Intimate partner violence against women in western Ethiopia: prevalence, patterns, and associated factors

Violence against women (VAW) is "...any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life" [1]. Since women are disproportionately affected than men (95% Vs 5%), gender based violence is often used interchangeably with violence against women [2, 3]. Furthermore, the most common and universally occurring (85%) form of VAW is that perpetrated by a husband or other intimate partners [3‐5].

Intimate partner violence against women (IPVAW) is the most pervasive yet under estimated social and health problem that occur in pandemic proportions [2‐8]. The proportion is comparable to those for cancer, cardiovascular disease, HIV/AIDS, malaria, and traffic accident in the world [2, 5, 9, 10]. In fact, it becomes increasingly known as a health and human rights concern, and prevents women's enjoyment of their fundamental right and freedom that can hinder development [3, 4, 11].

In spite of the definitions and methodological differences, several population-based studies from around the world indicated that 10%-71% of married or cohabited women have experienced IPVAW [2, 5, 12, 13]. On the other hand, World Health Organization (WHO) multi-country study on VAW in 10 different countries confirmed that the lifetime and current (past 12 months) prevalence of physical or sexual violence ranges between 15 and 71% and 4-54%, respectively. According to the findings of the study, the lowest rates have been found in Japan and the highest in Ethiopia, Peru, and Bangladesh [14].

The root causes of intimate partner violence against women are diverse and there is no single factor that explains further why some individuals are violent, or why violence is more prevalent in some communities than in others [2, 4‐6]. Rather, several complex and inter connected social and cultural factors are involved. Indeed, all of them are manifestations of unequal power relations between men and women [15]. Moreover, an ecological model for understanding the factors of IPVAW was described at the levels of individual, relationships, community, and society [5, 15].

In Ethiopian context, although women represent 49.8% of the population and highly contribute to socio-economic development, they occupy lower status than men. They experience longer working days, low levels of education, and lack of adequate assignments in leadership and decision making positions [16]. However, studies from Ethiopia on IPVAW are few irrespective of different lifestyles, customs and culture of the people [16]. According to a handful of available population based studies from the northern and southern part of the country, the prevalence of IPVAW varies from 50 to 71% during lifetime and 30-54% for past 12 months [17‐21].

Yet, in western part of the country where the culture of the community is fairly different, population based study on IPVAW is hardly found. Thus, this research was aimed at investigating the extent, patterns, and associated factors of IPVAW in a sample of women aged 15-49 years living in urban and rural settings of East Wollega Zone, Western Ethiopia.

The study was conducted in one urban local government (Nekemte) and rural areas of four districts in East Wollega Zone, which is one of the 18 zones of Oromiya regional state, Ethiopia. East Wollega Zone is located at the western part of the country 331 KMs from Addis Ababa, Ethiopia. In the year 2011, the total population of the zone is 1,340,581 [22]. Oromo is the predominant ethnic group in the zone and Afan Oromo is used as a working language [22].

The objective of this study was to investigate the extent, patterns and associated factors of intimate partner violence against women. Most data on the prevalence of intimate partner violence comes from cross-sectional population based surveys [32]. Prevalence figures are liable to under or over reporting as the issue is surrounded by taboo and stigma [33, 34].

The overall prevalence of IPVAW in this study is greater than any studies elsewhere [2, 13, 14], including studies from other parts of Ethiopia [17‐21, 35]. For instance, the findings from Butajira, Ethiopia, showed 71% and 54% of ever married/cohabited women experienced lifetime and current IPVAW. The study also showed that 49% and 29% of women had the experience of lifetime and past 12 months physical violence, respectively. In the same study, the corresponding figure for sexual violence was 59% and 44% [17]. These variations are likely due to the inclusion of psychological violence for measuring IPVAW into the present study. Cultural differences may also explain the discrepancy [22]. The prevalence of IPVAW in this study is also higher compared to the findings of Deribew from Agaro, Ethiopia used similar method reported the prevalence of IPVAW of 51.8% with 32%, 33%, and 46% for lifetime physical, sexual and psychological violence, respectively [18].

The high prevalence figures found for past-year and lifetime exposure for the three forms of violence indicate the fact that women's opportunities to end violence are few due to perpetration of violence being considered as normal male behavior. In other words, the subordinate role of women in the society and family allows violence to continue and keeps the divorce rates low especially among the low and middle income groups [36]. Moreover, the high prevalence in the present study might be due to the fact that women were interviewed by female data collectors who were known and familiar with the people in the community. This creates an opportunity for disclosure of violence by the women.

Another feature which was investigated in this study is the abundance of forced sexual acts in intimate relationships. It basically accounts for 58.7% during women's lifetime and 51.0% in the past 12 months which is far greater than 46% and 33% during lifetime and past 12 months in the study of Butajira, Ethiopia [17]. This showed a lot of non-consensual sex is happening in consensual marriage/cohabitation. On the other hand, the 2005 amended Criminal Code of Ethiopia [37] doesn't recognize forced sexual acts in marital relationship as crime. Accordingly it ignores the act of compelling a woman to submit to sexual intercourse within wedlock.

Despite various efforts which have been made by different governmental and non-governmental organizations to achieve MDG 3, much smaller variations were observed across the current, previous and lifetime experiences of IPVAW. However, much decline in the current practice has been expected.

The overlap of physical and psychological violence is the most commonly occurring form than the other two joint occurrences. This is consistent with studies from Nicaragua and South Africa [33, 38] which is best explained as physical violence is often accompanied by psychological attacks, threatening and controlling behaviors [39]. Moreover, WHO multi-country study on VAW states that the most acts of physical violence reflect a pattern of abuse rather than an isolated incident [13]. Additionally, the present study shows the most severe violence seemed to be associated with greater overlapping of the different forms of psychological, physical and sexual violence that accounted for 56.9% of the total violence. This constitutes extremely serious situations and is much higher than 42% reported overlaps of physical and sexual violence in study from Butajira, Ethiopia [17].

There is no substantial overlap between psychological and sexual violence for women experienced any lifetime IPVAW. Again, of all abused women, 2.8% reported the experience of isolated sexual violence in their lifetime. This suggests that forced sexual acts alone by an intimate partner were not as prevalent in this population compared with isolated sexual violence by an intimate partner reported for other developing countries of WHO multi-county study on VAW that showed 31% in Butajira and 33% in Bangladesh [13]. The possible explanation is that women are less inclined to disclose sexual violence because it is shameful and very sensitive topic to be more pronounced in poor socio-economic country including Ethiopia.

Rural residents were less likely to report both lifetime and current experiences of IPVAW than urban residents. This is consistent with study from Philippines found a lower frequency of intimate partner violence among rural women [40]. This possibly indicated how women cope-up with urban life and what factors in the process of urbanization could be modified to decrease stress induced violence between women and men at intimate relationships. However, the finding of the current study is not consistent with the conclusion of WHO multi-country study and others that indicated rural localities presented higher rates than urban localities [13, 41]. This might explain as gender relations in urban regions are more distant from traditional patterns and greater presence of women's movements and support services [42]. Similarly, rural communities are usually more conservative and the bedrock of the socio-cultural values of traditional societies that may promote the norms and tolerance of IPVAW. This is also true in the study area.

Older age of the respondents was significantly associated with increased risk of lifetime IPVAW corroborating other study [43]. This is possibly explained that the experiences of IPVAW are persistent from time to time in which the women report their cumulative experiences in lifetime. However, this is not consistent with Fernandez idea who described as the age of woman increases she often grows in social status as she becomes not only a wife, but also a mother and a socially influential member of her community. Thus, older women are less likely to report current experience of IPVAW than younger women [44].

The level of education for women and men were identified as statistically significant factor of IPVAW, which is consistent with studies elsewhere [13, 42, 45, 46]. This is justified as educated women have greater range of choices in partners and able to negotiate greater autonomy and control of resources within the family. This in turn helps change norms and improves socio-economic conditions that capacitate them to protect themselves from IPVAW [42].

Compared to women who had no job, female headed respondents engaged into agricultural occupation and other activities appear to experience significantly lower levels of IPVAW. This could be explained that women are autonomous and empowered when they lead their livelihood while they are the head of the household. Indeed, this is not always true in Ethiopian context for which most of the households are headed by men.

This study also shows the increasing of the household socio economic status from poorest to richest is significantly associated with decreased risk of lifetime and current experiences of IPVAW while controlled for other variables. This association goes with Jewkes's explanation that poverty and associated stress are key contributors to intimate partner violence [42]. Here, poor socio-economic conditions contribute to violence in the family [47‐49]. Although violence occurs in all socioeconomic groups, it is more frequent and severe in lower groups across such diverse settings of developed and developing nations [30, 42].

Marriage by abduction increases the likelihood of experiencing lifetime IPVAW. This is so because abduction by itself is physically, psychologically, and sexually forcing a woman to have sexual intercourse often followed by marriage or cohabitation. This clearly indicates that male behaviors commonly associated with 'traditional' masculinity, which is strongly associated with IPVAW [50].

With this regard, for women who married/cohabited to polygamous husbands/partners, there is about four and two fold risks of experiencing lifetime and current IPVAW, respectively. This is consistent with the study findings from China and Uganda [51, 52]. This could explain how IPVAW put women's reproductive health at risk. Hence, it was described for having multiple sexual partner could put women at increased risk for sexually transmitted infections together with violence contributes to psychological burden, low self esteem, feelings of embarrassment and humiliation [53].

On the other hand, husbands'/partners' extra marital affairs were more strongly associated with both lifetime and current experiences of IPVAW at bivariate level. Again, the associations of frequent use of alcohol by husbands/partners and increased risk of perpetrating their wives/partners is consistent with other studies elsewhere [47, 54‐56]. This could be attributed for heavy consumption of alcohol is thought to reduce inhibitions, cloud judgment, and impair ability to interpret social cues [57].

Moreover, male or female witnessing inter-parental violence during their childhood increases the risk of his/her later experience of IPVAW coincides with earlier findings from Ethiopia and other countries [17, 49, 55, 58, 59]. It has been suggested that witnessing inter-parental violence could lead to a normative understanding of violence and regarded as a fitting means of conflict resolution [42]. With this view, violence was confirmed as a learnt behavior that passes from generation to generation [60].

Similarly, men who witness parental violence are more likely to have attitudes that condone a husband's right to control his wife and to be violent to her [61]. This is to explain why a similar belief in male control of the family and the use of violence to achieve it exist in the world. It also explains why there are certain scenarios where intimate partner violence against women is seen as being justifiable by some men [62]. On the other hand, women who witness violence against their mothers (as children) are more likely to tolerate violence by their partners and respond in a passive manner. It is possible, therefore, that in the future these silent observers themselves will be victims or perpetrators of abuse and play a role in propagating IPVAW.

As to the limitation of this study, the cross-sectional nature could cause difficulty of determining the direction of the association between study variables. The associations could only be discussed in terms of plausibility. A further limitation is that the research team interviewed only women as proxy respondents for their husbands/partners, and hence relies on women's reports only. This can be biased when it comes to reporting on husbands'/partners' characteristic and the childhood experiences. However, the proxy respondents have been shown to produce reliable estimates in other contexts especially in asking husbands'/partners' behavior including frequency of alcoholic drinking [63]. Also, some husbands/partners might be conservative for telling their own childhood and current history to their partners.

As to the strengths of this study, it has got community-based nature and the respondents have been selected by random sampling technique with relatively large sample size. Again, the team already adopted standard and validated instrument of WHO multi-country study on VAW including special training of interviewers designed to maximize disclosure of violence across different social and cultural groups [64]. In addition, the team used interviewers and supervisors who have past experiences of data collection from their respective community. Because of all these measures, it was found an extremely high response and prevalence rate of the study.

To the best of the investigators' knowledge, this is the first to document and identify the patterns of IPVAW over the current, previous and lifetime experiences in Ethiopia. The information on pattern and severity of abuse might warrant the concerned body to guide the development of screening, treatment, and intervention programs for abused women and their perpetrators.

Intimate partner violence against women is widely observed in the study area. Compared to similar studies the finding is among the highest. The study noted that more than three in four women were experienced at least one incident of IPVAW in their lifetime. Moreover, the patterns of IPVAW are similar across the time periods.

The joint occurrence of physical and psychological violence is the most commonly reported features of IPVAW. Moreover, overlapping of psychological, physical, and sexual violence accounted 56.9% of cases that indicate an extremely serious situation. Alarmingly, more than three quarter of women who experienced any physical violence had severe acts that could threaten them in their lifetime.

Area of residence, literacy status, socio-economic status, occupation, age of the respondents, and other cultural and behavioral factors were negatively or positively associated with IPVAW in the study area.

There is a need for protective efforts to break the norms that sustain women vulnerability in the society. Beside, the promotion of higher education and socio-economic development becomes vital. Additionally, education should target to shape children during their early age. This needs an urgent attention at all levels of societal organization including policymakers, stakeholders, professionals and other concerned body. Still interventions targeting behavioral and social factors promoting IPVAW should be instituted through the involvement of different stakeholders using a multi-sectoral approach and information dissemination tools. Moreover, extensive and longitudinal research is needed to validate the current findings.