treaty depends on a state party’s constitutional structure and the manner it ratifies treaties E. Moulton, (1990). International treaties can be implemented into domestic law in two ways. First, by “general transformation”, the treaty becomes part of domestic law when a constitutional provision incorporates it into domestic law A. Brudner, (1985). Like all other laws it has to be ratified by legislation. Second, there is “special transformation”, treaties become part of domestic law, by the use of a separate legislation to incorporate it into domestic law. Nigeria practices the “special transformation’ method. For a treaty to be part of municipal law applicable in Nigeria’s domestic courts, it has to be transferred into local law by legislation validly passed by the National Assembly. The Judiciary can also make use of these ratified conventions either as domestic law or as tools to interpret domestic laws. Justice Niki Tobi applied this in the case of Mojekwu v. Ejikeme, where the learned justice, inter alia utilized the provision of women’s international convention in declaring null and void a native custom that discrimination against women.

Under the 1999 Constitution, implementation of a treaty into domestic law vests with the legislature. It reads:

  1. “No treaty between the federation and any other country shall have the force of law except to the extent to which such treaty has been enacted into law by the National Assembly.
  2. The National Assembly may make laws for the Federation or any part thereof with respect to matters not included in the executive legislative List for the purpose of implementing a treaty”.

Community Response to Domestic Violence: An Option for Reform in Nigeria


Spousal battering is also a fundamental issue and crime against women in Canada. According to the statistical profile released by Statistics Canada in 1996, approximately “22,000 incidents of spousal assault were recorded, of which 89% involved female victims while 11% were male victims” Statistics Canada, (1998). This crime too often degenerates to more tragic crimes such as homicide. In Canada between “1977-1996, 1,525 wives were murdered by their husbands, as opposed to 513 husbands murdered by their wives”.

Various Canadian provincial governments, in an effort to eradicate this problem from the society, enacted provincial legislation that basically uses the civil approach and remedies to prosecute this crime. In Canada, the Constitution divides the power of lawmaking between the federal and provincial governments. The Federal Government has exclusive power to “develop criminal law, to decide if behavior is criminal and to determine criminal procedure”. The Provincial Government is responsible for the administration of justice within the province, thereby ultimately enforcing criminal law. It has jurisdiction over “property and civil rights in the province, which include power to legislate in relation to family-law-related matters such as matrimonial property, child and spousal support, and custody”. In other words, the provincial government cannot deal with domestic violence in terms of criminal sanctions but can impose penal sanctions for violation of provincial orders. Despite the existence of these laws, spousal battering still exists in Canada. The operation of law in a society as an instrument to deter crime has certain limits. It can enforce certain behavior in the society to conform to the laid down rules, but has no capacity to change human behavioral pattern. For this reason, crimes are still committed, despite the existence of express laws sufficient to prohibit criminal acts or omission. Victims sometimes refer to this phenomenon to express their distrust in the criminal justice system and its agents. Communities that record a high rate of domestic violence incur a lot of financial and social expenses, which includes increased health care, security, and loss of productivity. This leads to a gradual destruction of the community. Communities have been and are in the process of addressing the effects of domestic violence. They are also devoting human energy and financial resources to stopping this crime. This process normally takes an integrated multi-disciplinary approach, which addresses needs of the victims, batterers and children.

The problem of spousal battery experienced in Canada in similar to the Nigerian situation. The only difference is the socio-cultural stereotype, which particularly affects this issue in Nigeria. Both countries have laws that women can use against spousal battery, yet statistics still record a high incidence of this crime, the only difference being that Canada has taken practical initiatives to end this crime in the society. The provincial governments in Canada have gone further in addressing the issue of spousal violence in various communities within their provinces. One of such provinces is Alberta.

Edmonton Safer City Initiative

Individuals from various government departments and NGO’s met to address the need of keeping a safe community. The proposal from this meeting led to the development of the Mayor’s Task Force on Safer Cities on the 28th June 1990, chaired by Mayor Jan Reimer and 15 citizens. It was formed to combat crime through “social development”. Upon the first report of this task force in 1992, the city council created the Safer Cities Initiative Office to oversee the implementation of the report’s recommendations. Amongst many of programs initiated is the Family Violence Follow up Team, now called the Spousal Violence Intervention Team.

Edmonton Spousal Violence Intervention Team

This is a joint venture of the Edmonton Community Service and the Edmonton Police Services, established to address incidents of spousal violence within the community. Each team consists of a detective and a senior social worker. Cases of spousal battery, which the unit handles, are often identified though police investigation and basically they ensure that adequate and quality services are given to victims and perpetrators.

A spousal violence intervention team is assigned to each of the North, South, Downtown, and West, police in Edmonton. The primary goal of a team is to adequately deal with the issue of spousal abuse.

The objectives of each team include:

  1. “Working to eradicate the incidence of spousal abuse in Edmonton.
  2. Identifying cases in which victims are subject to high risk and initiating follow up contact.
  3. Providing various services to victims and perpetrators, including counseling, referrals to social agencies, to child welfare in case of child abuse and neglect etc.
  4. Initiating an environment of safety for clients.
  5. Providing prompt police response in cases of abuse.
  6. Educating the community about spousal abuse, in order to develop increased understanding of the community and also to encourage cases of spousal abuse to be reported”.

Suggested Reforms in Nigeria

The socio-cultural environment has to be taken into consideration, given the cultural diversity and cultural difference between Canada and Nigeria. The objective of this part of the chapter is to offer practical suggestions on addressing spousal battery.

Laws that condone spousal battery in Nigeria need to be reformed. Nigeria has a Law Reform Commission. Its basic responsibility is to make proposals to the government about areas of law that need to be amended, such as obsolete laws that do not accord with the present state of affairs. Laws that discriminate against women are still very much in existence in Nigeria but, as observed above, cannot stand in the face of the Nigerian Constitution.

Many NGO’s in Nigeria address the degenerating rights of women in the family, especially their rights against spousal battery. These NGO’s account for the many changes aimed towards the elimination of domestic violence in Nigeria. These NGO’s include Project Alert against Violence against Women, the Legal Research and Development Centre, and the Civil Liberties Organization. These organizations also carry out public education enlightenment programs by such means as seminars, posters, and public forums.

One suggested reform involves a more closely monitored project aimed at eliminating spousal battery in the community. One or more NGO’s can come together to create a committee to address spousal battery in the community. A district should be chosen, by criteria that should include a high incidence cases of spousal battery reported to police, the rate of crime associated with it and high risk factors such as the threat to victims and children. Influential members of the community should also be invited to join this committee, such as traditional rulers, police officers, teachers, lawyers, and philanthropists. Arizona adopted this model in selecting core members of the local councils, so as to have a multi-disciplinary approach to addressing domestic violence in the community. The nature of spousal abuse in this community should be analyzed through data, with the objective of revealing the reasons for abuse, the vulnerable people in the community, and the most victimized. For the nature of the problem has to be identified before adequate solutions can be tendered. The needs of the women should be specifically attended to, through public fora. The fora should never be gender restricted: if this were done, some men would discourage their wives from attending, regarding the fora as usurping their much-guarded authority and power, and displacing their role in the family. In order to attract women, their needs should be targeted and provided for as much as possible. The nature of these educational fora should not be accusatory or finger pointing rather, a reconciliatory approach should be adopted and thus further address the need for peace and love in the home for a safer community. Individual counseling can be made with families. A team selected from the committee and with the requisite expertise to counsel abused spouses can provide counseling services to these families. The goal is to build trust between these families and the team members. The local traditional ruler can also make up this team. This is of particular significance in those traditional communities in Nigeria where disputes come before the traditional ruler, who mediates between the parties. This will make the victim more comfortable and further heighten trust between the team members and the victim. The model of the Edmonton spousal violence intervention team will be effective here.


This research has analyzed the issue of spousal battery in Nigeria and suggested practical solutions to remedy the situation in Nigeria. Basically, the perception of the issue is the beginning of the problem. As identified above, some men will perceive this reform as a challenge to their authority and a probe into their marital affairs. The question here is, can there be an express law against spousal abuse that would be effective in Nigeria now? This cannot be answered definitely. Still, regarding the state of affairs in Nigeria today, there is a limit to which laws can help. Laws cannot change human perception but can only serve as a source to guide and incur orderly behavior in the society. A legal solution is therefore not the answer. It can come after other solutions have been explored. A positive change in the rate of crime arising from spousal battery will encourage the enactment of laws to protect victims of this crime.

As examined above, countries have gone beyond the law, to a more practical approach to spousal abuse. The City of Edmonton has recorded success over spousal abuse through a coordinated community response to it. Arizona has used this approach to bring positive changes to its laws and has revised its statutes to integrate laws against domestic violence, which offers adequate protection to victims. Nigeria can explore this option. When the Nigerian government realizes the success recorded in this project, it will get involved.

Obviously there will be mixed reactions to this step in Nigeria but if nothing is done about it, it will further heighten the rate of crime in the family. The family is the unit of socialization. A dysfunctional family can sometimes produce dysfunctional individuals, and, ultimately will affect the whole nation even more than spousal abuse effects Nigeria at present.

Nigeria can start now to look into this alternative means of ending spousal violence as other countries have done and create a safer nation for the future of all Nigerians.


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Sample Dissertation on Postoperative Cognitive Dysfunction

Investigations of effects of surgical treatment on physical and mental status have attracted increasing interest. Advancements in surgical and anesthetic techniques have improved overall morbidity and mortality in patients undergoing major general and cardiac surgery. However, postoperative cognitive dysfunction (POCD) and decline remain as significant complications, particularly in older patients. POCD is defined as deterioration of intellectual function presenting as impaired memory or concentration. POCD is a common complication in older patients undergoing cardiac and non-cardiac surgery under general and local anesthesia. Postoperative cognitive deficits and decline result in prolonged hospitalizations, increased morbidity and mortality, and increased costs, and has an adverse impact on quality of life (Stockton, Cohen-Mansfield, and Billig., 2000; Canet et al., 2003; Hanning, 2005).

Research has progressed from case-study vignettes to epidemiologic analysis of morbidity and mortality. In order to achieve comparability across cases, some studies have focused on specific procedures, including varicose vein stripping, prostatectomy, cataract surgery, and hip replacement, whereas others have assessed outcomes related to more than one type of surgical intervention. Some investigators measured recovery time, as determined by cognitive functioning after the administration of different anesthetic agents (Ancelin, Roquefeuil, Ledesert, et al., 2001). It has frequently been speculated that POCD might be avoided by performing appropriate surgical procedures under regional anesthesia (Makensen, G. and Gelb, A., 2004). Numerous comparative studies using various assessment techniques have been conducted to test this hypothesis but no significant difference has yet been found. Some studies have compared outcome of surgery using different techniques, for example, spinal vs. general anesthesia for procedures including hip surgery and prostatectomy, and general vs. local anesthesia for cataract extraction. Follow up times have varied from 24 hours or less, to 1 month, 3 months, 10 months, and 1 year (Abildstrom, Rasmussen, Rentowl et al., 2001; 2004)

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However, with the exception of open heart surgery, where a risk of prolonged neurological and neuropsychological deficits has consistently been identified, not merely in older patients, only two studies of other elective procedures reported significant mental changes that persisted and adversely affected the quality of life several months later. One study of other elective procedures reported significant mental changes that persisted and adversely affected the quality of life several months later. Hole et al. (1983) identified these changes in participants randomly assigned to general as compared with spinal anesthesia for hip replacement, but no standardized pre or post operative testing was conducted to validate the report.

Subsequent studies in various surgical groups have attempted to relate postoperative cognitive changes to 1) specific parameters of mental status, 2) time at which these parameters were studied, 3) type of surgery, 4) type of anesthesia, 5) demographic variables, and 6) pre-, intra, – and postoperative medical conditions (Vingerhoets, VanNooten, and Vermassen, 1997; Collie, Darby, Falleti et al. ,2002; Canet, Raeder, Rasmussen et al., 2003) . The most recent studies have been carried out preoperatively, postoperatively, and at short and long term follow-up. Moller and colleagues (1998) studied mental status changes pre and postoperatively using various non-cardiac surgical groups (including elective orthopedic patients) in an international multicenter program. Although they did find POCD in their patient group, it is not known if POCD exists for purely elective orthopedic surgical patients.

Preoperative and immediate postoperative cognitive comorbidities as well as physical comorbidities as predictors of outcome have been included in more recent studies in various surgical groups (Billing, Stockton, Cohen-Mansfield, 1996; Goldstein, Fogel, Young, 1996; Goldstein,Young, Fogel, and Benedict,1998). Several studies have also focused on the effects of anesthesia type on postoperative mental status (Williams-Russo, Urquhart, Sharrock et al., 1992; Crul, Hulstijn, and Burger, 1992; Goldstein et al., 1998). Despite these advances in methodology, all except for one of these studies have failed to find significant mental status changes among patients undergoing elective orthopedic surgery.

Advances in anaesthetic and surgical techniques have led to the conclusion that postoperative cognitive decline is currently less common than previously thought (Abilstrom et al., 2000; Rasmussen, Larsen, Houx, et al, 2001; Rasmussen, Johnson, Kuipers et al., 2003) . The benefits of such technological advances, however, may have been offset by the inclusion of older patients with more comorbidity. The extent to which postoperative cognitive dysfunction is detected will depend on measurement techniques, timing of the assessment, and statistical methods. One issue concerns the selection of neuropsychological tests. Because the cognitive changes may arise from more than one etiological mechanism, a procedure that assesses all major cognitive domains is preferable. If the test battery does not include assessment of, for example, frontal-lobe functions such as planning and abstraction, or parietal-lobe functions such as spatial and constructional abilities, abnormalities in these areas will be missed. Because of the limited time available for neuropsychological testing preoperatively, few studies have included tests that cover all major cognitive domains.

A second issue is preoperative baseline performance. There is substantial variability in neuropsychological performance at baseline, with some patients performing at expected age-adjusted and education-adjusted levels and others performing significantly below expected levels. This variability has been ascribed to emotional distress and preexisting cognitive impairment in some patients (Shaw, Bates, Cartlidge et al., 1986; Stump, Newman, Coker, Phipps, Miller, 1990; Moller, Cluitmans, Rasmussen, 1998), These findings continue to complicate interpretation of studies of cognitive outcome. A decline secondary to surgical procedures in patients who are already impaired at baseline may be underestimated. On the other hand, surgical procedures itself may be associated with cognitive dysfunction. The most common definition of cognitive change is a decline in performance by 1 SD on two or more tests (Rasmussen, 1998). An alternative is to assess change in specific cognitive domains, by examining the proportion of patients who show change in memory, language, and other areas (Rasmussen, 1998).

This approach may shed light on the pathophysiology of cognitive changes after surgical procedures. For example, if some cognitive domains are more susceptible to the effects of pain as a result of surgical procedures, changes might occur in certain cognitive domains but not in others. This domain specific approach also has the advantage that the pattern of cognitive changes may be differentiated from expected changes in normal aging, or with other causes of cognitive decline in the elderly.

Postoperative Cognitive Dysfunction

Cognition is defined as the mental processes of perception, memory, and information processing, which allows the individual to acquire knowledge, solve problems, and plan for the future. It comprises the mental processes required for everyday adaptive living. Cognitive dysfunction is therefore the impairment of these processes. It is usually expressed by patients in terms of failure to perform certain tasks, or inability to complete mental tasks that were previously attainable. More specifically, deficits are generally characterized as limitations in attention, cognition, recognition, orientation, memory, and learning (Rasmussen, 2001). According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), cognitive disorders can be divided into several conditions that are characterized by clinically significant deficits in cognition and memory, and representing a significant change from a previous level of functioning:

Delirium is an acute disturbance of consciousness and a change in cognition that tends to fluctuate during the course of the day.

Dementia is characterized by multiple cognitive deficits including memory impairment. The condition causes impairment in occupational or social functioning.

Amnestic Disorders are characterized by memory impairment in the absence of other significant cognitive impairments.

Mild neurocognitive disorder is one of the cognitive disorders not otherwise specified and for which research criteria have been suggested. This presentation is characterized by cognitive dysfunction presumed to be caused by either a general medical condition or substance use that does not meet criteria for any other disorders. An essential feature is that impairment in cognitive functioning is evidenced by neuropsychological testing.

Several researchers have attempted to categorize these different entities of cognitive dysfunction. The central anticholinergic syndrome is a complication observed following general anesthesia with manifestations ranging from excitatory symptoms such as agitation to central nervous system depression such as stupor, coma, and respiratory depression. The incidence varies between 1 and 40%. It is assumed that drugs used for general anesthesia are blocking central cholinergic transmission result in a relative lack of acetylcholine in the brain, which is essential for learning and memory (i.e. benzodiazepines, opioids) (Link, Papadopoulos, Dopjans, Guggenmoos-Holzmann, and Eyrich,1997). POCD has to be differentiated from delirium, which is a separate clinical syndrome. It is characterized by an acute decline in attention and cognition. Following surgery and anesthesia the incidence varies between 0 and 73% dependent on the type of surgery and studied patient population. The incidence is highest following cardiac and orthopedic surgery and in elderly patients. The symptoms of delirium usually develop within the first 4 to 5 days of the postoperative period with an acute onset and with a peak on the 2nd or 3rd postoperative day (Dyer, Ashton, and Teasdale, 1995). These two were harbingers for longer lasting postoperative cognitive deficits (POCD).Postoperative cognitive dysfunction (POCD) varies enormously depending on the definition, the composition of the test battery, and the time of the postoperative assessment. The incidence is reported to be 30-80% a few weeks after cardiac surgery and 10-60% after 3-6 months.

In the vast majority of patients with POCD, it must be regarded as a mild neurocognitive disorder and it requires neuropsychological testing for detection. More recent investigations have began to select neuropsychological tests that are more sensitive to cognitive impairment. Neuropsychological testing evaluates several aspects of cerebral function, such as problem solving, speed of information processing, flexibility and memory. POCD is statically and conventionally defined by comparing the preoperative performance to the postoperative performance at different moments in time.

There are several ways to define POCD. You can compare the individual cognitive performance of the patients before and after surgery, in which the patients also acts as his “own control.” This method has the advantage of revealing the individual magnitude of the cognitive dysfunction. This definition is conventional and what is considered as sufficient decline is defined different ways by various authors. Another method is applying pre and postoperative neuropsychological tests between different groups of patients. Rasmussen (2001) states that if an incidence of POCD is to be calculated, it is necessary to define diagnostic criteria based on the test battery used. This is usually done by considering deficits in the single tests. The degree of change in a test deemed to constitute POCD has varied widely between studies ranging from a deterioration of 1 SD in one or more tests in a battery to a more rigorous z-score (Rasmussen, 2001). The amplitude of POCD can be arbitrarily quantified as mild, moderate or severe, depending on the SD change score from baseline (J, 1.5, or 2 SD’s respectively). The computation of a z-score for each neuropsychological test; most authors agree that a Z-score >1.96 in more than 2 tests or a value of the composite Z score >1.96. Lastly, the earliest test point should be about one week after surgery once centrally acting analgesics are no longer required and any active metabolites have been eliminated.

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Risk of POCD

The etiology leading to POCD is still poorly understood and is most likely multifactorial. Risk factors for POCD are either present preoperatively, including patient comorbidities and baseline cognitive function, are generated during surgery or are developed in the postoperative period mainly as complications. There have been several risk factors identified in the literature. Majority of studies to date have reported that advanced age as a risk factor for POCD. Particularly older patients with a history of alcohol abuse presented an increased risk for POCD compared to a control group (ISPOCD studies, 1998, 2000). Several studies point out that lower education level is associated with adyerse^mtcomes following cardiac as .well-as noncardiac surgery. Preexisting cognitive impairment and depression are often excluded from POCD studies, although they are at high risk to aggravate cognitive dysfunction Ancelin, Roquefeuil, Ledesert et al., 2001).

Many studies directed at POCD have studied patients immediately after surgery or within 1-2 days following surgery. Clearly, patients who are still under the influence of anaesthetic or analgesic drugs may be affected. This is of significance if they are expected to remember instructions or carry out complex tasks, such as driving a motor vehicle but this does not constitute POCD (Rasmussen et al., 2003). Rasmussen and colleagues (1998) state that the earliest test point should be about one week after surgery once centrally acting analgesics are no longer required and any active metabolites have been eliminated. Motivation may also be a problem in the early postoperative period. False negatives were encountered in a study of mid latency auditory evoked responses to awareness with patients who heard the command (and thus were aware) but did not respond (Wu, Hsu, Richman et al, 2004).

Duration and type of surgery have been determined to play a crucial role in the development of POCD. While elderly patients undergoing minor surgery with a mean duration of 33 minutes have not demonstrated a greater risk of developing POCD than a nonoperated control group. Older patients undergoing major noncardiac surgery with a mean duration of 190 minutes showed an increased incidence of POCD. The type of surgery presents an important risk factor for POCD with an increased risk for vascular, orthopedic and cardiac surgery (ISPOCD studies, 1998, 2000; Canet, Raeder, Rasmussen et al., 2003). A recent study has shown that older patients after non-cardiac surgery who experienced POCD were more likely to demonstrate moderate pain compared to patients without any cognitive deficits. Additionally, adequate pain management in this study appears to play an important role as orally administered analgesia was related to a lower risk for POCD compared to patients with intravenous patient controlled analgesia. However, the treatment was not randomized in this study so oral analgesia may only be a marker for a less painful state and the assessment of cognitive function was restricted to the 1st and 2nd postoperative day and might have been compromised by the sedating effects of the opioids (Wang et al., 2007). Hypothermia during the early postoperative period has also been associated with cognitive decline six weeks following cardiac surgery (Grocott et al., 2002).

Cause of POCD

The role of anesthesia was examined in a randomized comparison of 364 elderly patients undergoing major, predominantly orthopedic surgery, under either general anesthesia (GA) or regional anesthesia (RA) (Rasmussenet al., 2003). Cognitive function was assessed using five neuropsychological tests undertaken preoperatively and 7 days and three months postoperatively. POCD was defined as a combined Z score >1.96 or a Z score >1.96 in two or more test parameters. At 7 days, POCD was found 19.7% of patients after GA and 12.5% in RA. After 3 months, POCD was present in 14% after GA and 14% after RA. The incidence of POCD after one week was significantly greater after GA when they excluded patients who did not receive the allocated anesthetic. There was no significant difference in the frequency of POCD between the groups receiving GA and those receiving RA after three months, suggesting that anesthesia was not a risk factor. The investigators concluded that there was no causative relationship between general anesthesia and long term POCD. Regional anesthesia may decrease the incidence of POCD early after surgery. However, as most patients in the RA group received a sedative infusion of propofol, this conclusion may be questioned.

Animal Studies

Harming and colleagues (2003) investigated the effects in rats of repeated anesthesia throughout life with pentobarbital, compared with a control group. Central cholinergic function was estimated by radiolabeled alpha-bungarotoxin and epibatidine binding in the cortex, striatum and hippocampus when the rats were.26 months old.

There was a highly significant reduction in the bungarotoxin binding in the superior cortex. Aipha-Bungarotoxin binds to the alpha-seven subunit of the nicotinic receptor, which is also one of sites for anaesthetic binding (Backman, Fiset, and Plourde, 2004)., and is often most reduced in patients with Alzheimer’s Disease (Culley, Baxter, Yukhanov, and Crosby, G., 2003; 2004). This was a small study with an agent no longer used in human anaesthetic practice and the results should be interpreted with caution. There is however, some support for an effect of long term administration of cholinergic drugs on cognitive function from other fields. For example, patients with Parkinson’s disease treated with anti-muscarinic drugs are more likely to show Alzheimer pathology at post-mortem examination (Perry, Kilford, Lees et al., 2003). Nicotine has been shown to be protective of nicotine cholinergic receptors and low level exposure to organophosphorus esters may cause neurotoxicity (Jamal, Hansen, and Julu, 2002).

Greater impulsivity in behavioral task performance was noted between the older rats that had been subject to repeated anesthesia throughout life and the control animals mentioned above. Culley and colleagues (2003) have reported long term effects of anesthesia on cognitive function in rats with agents commonly used in human practice.


The apolipoprotein (APOE) genotype has been shown to be one of the first genetic variants to be associated with POCD. The role of APOE genotype was investigated in 976 patients undergoing major surgery in the ISPOCD2 studies (Abildstrom, Rasmussen, Christiansen et al, 2000; 2004) In this study, the e4 allele was not considered a risk factor for POCD. This does not rule out the possibility of a genetic proprensity for POCD but suggest that other candidate genes should be sought. Other recent studies have questioned the impact of APOE on the development of POCD, speculated that the APOE is only one of multiple gene variants altering cognitive outcomes.


Hypercortisolaemia has been known for some time to impair cognitive function. It was hypothesized that hypothalamic cell loss in the elderly impaired the normal mechanisms that damp down the increased Cortisol secretion that follows stress and the normal hypercortisolaemia of surgery would be enhanced and prolonged. Morning and afternoon salivary Cortisol concentrations were measured in patients receiving a general anesthetic in the randomized study of major surgery in the elderly, which formed part of the ISPOCD2 studies. Other stress markers such as IL-6 were also measured. There was no evidence of greater or prolonged Cortisol release in participants with POCD although there was a loss of circadian effect in those patients (Rasmussen et al., 2003).

It is still unclear if patients undergoing noncardiac surgery and anesthesia have long term or permanent decline in cognitive function, at least after the first week in older patients. There is a body of evidence suggesting that POCD does occur in these patients, but further research is necessary.

Non-Cardiac Surgery

The evidence for POCD following cardiopulmonary bypass (CPB) is much stronger and the incidence is much greater than noncardiac surgery. However, two studies used the same test battery and methodology in both cardiac and major abdominal surgical patients and reported a similar or greater incidence of POCD in the non-cardiac group as recorded in Appendix A. Before the 1990’s, most reports of POCD in noncardiac surgery were anecdotal and were generally felt to be a response to some perioperative catastrophe that was not caught by the medical staff. Many studies demonstrated marked hypoxemia at night which was at its worst on the second to fourth night after surgery (DeKosky, Ikonomovic, Paulin et al., 2000). Other studies showed that this was a result of rebound slow wave and rapid eye movement on those nights, following their suppression on the first postoperative night coupled with the parallel decline in lung function. This previously unreported hypoxemia seemed to be the cause of several postoperative complications including myocardial ischemia and infarction and cognitive dysfunction.

Moller and colleagues (1998), conducted a major international multicenter study on the benefits of pulse oximetry in anesthetic practice, co-ordinated an international group of investigators (ISPOCD) to determine the prevalence or absence of POCD in the elderly. Thirteen hospitals in eight European countries and the United States recruited patients to same study by the same protocol. Eligible patients had presented for major abdominal, non-cardiac thoracic, or orthopedic surgery under general anesthesia and a hospital stay of at least 4 days. They gave priority to patients presenting for major abdominal and thoracic surgery. Centers were asked to recruit no more than 25% of their patients from those admitted for major orthopedic surgery (hip and knee arthroplasty). The neuropsychological test battery included a visual verbal learning test (based on Rey Auditory Test), concept shifting test (based on trail making test from Halstead and Reitan’s neuropsychological test battery). It also included the Stroop Color-Word Interference test, a paper and pencil memory scanning test, letter-digit coding test (adopted from Weschsler Adult Intelligence Scale), and the four boxes test. Patients IQ was measured preoperatively by part III of the Cattell culture fair IQ test. Mood was assessed with Zung depression scale, and patients self assessed cognitive decline from the short Cognitive -failures questionnaire.

The neuropsychological test battery and continuous physiological monitoring were done on 1218 patients, aged over 60 years old, before and one week and 3 months after major surgery. A subgroup of 336 patients was studied again 1-2 years later. Forty seven normal participants were studied with the same test battery at the same time intervals. POCD was defined as a z-score of more than 2.0 in at least two tests or a composite z-score above 2.0. At 7 days postoperatively, investigators found cognitive dysfunction in 266 (25.8%) patients. The second postoperative test was done in 3 months and found cognitive dysfunction in 94 patients (9.9%). The investigators also found a significant relation between early POCD and increasing age, increasing duration of anesthesia, less education, second operation, postoperative infections, and respiratory complications. The investigators concluded that POCD existed and age was a major risk factor. Neither hypoxemia nor hypotension, nor the combination, were risk factors for POCD.

The same group conducted, in a second multicenter collaborative program of research (ISPOCD2) to investigate further whether POCD followed minor surgery in the elderly and major surgery in the middle aged. Inpatient surgery was characterized by a maximum expected stay of 1 night and 1 preoperative night’s stay. Outpatient surgery was characterized by expected discharge from the hospital on the day of surgery, with no preoperative night’s stay. Subjective assessment of cognitive decline was evaluated using the Subjective Cognitive Functioning questionnaire (SCF). Mood was evaluated with the Geriatric Depression Scale (GDS) and degree of independence in activities of daily living was evaluated with the Instrumental Activity of Daily Living questionnaire (IADL). Twenty- two of 323 patients undergoing minor surgery displayed POCD (6.8%) 7 days postoperatively. At 3 months, the incidence of POCD was 6.6%. They concluded that POCD was present to a very small degree in the elderly after in-patient minor surgery after one week, but not at three months. The same was true for the middle aged undergoing major surgery (Rasmussen et al., 2001).

Abildstrom and colleagues (2000) examined if POCD persisted 1-2 years after surgery. Investigators recruited 336 patients and subjected them to the same battery as the ISPOCD studies at 12 months and 24 months. A control group of 47 non-hospitalized volunteers of similar age were tested with the same test battery at the same intervals. They found 1-2 years after surgery, 35 out of 336 patients (10.4%) had cognitive dysfunction. Three patients showed POCD at all three postoperative test sessions.

Logistic regression analysis identified age, early POCD, and infection within the. first three months as significant risk factors for long term cognitive dysfunction. While the ISPOCD studies remain the largest and best controlled of the studies conducted to date, it can properly be questioned whether the psychometric test battery was sufficiently sensitive and robust. Rasmussen (2004) reanalyzed the data from all patients that participated in the ISPOCD studies to examine the effects of test-retest variability. He concluded that by comparing the ratio of POCD with postoperative cognitive improvement (POCI), he could be confident of cognitive decline only in older patients one week after major surgery. Only 30-48% of patients with POCD at 3 months also had POCD at one week. POCD may be progressive and only become apparent several months after surgery.

Post-Cardiac Surgery

The greatest incidence of POCD and the greatest number of studies is in patients undergoing cardiopulmonary bypass surgery (CPB). Many studies do not meet the stringent criteria set by Rasmussen, but there are sufficient large scale studies using appropriate test batteries and control groups to suggest that POCD, both early and late, does commonly occur in these patients. Phillips-Bute, Matthew, Blumenthal et al. (2006) examined POCD on the quality of fife after coronary artery bypass grafting surgery (CABG) from the patients’ perspective. Surgical patients from Duke University Hospital (N=551) were assessed at baseline, 6 weeks, and 1 year following surgery. The cognitive battery consisted of a short story module of the Randt Memory Test, the Digit Span subtest from the Weschsler Adult Intelligence Scale -Revised (WAIS-R), Modified Visual Reproduction Test from the Weschsler Memory Scale (WMS), Digit Symbol Coding subtest from the WAIS-R, and the Trail Making Test (Part B). Neurocognitive deficits, defined as 1 SD decline in one or more domains, occurred in 41% of patients at the 6 week follow up. At one year, 36.8% of patients demonstrated POCD.

Newman (2001) used the same battery and found an incidence of 53% at discharge from the hospital and an incidence of 36,24, and 42% six weeks, six months, and five years respectively, after surgery. Early decline predicted later decline in this patient group. Similar findings have been reported by Stygall and colleagues (2003). However, neither study used a rigorous definition of POCD or a control group to control for learning effects. Such studies raise the possibility that operation is a risk factor for early cognitive decline.

Further evidence comes from studies by Collie and colleagues (2002). The development of Alzheimer’s 5-6 years after surgery was determined in 5216 patients who had undergone coronary bypass grafting (CABG) and compared with 3954 patients who had undergone percutaneous transluminal corornary angioplasty (PTCA). Assessment data was collected postoperatively only. The adjusted risk of CABG vs. PTCA was 1.71 (P=.04). However, in a further study, the same group compared the incidence of Alzheimer’s patients who had undergone either a prostatectomy or a herniography under general (GA) or loco-regional anesthesia (LA). The adjusted risk of GA vs. LA was .65 and .71 respectively. The authors suggest that this may indicate that GA may delay the onset of AD. As the patients were not randomly allocated to LA or GA however, it may indicate also that frailer patients had their operations under LA.

Orthopedic Surgery

There have been several studies (listed in Appendix B) examining the mental status of orthopedic patients after surgery, although not purporting to study POCD. Sosa Rex, Worland, and Blanco (2004) investigated the incidence of mental status change following total joint arthroplasty. They examined cognitive status in thirty total knee arthroplasty patients pre and postoperatively using the MMSE. There was no reported change in MMSE scores from baseline to third day postoperatively and after discharge six weeks later.

Kagansky, Rimon, Simona and colleagues (2004) sought to determine the incidence of delirium and its precipitating factors in older hip fracture patients. A group of 137 hip fracture patients, over the age of 75, had their cognitive status, measured pre and post operatively using the MMSE. Cognitive assessment was taken on admission, one week after surgery, and one month after surgery. Delirium participants were assessed even further at three months after surgery. Non delirious patients (N=90) MMSE scores were higher than the delirious patients and their scores gradually improved from baseline, one week, to one month after surgery.

Milisen, Foreman, Abraham et al. (2001) developed an intervention program for older hip fracture patients that experience delirium during their hospital stay. They assessed cognitive status in 60 patients using the MMSE at admission and on the first, third, fifth, eighth, and twelfth postoperative day. Investigators found that the nondelirious patient group’s MMSE scores gradually improved on each postoperative day.

Williams-Russo et al. (1992) compared the effects of postoperative analgesia using epidural vs. intravenous infusions on the incidence of delirium in bilateral knee replacement patients. Fifty one patients, age 65 years and older, were candidates for orthopedic surgery. They used the Mattis Dementia Rating Scale (DRS) as the assessment of cognitive status at baseline preoperatively and daily postoperatively until discharge (days 1 -7). All participants received regional anesthesia. Non delirious surgical group (N~30) showed general practice effects for the MMSE showing daily incremental improvement approaching the maximum possible score.

Two orthopedic studies to date have studied postoperative cognitive decline and its influence on other patient postoperative factors such as delirium. Gruber-Baldini, Zimmerman, and Morrison (2003) studied cognitive impairment in hip fracture patients and its relationship to delirium and long-term cognitive decline. They recruited 674 hip fracture patients ages 65 and older from hospitals in Baltimore, Maryland. They used the MMSE as the measure of cognitive status. They administered assessments at admission, postoperatively, and again at 2 and 12 month follow-ups. Cognitive impairment first detected in the hospital (preoperatively, postoperatively) persisted over 2 and 12 months in more than 40% of patients with delirium. Fifty percent of non-delirious patients (N-263), with no baseline cognitive impairment showed gradual improvement in their cognitive function from admission to two and twelve month time periods.

Dolan et al. (2000) studied delirium and it relationship to long-term cognitive status in 682 hip fractured patients post-operatively only and at 2, 6, 12, 18 and 24-month follow-ups. Cognitive status was assessed with the MMSE. Non-delirious patients (N=590) MMSE scores stayed relatively stable between two and eighteen months. After eighteen months, non-delirious patients began to show a slight decrease in their MMSE scores by the 2 year assessment period. However, baseline cognitive status was not assessed in this group.

This review of the orthopedic literature brings up another issue in common with numerous other clinical and epidemiological investigations of the mental status of older people for more than a decade. The Mini-Mental State Exam (MMSE) has been the primary instrument used in examining cognition in surgical studies. However, methodologies have varied, with differences in the age range of study participants and other inclusion criteria, and also in outcome measures. For example, a score of 23/30 has been used to define and/or exclude participants with preoperative “cognitive impairment” in some investigations, but not in others. Evaluation criteria have included between group changes in mean MMSE score, within-subjects variation above and below the 23/30 impairment level, and a 2- point decrease in MMSE performance. The results of studies using the MMSE have largely replicated those in which other instruments were used; that is cognitive decline detected in the early postoperative period has resolved within hours or days.

Results from the review on POCD suggest that surgical procedures increase the risk of short and long-term neuropsychological decline. Unfortunately, the strength of the conclusion is limited by the methodological differences and limitations of the investigations, including the use of the Mini Mental State Examination (MMSE) specifically in orthopedic literature and in the methodological approaches used to identify cognitive impairment. The MMSE is not sensitive enough to the level of cognitive change in various patient groups as well as identify particular domains with impaired performance (Sosa Rex et al., 2004; Kagansky et al, 2004). Most normal adult participants of any age, score at, or very close to, the maximum score with ease. Subtle degrees of cognitive decline will therefore not be detected because of a ceiling effect. In addition, it has no parallel versions and consequently the same questions are administered with each application. This permits learning effects in participants who score just less than the maximum but retain sufficient mental capacity to learn, but not in those who score either very low or the maximum. Such differences make it difficult to generalize findings across studies and raise questions regarding the conclusions of specific individual studies, particularly as they relate to the incidence of cognitive impairment.

There are several reasons for studying elective joint replacement patients. Elective orthopedic surgery is commonly performed in older persons. The elective nature allows for more thorough and accurate determination of potential risk factors through preoperative assessment of medical, mental, and functional status. It also allows for more standardized presentation and delivery of surgery, anesthesia, postoperative nursing care, and surveillance. Lastly, it avoids the confounding effects of fracture-related pain, stress, and analgesia (due to use of local anesthetics as opposed to general anesthesia). However, this group of surgical patients have still shown to have one of the highest incidences of postoperative delirium which is believed to be a marker for postoperative cognitive decline.

Depression and Cognition

Patients with mood disorders in general and depression in particular to show cognitive impairment in various cognitive domains. The more severe their condition, the more apt they are to be cognitively impaired. Depressed individuals may have severe, global cognitive deficits or focal, discrete cognitive deficits, or they may be cognitively intact (Sabbe, Hulstijn,VanHoof et al., 1999; Ravnkilde, Videbech,Clemmensen et al.,2002; Rinck and Becker, 2003). Their cognitive status is dependent of age, depression severity, premorbid cognitive state, or whether they have a comorbid condition, such as stroke or early dementia. However, even mildly depressed patients without complicating factors can show more impairment, as a group than normals. Patients with bipolar disorder or depression with psychosis are more impaired than patients with nonpsychotic unipolar depression (Brown, Scott, Bench et a!., 1994; Jeste, Heaton, Paulsen et al.,1996; Barch, Sheline, and Csernansky, 2003).

Researchers have established that cognitive impairment is comorbid with affective illness, and deficits have been elicited in every domain. The focus of recent research has been to detect a pattern of specific cognitive functions that might be selectively impaired in depressed patients. Specific cognitive deficits have been demonstrated in tests of sustained and/or selective attention. Attention problems have been demonstrated in mixed groups of depressed patients, including young patients that are drug free, as well as geriatric patients after medical surgeries (Brown, Scott, Bench et al, 1994; Porter, Gallagher, Thompson et al., 2003; Kaiser, Unger, Kiefer et al., 2003). Impairments in working memory, a cognitive function that requires effortful attention, also occur in patients with depression. The attentional deficits of depressed patients are more likely to be evident in effortful tasks (Ancelin, Roquefeuil, Ledesert et al., 2001).

Studies of attentional impairment in depressed patients highlight the delicate nature of their subjective responses and the interaction between cognition and emotional response. Depressed patients tend to overreact to the mistakes they make. Farrin, Hull and Unwin et al. (2003) found that depressed men made more errors on a sustained attention task than nondepressed men, but they reported much higher incidences of cognitive failures on a standardized questionnaire. It was concluded that depressed patients responded “catastrophically” to errors. Making mistakes, even on a simple task of sustained attention, seemed to heighten their subjective sense of failure.

Another specific area of cognitive impairment observed in depressed patients is on tests of memory. Depressed patients are aware of memory impairment in their everyday lives. Studies have suggested that memory systems reliant on medial temporal lobe structures are impaired in patients with depression. The relationship between depression and some specific component of the memory system, however, is ambiguous. To date, studies have demonstrated problems with encoding as well as retrieval, recall as well as recognition. Depressed patients have particular difficulties with memory tasks requiring sustained effort, such as list learning and free recall, which are qualitatively different from tasks carried out automatically (i.e. memory for spatial tasks) (Barch et al., 2003; Goldberg, T.E., Gold, J. M, Greenberg, R., et al. (1999).

Psychomotor retardation is not necessarily pathognomonic of depression. However, it is one of the most persistent symptoms of major depression and one that is often demonstrable on cognitive tests. Psychomotor retardation can be demonstrated in depressed patients numerous ways including reaction time measures, information processing speed, writing and drawing tasks, and other fine and gross motor measures. Older depressed patients are also more likely to evidence psychomotor retardation than younger depressed patients (Houx and Jolles, 1993; Sabbe et al., 1999).

Language functions tend to be preserved in various forms of depression, although impairments in fluency have been noted. Fossati, Guillaume, Ergis et al. (2003) found verbal fluency impairments in patients with depression to be associated with reduced ability to shift mental set on card sorting tests, suggesting that language deficits were not primary but reflective of general executive functioning problems in depression.

Performance on measures of executive control functions tend to be impaired in depressed patients. Researchers have proposed that even if the impairment in brain function is global and diffuse, there is “particular involvement of the frontal lobes in nonpsychotic unipolar depression” (Fossati and Ergis, 2002). Moreover, executive dysfunction can be demonstrated in old as well as young depressed patients. Unipolar depressed patients exhibit executive deficits in tests of inhibition, problem-solving and planning. Cognitive inhibition deficits in depressed patients can lead to inefficient allocation of cognitive resources. They can cause the depressed patient to process information that is either irrelevant or counterproductive and thus reduce his or her capacity to deal effectively with depressive thinking and mood control (Fossati and Ergis, 2002).

Several studies have found evidence of problem-solving impairments in depressed patients. In card sorting tasks, depressed participants have difficulty with hypothesis testing and cognitive flexibility. This state of cognitive rigidity can prevent patients from coping with life events, thus perpetuating depressed mood by prolonging stress exposure. Planning tasks, such as Tower of London tests, also demonstrate that depressed patients fail to use negative feedback as a motivational boost to improve their performance (Fossati and Ergis, 2002; Fossati, Coyette, and Ergis, 2002). In addition, executive functioning deficits may predict a poorer outcome in depression. Thus initiation and perseveration scores – measure of cognitive flexibility – are associated with relapse and recurrence of depression and residual depressive symptoms (Brown et al,, 1994; Fossati et al, 2003; Bhalla, Butters, Zmuda et al, 2005).

Brain imaging studies show that reduced blood flow, particularly in the medial prefrontal cortex and dorsal anterior cingulate cortex, subserves executive impairments in depression. Neuroimaging studies also underscore the importance of mood-cognitive interactions in depression. A recent working model of depression implicates the failure of the coordinated interaction of distributed cortical-limbic pathways in the pathology of depression. According to this model, neocortical (prefrontal and parietal regions) and superior limbic elements (dorsal anterior cingulate) are postulated to mediate impaired attention and executive function, whereas ventral limbic regions (ventral anterior cingulate, subcortical structures) are postulated to mediate circadian and vegetative aspects of depression (Bell-McGinty, Butters, Meltzer et al. ,2002).

Depression in Surgical Patients

Several reports indicate an increased prevalence of depressive illness among general hospital inpatients compared to a non-inpatient population. Veroy and colleagues (2003) studied the prevalence of depression in general surgical patients between the ages of 18-65. These patients were undergoing orthopedic, gastrointestinal, or pulmonary surgery and were required to have an inpatient stay of more than two days. Current depression and dysthymia was diagnosed using the Structured Clinical Inte Depression is also known to influence attention and short term memory and it appears partly and variably involved in the decline in cognitive performance after anesthesia (Ancelin et al., 2001; Burns, Banerjee, Morris et al., 2007). Yesavage et al. (1983) alluded to the problem of discriminating between dementia and depression in older patients, since depressed mood may be manifest as passive refusal to respond appropriately to cognitive tests, and may also be accompanied by subjective experience of cognitive impairment, including memory loss and difficulty concentrating.

Chodosh, Kado, Seeman and Karlamangla (2007) studied 1,189 older surgical patients (age 70-79 at baseline) to look at the relationship between depression and long term cognitive decline. Cognitive performance was measured at baseline and at a seven year follow up with the Short Portable Mental Status Questionnaire (SPMSQ). Summary scores from standard tests of naming, construction, spatial recognition, abstraction, and delayed recall were studied. Depressive symptoms were also assessed at same time periods with the Hopkins Symptoms Checklist. After adjusting for several confounds such as age, education, and chronic health conditions such as diabetes and hypertension, a higher number of baseline depressive symptoms were strongly associated with greater seven-year decline in cognitive performance with higher odds of cognitive impairment (decline in SPMSQ score to <6). They concluded that depressive symptomatology independently predicts cognitive decline and cognitive impairment postoperatively in previously high functioning older adults.

As research has broadened in recent years, including data from neuroimaging technology, investigators have aimed to ascribe a pattern to the cognitive deficits that occur in depression. There are at least three theories that ascribe to a specific pattern to the neuropsychology of depression. One theory is the effort hypothesis, which states that performance on effortful tasks is disproportionately impaired in depressives comparedwith the performance on automatic tasks. The second, the cognitive speed hypothesis, states that depression is characterized by cognitive slowness and that slowing may be at the root of other cognitive impairments. Research indicates that cognitive functioning in depression is characterized by a reduced speed of information processing. Researchers who favor the cognitive speed hypothesis tend to dismiss the effort hypothesis, although the two are by no means mutually exclusive. The third hypothesis, is that impairment in executive control functions is central to the cognition in depressed patients. Because at least some degree of neuropsychological impairment is a trait marker for depression “localizing” the deficits of depressed patients to one particular functional system would be a signal advance. In contrast to theories of specific impairment is what could be referred to as the global impairment hypothesis; that depressed patients suffer from diffuse cognitive impairments – that their test performance is heterogeneous and that group analysis does not reveal any coherent pattern of dysfunction. Ravnkilde et al. (2002) concluded that “the large range of existing neuropsychological, neuropsychiatry, and more recently, neuroimaging investigations have not yet given a consistent picture of the psychological disturbances involved in depression”. Their research indicated that 1) depressed patients suffer from widespread cognitive impairments, 2) test performance was heterogeneous, and 3) group analysis did not allow any hypothesis on a possible pattern to the dysfunction.

Pertinent literature is compromised by studies of heterogeneous patients and the use of different tests that render comparisons across studies extremely difficult, or they administer test batteries that address performance in only one or two cognitive domains. Nevertheless, the literature is clear in showing that patients with depression are, as a group, subject to neuropsychological deficits in attention, memory, psychomotor speed, processing speed, and executive dysfunction. Although many prospective studies support a causal relationship between depression and cognitive dysfunction and decline, they may be confounded by preexisting participant comorbity (i.e. pain) that contribute to the development of both depression and cognitive dysfunction.

Pain and Cognition

Physiology of Pain

The neuroanatomical pathways associated with pain perception include complex mechanisms at the level of the spinal cord and complex supraspinal neural networks involved in processing acute and chronic pain. There are two systems involved in pain perception that include the lateral and medial lemniscus pain system which is made on the basis of the divergence of the spinothalamic or trigeminothalamic projections in the thalamus. The lateral system refers to the projections to the ventral posterolateral and the ventral posteromedial thalamic nuclei which in turn project to somatosensory cortex. The medial system involves projections to the medial thalamic nuclei and from there to limbic cortices including the anterior cingulated cortex, orbitofrontal cortex, amygdala, and other structures. In addition, the medial system involves connections with the periaqueductal gray matter that is involved in mediating nocioceptive inhibition as well as integrating behavioral response to potentially threatening or stressful stimuli (Nicholson and Martelli, 2004).

In most affected patients, postoperative chronic pain closely resembles neuropathic pain (Jung, Ahrendt, Oaklander, Dworkin, 2003; Mikkelsen, Werner, Lassen, Kehlet, 2004). Major nerves trespass the surgical field of most of the surgical procedures associated with chronic pain, and damage to these nerves is probably a prerequisite for the development of chronic pain. An ideal model for studying chronic pain in surgical patients, and establishing predictive factors for the condition, would include preoperative and postoperative assessment of psychological and neurophysiological factors, as well as thorough clinical investigation to exclude other causes of the chronic pain state.

Pain and Cognition

Physical disability is one of most feared consequences of aging, and can be contributed to by a wide range of factors, including cognitive impairments, psychosocial disruption, and physical disorders that directly impact function, such as cerebrovascular accidents, hip fractures, and arthritis. Because pathology in each of these domains (i.e., cognitive, psychosocial, and physical) can independently lead to functional decline, disorders that impact all three raise a red flag in the minds of geriatric practitioners.

The American Geriatric Society (2002) defines persistent pain as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. Given their longer life expectancy and greater likelihood of having multiple disabling health problems, older women are more likely than their male counterparts to experience pain as part of their daily lives. Because of the physical discomfort of pain, older women often develop a range of undesirable consequences, including impaired mobility, decreased socialization, depression, and sleep disturbances (Peat, Thomas, Handy, and Croft, 2004; Roberto and Reynolds, 2002). Further, less obviously related phenomena may be worsened by pain, such as gait disturbances, falls, malnutrition, slow rehabilitation, and cognitive dysfunction (Williams, 1995) more so than their male counterparts.

Neuropsychological testing is an important tool to assess cognitive performance and its impact on physical disability. However, a number of potentially confounding factors also can interfere with performance on these tasks. Among the many medical and psychiatric conditions that are known to be particularly prevalent in older persons is the experience of chronic pain. Epidemiological evidence suggests that chronic pain may be present in a range of one quarter to more than one half of persons over age 65 (American Geriatrics Society, 2002). Pain has been shown to be related to many cognitive difficulties including areas of memory and concentration, problem solving, abstract thought, and cognitive efficiency (Karp, Reynolds, Butters et al., 2006). Examples of difficulties reported by chronic pain patients include problems keeping scheduled appointments, keeping track of medications, following through on an exercise program, being able to perform previous work tasks, following conversations in interpersonal interactions, and making simple decisions in daily living.

Chronic pain in older adults is also related to sleep difficulties, increased medication usage, depression, decreased mobility, and lower self-perceived quality of health. In addition, pain and medications such as opioids used in its treatment have been reported to have adverse effects on cognition in mixed age groups (Eccleston, 1994b). Declines across the adult lifespan have been observed in both cross-sectional and longitudinal studies of the performance of tasks that require different perceptual or cognitive processes. Older adults may be at greater risk of cognitive impairment from both pain and its treatment with opioids, which may further degrade cognitive abilities that are already stressed by normal age-related cognitive decline, depression and polypharmacy, and in some cases preclinical dementia (Eccleston, 1994a).

Weiner, Rudy, Morrow et al. (2006) studied 323 older adults to examine the relationship between chronic lower back pain and neuropsychological performance (NP). All participants (pain vs. pain free) had neuropsychological testing with the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test, and the Grooved Pegboard Test. Pain intensity was measured using the McGill Pain Questionnaire Short Form. Investigators found that older adults with chronic lower back pain demonstrated impaired NP performance as compared with the pain-free older adults. The differences were noted on five scales including immediate memory, language, delayed memory (RBANS domain scores), mental flexibility (Trails B), and fine motor function (Grooved Pegboard). Further, pain severity was inversely correlated with NP performance, and NP function mediated the relationship between pain and physical performance.

Pain in Surgical Patients

Neuropsychological testing has often been used to evaluate outcome after surgery. In some surgeries, pain is not a significant factor, for example, in coronary artery bypass surgery or carotid endarterectomy. However, in other surgeries such as spine surgery and orthopedic surgery, pain is present both before and after surgery. Therefore, pain may interfere with cognitive test performance. The etiology behind the development of chronic pain after surgery is not fully known, but several risk factors have been identified. Preoperative pain and acute postoperative pain have been shown to increase the risk of postoperative pain. Intra-operative events, such as intra-operative nerve damage may play a role in chronic pain, as well as genetic and various psychosocial factors. Nikolajsen and colleagues (2006) examined chronic post surgical pain after orthopedic surgery. Moderate to severe pre-operative pain in the primary hip joint was indication for a total hip arthroplasty (THA). Therefore, investigators examined the prevalence of chronic pain after THA in relation to pre-operative pain and early postoperative pain. Investigators sent out a questionnaire to 1231 patients who had undergone THA 12-18 months previously. They found that 294 patients (28%) had chronic ipsilateral hip pain at the time of completion of the questionnaire, and pain limited daily activities to a moderate, severe or very severe degree in 12.1% of those patients. The chronic pain state was related to the recalled intensity of early postoperative pain and pain complaints from other sites of the body, but not the pre-operative intensity of pain. However, it is important to note that 29% – 53% of patients described moderate to severe pain preoperatively, and 15% of patients reported disabling pain postoperatively.

Clinical studies examining the relationship between pain and cognitive function in older adults have been performed in the postoperative setting. While a number of postoperative factors have been shown to contribute to cognitive dysfunction, such as delirium, infection, electrolyte disturbances, and hypoxia, multiple studies have demonstrated the importance of pain itself as a cause of postoperative cognitive dysfunction. Morrison, Magaziner, Gilbert et al. (2003) demonstrated a cause and effect relationship between pain and delirium in older surgical patients and between higher doses of morphine and improved neuropsychological performance. Dugleby and Lander (1994) suggested that pain following total hip replacement in patients aged 50-80 years was a strong predictor of mental status decline in the postoperative period. Lynch, Lazor, Gellis et al. (1998), in a study of 361 patients (mean age 67 years) undergoing elective noncardiac surgeries, found that pain was an independent risk factor for the development of delirium. Heyer, Sharma,Winfree et al et al.(2000) found that postoperative pain, not duration of surgery or dose/type of anesthetic, predicted impaired neuropsychological performance in postoperative spinal surgery patients over the age of 60 years old.

There have been several studies on the effects of postoperative pain, postoperative pain treatment and its effect on postoperative cognitive dysfunction. Two prior studies investigated the association of postoperative analgesia and development of postoperative cognitive dysfunction, but they revealed mixed results with one study showing that postoperative pain treatment had no effect on the development of change in cognitive status and another showing that the use of epidural analgesia was associated with the onset of postoperative cognitive dysfunction. Neither of these studies considered the contribution of preoperative pain to the development of postoperative cognitive dysfunction (Goldstein, Fogel, Young, 1993; 1996). Wang et al. (2007) examined the effects of postoperative pain in 225 older adults over the age of 65 after noncardiac surgery on change in cognitive status. They found 15% of patients who experienced postoperative cognitive dysfunction (POCD) reported moderate pain postoperatively compared to those who did not experience postoperative cognitive changes. They also found patients that experienced POCD were more likely to have experienced hip and knee surgery as opposed to other noncardiac surgeries. One of their suggestions for future research was to study preoperative pain experience and its effects on POCD to ascertain how physical discomfort preoperatively can be a predisposing factor to cognitive decline.