Title: Experience of controlling behaviour and intimate partner violence among women of
reproductive age in sub-Saharan Africa
Version: 0 Date: 22 Feb 2024
Reviewer's report:
Journal: BMC Women’s Health
Manuscript Number: c3b8a3c9-5837-4796-afff-f27d556fa671
Title: Experience of partner controlling behaviour and intimate partner violence among women
in sub-Saharan Africa
Overall, this paper adds evidence to the literature on the prevalence of controlling behavior and
intimate partner violence among women in sub-Saharan Africa, and the association between
controlling behavior and IPV. I think the paper could be strengthened by some edits, especially to
how controlling behavior and IPV are conceptually different and how/why controlling behavior
leads to IPV. Definitions of IPV (including WHO and CDC) generally include controlling
behavior, so it is important for the authors to explain how they believe they are conceptually
different and why this matters. The CDC’s definition of psychological aggression includes
coercive control, which is essentially controlling behaviors. In addition, a bit more detail is
needed in the methods (see notes), particularly how the levels of controlling behavior were
defined and covariates adjusted for with each model. Overall, the paper needs some grammar
and editing improvements before publication.
• Abstract
o I would recommend making it clear in the introduction or methods that you are referring to
IPV against women.
o Methods: It should be “Demographic and Health Surveys”
o Methods: Do you perhaps mean you performed a weighted analysis (versus using a weighted
sample)?
o Methods: It would be good to mention the data/analysis is cross-sectional.
o Methods: How did you define medium and high levels of controlling behavior?
o Results: Were these results in comparison to women who did not experience any controlling
behavior or who experienced low levels of controlling behavior?
o Results: The first sentence correctly says “The odds” but then then other sentences say “times
more likely” or “more likely”. I would be consistent and use language around odds since you
are reporting odds ratios.
o Results: I would change the confidence intervals to have dashes in between the values instead
of a comma.
o Conclusions: With the 3rd sentence, it is unclear what you mean by “identified factors in this
study”.
• Introduction
o The CDC’s definition of psychological aggression includes coercive control, which is
essentially controlling behaviors.
o The second sentence of paragraph one – it is not clear what is meant by “and may be impacted
by social, economic, and cultural determinants”.
o Paragraph 1: I don’t think human sexuality is the term most appropriate here. If you are
referring to males and females, it is just humans, or sex or gender, or relationships perhaps.
o Paragraph 1: “According to a recent survey…” – Can you provide more details about this
survey? When was the data from or when was it published? Was the data cross-sectional?
Population-based?
o The term “victimization” is used a lot. Throughout the paper, I would avoid using this
terminology as it can be controversial. The debate on whether people who experience violence
are victims or survivors…it’s better to avoid this.
o Paragraph 2: I would edit to: “Women who experience IPV are increased at risk of
posttraumatic stress disorder…”
o “In extreme cases, IPV could result in deaths among young people” -> I would think age does
not matter here. Women of any age could die from severe IPV.
o Last sentence, paragraph 2: instead of occurrence, do you want to use prevalence? Or what
do you mean by occurrence?
o 3rd paragraph: by egalitarian decision-making, do you mean equal decision-making? If so, I
don’t think this sentence reads correctly as I believe it should be unequal decision-making leads
to violence against women.
o 4th paragraph: change to “placed on the association between partner controlling behaviours
and IPV”
o 4th paragraph: “Controlling behaviours are described as when one spouse threatens or
emotionally abuses the other partner” -> this sounds more like emotional violence. I would use
a description of controlling behavior that is more about controlling behavior.
o 4th paragraph: “Two studies considering data from seven [27] and eight countries [28] have
also been conducted and revealed an association between a partner’s controlling behaviour and
IPV in line with studies from other regions” -> What kind of studies were these? Using pooled
data? Cross-sectional data? Were they from SSA?
o 4th paragraph: change to: “These studies provide very important information on controlling
behaviours and IPV…”. I would use “controlling behaviours” instead of “control behaviours”
throughout the paper.
o 4th paragraph: can you expand more on the limited covariates these studies considered?
o Last sentence – I’m not sure we can say controlling behavior is a root cause of IPV.
Conceptually, it’s unclear whether controlling behavior is a separate type of IPV or is not IPV.
But the WHO includes it in their definition of IPV, and so does the CDC actually. I think you
can only say they are associated – especially using cross sectional data.
• Methods
o Again, my comment on weighted sample versus weighted analysis applies to the description
under data source.
o Paragraph 1, last sentence: Doesn’t quite make sense, needs editing?
o Table 1: Pooled weighted sample and pooled weighted percentage are unclear titles. Do you
mean the weighted number of women and weighted percentage of women?
o Variables: now that I’m seeing your outcome was past-year IPV (versus lifetime or some other
time) I would make that clear throughout the paper.
o Variables: it’s unclear how you defined low, medium, and high levels of controlling behaviors.
o Variables: Did you choose to control for these 10 variables a priori? Or based on some analysis
you conducted?
o Statistical analyses, last sentence: Why set the significance at 0.05? This is an outdated way
of looking at statistical results and I would suggest removing. Instead, judge the p-value on it’s
value and give it a rating (ie. Good evidence for <0.05, or weak evidence for <0.01. If you want
to set the significance level, please cite a reason and reference.
o How was missing data handled? Was there any?
o I would list the age of women included in the sample, probably in the first paragraph.
• Results
o Paragraph 1, sentence 1: Do you mean prevalence of IPV for each country? I would use
“prevalence” instead of “proportion”. This applies throughout.
o “with the least proportion being witnessed in Gambia (2.30%).” – I would be consistent with
terminology and say “with the lowest proportion being reported in Gambia (2.30%)”.
o Figure 1: I would specify that the map for “Intimate partner violence” includes physical,
emotional, and sexual, if that is the case. It’s unclear what this is an based on the prevalence
values, maybe it is not all three.
o “Distribution of intimate partner violence across the explanatory variables” -> I would
consider rephrasing this to across the confounding variables, or covariates. Since your analysis
only considers one exposure variable, controlling behavior, and the rest of the variables were
considered a priori confounders (at least that is what I’m assuming).
o “The result showed substantial differences in physical, emotional, and sexual violence by
explanatory variables at p<0.005.” -> You might consider saying something like, crude analyses
showed each covariate was strongly associated (p<0.005) with physical, emotional, and sexual
violence.
o “Furthermore, physical violence was found to be prevalent among women who experienced
partner controlling behaviour (34.5%). “ -> does this refer to women who experienced ANY
level of controlling behavior? From your table, it looks like high level.
o Table 2: Again, instead of weighted sample, I would use “weighted number of women” or
something similar. For the columns labeled with the types of violence, is this proportion with
95% CI? Please specify. Lastly, you have a starred footnote on the bottom of the table but no
* in the table itself to refer to.
o Why did you choose to make the comparison group women with low partner controlling
behavior instead of those with no partner controlling behavior? Might specify in the methods.
o “From Table 3, model I (crude regression), women who experienced medium [aOR =
2.54; 95% CI = 2.35, 2.75] and high [aOR = 6.76; 95% CI = 6.26, 7.30] partner controlling
behaviour…” -> if these are crude, why is there an aOR instead of OR? This suggests adjusted.
o Table 3-5: You have different models with different levels of covariates but I do not see these
defined anywhere. It should be made clear what covariates were adjusted for in each model (this
could also be defined in the methods if it was systematic). In addition, it would be preferred to list
the p-value so that the reader may make their own judgements on the strength of the evidence.
Alternatively, it looks like all the odds ratios had a p-value of <0.001 so maybe you don’t need
all the different options at the footnote. Also please define cOR like you have done for aOR.
o Again, I would suggest saying “three times the odds” versus “3 times more likely” if you’re
reporting odds.
o Why have you presented the crude and adjusted results for physical violence in the text but
only the adjusted results for emotional and sexual violence?
o Instead of referring to Model IV as the “complete model” you might say, the model adjusting
for all covariates.
o Table 6: Instead of “One IPV” or “Two IPVs” I would say “One IPV type”. Perhaps define this
clearly in a footnote. Make clear that two IPV types could be physical and emotional, physical
and sexual, or emotional and sexual.
• Discussion
o You could remove the first sentence as you don’t need to restate the aim. Just start with your
more interesting findings. When you refer to IPV, please refer to the types of IPV included. Also
remember to remind the reader this is past-year IPV.
o 2nd paragraph: conceptually, I have a hard time considering controlling behaviors as
completely separate from IPV, and therefore a risk factor. Instead, it more seems like they could
be related, and associated. So what you’ve shown is women who experience medium-high levels
of partner control are more likely to experience physical, sexual, or emotional IPV compared
to women who experience low levels of partner control. To me, this is the main finding. From
this data, I don’t think you can say partner control is a “predictor” since you cannot make causal
inference from cross-sectional data.
o “Moreover, a multi-country study done in Asia revealed that controlling behaviour serves as
a risk factor for the occurrence of physical violence among women” -> was this longitudinal
data or cross-sectional data?
o “Women mainly rely on their partners in household decision-making and for resources due to
their low socioeconomic status.” -> What women? What population are you referring to here
and do you have a reference?
o “Additionally, sociocultural norms also reinforce women’s exposure to emotional violence
through their tacit support of perpetrators of such actions. This largely situates a woman as a
subservient actor within a largely patriarchal society [50].” ->The way this is stated could be
a little more delicate. This seems to place blame on the woman for supporting IPV behaviors
and being a “subservient actor” as if they have no thought behind their actions or desires for
a different situation.
o “Findings from the study revealed that there is a significant association between experiencing
partner control behaviour and IPV. Specifically, women who reported high experience of partner
control behaviour had higher odds of experiencing IPV.” -> You have basically said this already.
Do you mean IPV overall (multiple types)?
o “This makes them to be submissive to their partners and may have less involvement in
decision-making and resource mobilization [57]. Moreover, women may largely have lower
education and socio-economic status, which places them at a disadvantage position. These
factors collectively make the women susceptible to being controlled by the men and therefore
being more vulnerable to IPV [58].” -> This section seems to place the importance upon the
vulnerability of women versus the perpetration of men. Since your study is focusing on men’s
controlling behavior, I would focus on why men perpetrate versus why women are vulnerable.
It may just require some tweaking of the language/text. I also don’t feel as if this paragraph
adequately explains why partner control leads to IPV.
o Strengths and limitations: I would think the large sample size is a strength, but not for
generalizability. Generalizability has to do with the large breadth of populations you are covering
with multiple countries, etc. What about recall bias and social desirability bias with self-reported
data? Another limitation is the study did not measure financial violence. Adding some discussion
around why women don’t always report (with reference) may be helpful. This could be due to
stigma, the sensitive nature of the topic, fear of reporting, etc.
o Conclusion: this is the first mention of the Aspiration 6 – I would mention this sooner, perhaps
in the introduction. Or create a separate paragraph for policy implications in the discussion.
o I would include more discussion on why and how partner control may lead to IPV. Why are
these conceptually different and how would focusing on controlling behavior reduce IPV? Why
focus on controlling behavior and not forms of IPV itself?