Intimate partner violence (IPV) is a global problem that affects one-third of all women. The present study aims to develop and determine the validity of a screening instrument for the detection of IPV in pregnant women in Tanzania and Vietnam and to determine the minimum number of questions needed to identify IPV.th-34th gestational week where the World Health Organization (WHO) IPV questionnaire was used as the gold standard. In all, 255 combinations of eight different questions were first tested on the Tanzanian study population where sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. In the evaluation of the performance of the question combinations, different IPV types and the frequency of abusive acts were considered. The question combinations that performed best in Tanzania were subsequently evaluated in the Vietnamese study population.An IPV screening instrument based on eight questions was tested on 1,116 Tanzanian and 1,309 Vietnamese women who attended antenatal care before 24 gestational weeks. The women were re-interviewed during their 30In Tanzania, a combination of three selected questions including one question on emotional IPV, one on physical IPV and one on sexual IPV was found to be most effective in identifying women who are exposed to at least one type of IPV during pregnancy . The performance of the identified combination was slightly less effective in Vietnam . Focusing on different IPV types, the best performance was found for exposure to physical IPV in both Tanzania  and Vietnam . In both countries, the sensitivity increased with the frequency of abuse whereas the specificity decreased.By asking pregnant women three simple questions we were able to identify women who were exposed to IPV during pregnancy in two different countries. The question combination performed best in assessing physical IPV where it identified 93% and 96% of Vietnamese and Tanzanian women, respectively, who were exposed to physical IPV. Intimate partner violence (IPV) is a worldwide problem, which globally affects one-third of all women –4. IPV dAddressing the problem of IPV is an international priority  and consIn the implementation of any screening programme, the validity of the screening instruments should be considered. According to a systematic review, there is a great variation in sensitivity (0.30–1.00) and specificity (0.55–0.99) of different IPV screening instruments used in health care settings . There iAccording to a recent Cochrane review, screening of women who attend antenatal care may be helpful in identifying women who are exposed to IPV . SimilarAlthough IPV during pregnancy is a major health problem in L/MIC, with severe adverse health consequences, few screening programmes have been evaluated and implemented in such settings . Againstth gestational week were enrolled. In both settings, the women were interviewed when included in the study, at 30–34 gestational weeks, at delivery, and 4–12 weeks postpartum. At enrolment, information on socioeconomic and reproductive characteristics was obtained and an agreement was reached regarding time and place for the second interview. In all, 1,116 Tanzanian women and 1,309 Vietnamese women were re-interviewed in gestational week 30–34. The second interview, which was performed in homes or similar places where participants felt comfortable to talk freely, included detailed information on the women’s exposure to IPV.The present study was part of a larger research project, "The Impact of Violence on Reproductive Health in Tanzania and Vietnam (PAVE)", with the overall aim of assessing the associations between IPV and adverse pregnancy outcomes and antenatal depression in Tanzania and Vietnam. The study was performed simultaneously in the two countries. In Tanzania, women were recruited from Majengo Health Centre and Pasua Health Centre, in Moshi District, and in Vietnam they were recruited from Dong Anh Hospital and Bac Thang Long Hospital in Dong Anh District. A total of 1,123 Tanzanian women and 1,337 Vietnamese women who attended antenatal care before the 24Different questionnaires and screening tools ,9,16 werTo investigate the validity of the 8 questions (4 questions on IPV exposure during the past 12 months and 4 questions on IPV exposure during pregnancy), the pregnant women were re-interviewed in gestational week 30–34. At the re-interview, the full WHO questionnaire for assessing Domestic Violence against Women was applied and used as a “gold standard”. The WHO questionnaire comprises 5 questions on emotional IPV, 6 questions on physical IPV and 4 questions on sexual IPV. For each question, the women are asked if they ever have been exposed to IPV and if yes, if they have been exposed during the past 12 months, and if yes, whether during the past 12 months it has happened once, a few times or many times. Since the study aimed at assessing exposure to IPV during pregnancy, the assessment period of “past 12 months” in the original instrument was changed to “during this pregnancy” and to operationalize the frequency of IPV exposure, “a few times” was defined as 2–5 times and “many times” as more than 5 times.All data were double-entered in Epi Data (Version 3.1) by two different data clerks, and discrepancies were identified and subsequently corrected according to the original data forms. All statistical analyses were performed using the STATA software package (version 14).To determine the properties of the eight questions for detecting exposure to at least one type of IPV (regardless of type), emotional IPV, physical IPV, and sexual IPV, the following values were determined: 1) sensitivity (proportion of women exposed to IPV who screened positive), 2) specificity (proportion of women not exposed to IPV who screened negative), 3) positive predictive value , 4) negative predictive value  and 5) accuracy. In all, 255 question combinations were generated for each type of IPV. The minimum score possible was zero  and the maximum score possible was eight . To select the optimal cut-off score, the properties of the question combinations were computed according to different cut-off levels (cut-off 1–8).at least one type of IPV and selected the combinations with a sensitivity > 0.75, an NPV > 0.75, and accuracy > 0.75 when assessed at a cut-off level of 1. This resulted in 144 combinations, which were subsequently assessed for their properties in predicting emotional IPV, physical IPV and sexual IPV with an accuracy > 0.70. The question combinations were subsequently evaluated for their properties in predicting exposure to the different forms of IPV according to the frequency of exposure; only once, 2–5 times and more than 5 times.The questions’ performance was first tested on the Tanzanian study population. In the evaluation of the different combinations of the questions, we first gave priority to their properties in predicting The combinations that performed best in identifying the different forms of IPV  were thereafter examined according to the cut-off value which resulted in highest sensitivity and specificity. Then, it was observed whether this cut-off also yielded the highest accuracy.emotional IPV, physical IPV and sexual IPV. The diagnostic ability of the question combination found to have the highest sensitivity and specificity for determining all four types of IPV was tested for different cut-off values in the Vietnamese study population as well.Finally, the combinations that were found to perform best in Tanzania were evaluated on the Vietnamese study population ,18 for tFemale nurses and community collaborators were recruited as research assistants. They received comprehensive training on the concepts of gender, gender discrimination, inequality, domestic violence and how to deal with participants who were exposed to violence. The WHO Ethical and Safety Recommendations for Research on Domestic Violence against Women  was usedAll women were informed in detail about the study and written informed consent was obtained. In Tanzania, none of the participants were aged below 18 years. In Vietnam, two were aged 17 and accompanied by their mother, who also signed the consent form. Ethical approval of the study was obtained from the Ethical Review Committee at Kilimanjaro Christian Medical University and Hanoi Medical University.In Tanzania, a total of 1,123 women met the inclusion criteria. As seven women did not show up for IPV assessment in gestational week 30–34, the final sample comprised of 1,116 women. In Vietnam, 1,337 women fulfilled the inclusion criteria and 1,309 presented for IPV assessment in gestational week 30–34.Socio-economic characteristics and ever-exposure to IPV among Tanzanian and Vietnamese women are listed in When focusing on exposure to IPV during pregnancy, almost one-third of the Tanzanian women had been exposed to at least one type of IPV during their current pregnancy, 23% had been exposed to emotional IPV, 6.0% to physical IPV and 15% to sexual IPV . The vasThe psychometric properties for detecting at least one type of IPV , using the WHO questionnaire as the “gold standard” were tested for all 255 combinations of the eight questions among Tanzanian women. Four combinations: 1+4, 1+2+4, 1+3+4, and 1+2+3+4 were found to have sensitivity > 0.75, NPV > 0.75 and accuracy > 0.70 for predicting at least one type of IPV  . QuestioThe diagnostic ability of question combination 1+3+4 in identifying IPV using the WHO tool as gold standard was tested for different cut-off values in Tanzania  and VietA combination of three screening questions was found to be effective in identifying women exposed to IPV during pregnancy. The found 3-item combination performed best in Tanzanian whereas the sensitivity was slightly lower in Vietnam. When evaluating the test performance for the different types of IPV, the 3-item combination performed best among women who were exposed to physical IPV, with a sensitivity of 0.93 among Tanzanian women and 0.96 among Vietnamese women.Approximately one-third of the participants in both countries had been exposed to at least one type of IPV during pregnancy. When focusing on the different types of IPV, 23% had been exposed to emotional IPV, 6.0% to physical IPV and 15% to sexual IPV in the Tanzanian setting. The corresponding Vietnamese figures were 35%, 3.5% and 10%, respectively. Globally, there is a great variation on the reported prevalence of IPV, which has been illustrated in a recent systematic review based on data from antenatal clinics, where the prevalence rates of IPV during pregnancy were found to be 2–57% (n  =  13 studies), with meta-analysis yielding an overall prevalence of 15% . The larWe found that a screening based on the three questions with a 93% probability would be positive among Tanzanian women exposed to physical IPV and with 96% probability would be positive among Vietnamese women exposed to physical IPV. When focusing on emotional and sexual IPV, the probability dropped to 78% and 87% among Tanzanian women and to 76% and 71% among Vietnamese women. The three-question combination’s poorer performance in predicting emotional IPV may reflect that an experience defined as emotional IPV in a screening instrument is not always considered as abuse by the victim and therefore the act may not be disclosed by them. When it comes to sexual IPV, a comparatively lower sensitivity was found in the Vietnamese study setting. This shortcoming of the found item combination most likely reflect that there are a number of barriers that may hinder questioning adult women about sexual abuse as well as barriers that may hinder women from sharing such experiences. In other words, a brief screener, like the one we have developed, may not provide sufficient confidentiality to obtain valid answers on sensitive topics such as sexual activity. Other studies have likewise shown that asking about sexual IPV specifically may be even more difficult than asking about physical IPV . This maBased on our findings we argue that antenatal care can play an important role in identifying women who are exposed to IPV. It should, however, also be stressed that screening for IPV has to go hand in hand with supportive responses and information so the women can plan for their safety. Hence, in any screening for IPV, the expenditure of resources spent on screening must be justifiable in terms of eliminating or decreasing IPV exposure and associated adverse outcome. Therefore acceptable and affordable interventions must be in place before routine IPV screening is considered implemented . In the There are some important limitations in this study. Firstly, both the screening questions and the WHO questionnaire rely on interviews performed by health staff, which implies that the results do not automatically reflect the IPV that actually took place and there is a risk that the women may have denied or minimized the IPV they had been exposed to. Alternative ways to obtain information on IPV exposure have been evaluated and the results have been compiled in a recent systematic review. The review found that computer-assisted self-administered questionnaire lead to higher rates of IPV disclosure in comparison to both face-to-face interview and self-administered questionnaires on paper . It may,By asking pregnant women three simple questions, one on emotional IPV, one on physical IPV and one on sexual IPV, we were able to identify women who were exposed to IPV during pregnancy in Tanzania and Vietnam. The question combination performed best in predicting physical IPV, where it identified 93% and 96% of Tanzanian and Vietnamese women, respectively, who were exposed to physical IPV measured according to the gold standard. Based on our findings we conclude that the developed screening instrument can help identifying women exposed to IPV so relevant action can be taken to address the problem and its associated consequences. Ideally, the tool should be incorporated in the first antenatal care visit together with questions about other risk factors that are routinely asked in early pregnancy.S1 Dataset(SAV)Click here for additional data file.S2 Dataset(SAV)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.


There is growing awareness of the problem of intimate partner violence (IPV) among military populations. IPV victimisation has been shown to be associated with mental disorder. A better understanding of the link between IPV and mental disorder is needed to inform service development to meet the needs of military families. We aimed to systematically review the literature on the association between IPV victimisation and mental health disorders among military personnel.Searches of four electronic databases  were supplemented by reference list screening. Heterogeneity among studies precluded a meta-analysis.Thirteen studies were included. There was stronger evidence for an association between IPV and depression/alcohol problems than between IPV and PTSD. An association between IPV and mental health problems was more frequently found among veterans compared to active duty personnel. However, the link between IPV and alcohol misuse was more consistently found among active duty samples. Finally, among active duty personnel psychological IPV was more consistently associated with depression/alcohol problems than physical/sexual IPV. The review highlighted the lack of research on male IPV victimisation in the military.There is evidence that the burden of mental health need may be significant among military personnel who are victims of IPV. The influence of attitudes towards gender in the military on research in this area is discussed. Further research is needed to inform development of services and policy to reduce IPV victimisation and the mental health consequences among military personnel.The online version of this article (doi:10.1007/s00127-017-1423-8) contains supplementary material, which is available to authorized users. Intimate partner violence (IPV) is a serious, preventable public health problem that occurs in all settings and among all religious, cultural, and socioeconomic groups . IPV incThere is a growing body of research on IPV victimisation among military populations, though these studies are very heterogeneous in terms of samples, method of measurement of IPV, and definitions of different types of IPV. To our knowledge, no UK studies exist. Studies in the US have found high levels of IPV victimisation among military personnel, both male and female –49, withThere is a large body of literature which has established the link between IPV victimisation and mental disorder in the general population. Research has focused on depression, PTSD, anxiety, eating disorders, substance misuse, and chronic mental illness more broadly, with the most consistent evidence highlighting a link between IPV and depression, followed by PTSD and anxiety disorders –72. TherThe aim of this study was, therefore, to systematically review extant studies to summarise the literature exploring IPV victimisation and specific mental health problems among male and female military personnel (both serving and ex-serving).A literature search was undertaken for studies examining mental health problems associated with IPV victimisation among military populations. Searches of the following electronic databases were carried out: Embase, Medline, PsycINFO, and Web of Science. The search terms and combinations used were identical for all four databases. Search results were limited to papers published in English. In addition to searching bibliographic databases, the reference lists of all relevant papers and reviews were searched. Authors were contacted to request raw data where necessary. This review followed PRISMA reporting guidelines and the protocol is registered with PROSPERO: registration CRD42016044119.Studies were eligible for inclusion if they: (1) involved male and/or female serving or ex-serving military personnel; (2) reported the risk of IPV victimisation among those with and without mental disorder or vice versa, and/or a measure of association between IPV and mental disorder; (3) measured IPV using a validated tool or adapted question(s); (4) measured mental health using a validated diagnostic or screening tool, e.g., the PTSD checklist (PCL), or the Alcohol Use Disorders Identification Test (AUDIT); (5) presented the results of peer reviewed research based on any quantitative study design capable of providing the data listed above; and (6) had a sample size of over 100 participants. IPV was defined as “any incident of threatening behaviour, violence or abuse  between adults who are or have been intimate partners regardless of gender or sexuality” . Mental Figure Heterogeneity among the studies in this review (primarily regarding the timing and type of IPV studied) precluded a meta-analysis.The key characteristics of the included studies are summarised in Table As shown in Table Studies examined IPV measured over a variety of time periods. Four studies reported on past-year IPV , 84, 85,Nine studies examined depressive symptoms among individuals who have experienced IPV victimisation , 84, 85,n = 529) similarly found that emotional violence victimisation (defined as experiencing threats of violence) was significantly associated with depression [The majority of study findings will be reported according to gender. However, two high-quality studies explored the association between depression and IPV experienced over the course of the current relationship among samples of male and female Canadian Armed Forces (CAF) members and did not stratify analyses by gender. The first study used a representative sample of 1745 CAF members and found that ‘probable depression’ was significantly associated with increased emotional and/or financial abuse, but not with any physical and/or sexual IPV . The secn = 248), the researchers grouped participants according to six different patterns of violence . It was found that mean depression scores were significantly higher among females who reported experiencing violence by a male civilian spouse compared to those who reported no violence. Mean depression scores did not differ significantly between the no violence group and the group in which the more severe violence was perpetrated by the enlisted female. The mean depression score for the group in which both the enlisted female and her spouse had engaged in severe violence and/or injury was significantly higher than all other group scores [In a study of past-year IPV among active duty females married to civilian spouses  IPV was significantly associated with increased cases of depression [n = 616) found no significant association between physical and/or sexual IPV and cases of depression [n = 369) during military service found no significant difference between the mean depression score of women who experienced sexual IPV compared to those who had not experienced sexual abuse [With regard to lifetime IPV, a high-quality study utilised data from a nation-wide telephone survey of non-institutionalised adults in the US and found that among female veterans  found that past-year physical and psychological aggression was significantly associated with depression [n = 13,765 males) found that among veterans lifetime IPV  was significantly associated with increased depression [One study of male active duty Army personnel  found that 32.2% of those who reported lifetime IPV had a PTSD diagnosis, compared to 14.8% of those who did not report IPV, and PTSD was significantly associated with physical IPV [n = 616) did not find a significant association between physical and/or sexual lifetime IPV and PTSD [A study of 160 female VA patients found that 41.4% of females who reported past-year IPV had a PTSD diagnosis, compared to 19.6% of those who did not report IPV, and past-year physical and/or psychological IPV was found to be significantly associated with PTSD . Similarical IPV . In contand PTSD . Finallyand PTSD . The PTSSeven studies explored alcohol misuse among individuals who have experienced IPV , 84, 85,n = 42,744; 8031 females) found that past-year clinically significant emotional abuse (defined as at least one reported act that caused significant distress that interfered with the victim’s functioning) was significantly associated with alcohol problems [A high-quality study utilising a representative sample of active duty US Air Force members (problems . In contproblems  and did problems .n = 249) found a significant association between sexual IPV  and problem drinking, but no association with either physical  or psychological IPV [n = 2670) reported that lifetime physical IPV increased significantly with AUDIT-C scores of five or more [Two studies examined lifetime IPV victimisation and alcohol problems among clinical populations of female VA patients , 82. One or more . HoweverA high-quality study of 34,713 male US Air Force members found that clinically significant emotional abuse was significantly associated with alcohol problems . AnotherA study of 160 female VA patients found that of those who reported IPV, 50% reported mental health multi-morbidity , compared to 20.6% of those who did not report IPV. Past-year physical and/or psychological IPV victimisation was significantly associated with mental health multi-morbidity .The aim of this review was to explore the association between IPV victimisation and mental health problems among current and former military personnel. The number and quality of studies which found an association between IPV and depression/alcohol problems was higher than for IPV and PTSD. An association between IPV and mental health problems was more frequently found in studies of veterans compared to active duty personnel. However, the link between IPV and alcohol misuse was more consistently found among active duty samples. Among active duty personnel, psychological IPV was more consistently associated with depression/alcohol problems than physical/sexual IPV.Six of the seven studies that examined the association between IPV and depression found a significant association after controlling for potential confounders, with four studies being of high quality. All studies that explored psychological IPV and depression found a significant association , 45, 54.Three of the five studies that examined the association between IPV and PTSD found a significant association after controlling for confounders. All three studies utilised female veteran samples, and none were rated as high quality. Two studies of active duty personnel  did not find a statistically significant association after adjustment for confounders , 58 see. Only onFour of the five studies  that investigated the association between IPV and alcohol problems found a significant association after controlling for potential confounders. An association between IPV and alcohol problems was more consistently found among male compared to female personnel in this review. However, it should be noted that the one high-quality study providing separate data on males and females reported identical odds ratios for emotional IPV and alcohol problems . Among mThe National Violence Against Women Survey (NVAWS) of males and females aged 18–65 found that psychological IPV was more strongly associated with adverse health outcomes (including depressive symptoms and substance use) than physical IPV . It is pSignificant associations between IPV and depression/PTSD were more consistently found among veterans than active duty personnel. Research has confirmed the under-reporting of mental health problems among serving military personnel , 100. IdResearch is also emerging showing higher rates of mental health and social problems among veterans than among active duty personnel , 111. A The number and quality of studies finding an association between IPV and alcohol problems were found to be higher among active duty than veteran samples. There is a culture of excess alcohol consumption in the military . It has Perhaps, the most striking finding of this review was the lack of research into male IPV victimisation and mental health. Research in the general population has shown that women are at greater risk of IPV victimisation compared to men, and the psychiatric burden of IPV is greater among women . ResearcStudies in both the general population and military samples have found that men and women are equally likely to be violent in intimate relationships, but women are more likely to suffer an injury and are at greater risk of serious and sexual assaults , 122–128To our knowledge, this is the first systematic review of studies of IPV victimisation and mental disorder among military populations. The strengths of this review are that it included studies of psychological and sexual IPV, rather than just physical violence, and it only included studies that used validated tools to measure symptoms of mental disorder. The interpretation of the review findings was limited by heterogeneity among the included studies. Diverse tools were used across studies to measure IPV and there were variations in the timing of IPV studied . These inconsistencies made comparisons between studies difficult.Problems with IPV measurement were not only a significant limitation of all studies in this review, but also are a criticism of the field of IPV research as a whole –132. IPVOnly two studies in this review considered differences in the severity of IPV , 85. It All studies included in this review used validated tools to measure mental disorder. However, some measured symptoms rather than providing a diagnosis, limiting the reliability and comparability of study findings. Studies did not consistently control for potential confounders when examining the association between IPV and mental disorder. Finally, all included studies were cross sectional, meaning that no conclusions can be drawn regarding the direction of causality between IPV victimisation and mental disorders.The findings from this review indicate that, just like among civilian populations , the burIPV is associated with adverse health consequences for both male and female victims , and theThis review highlights the need for further research to examine IPV victimisation and mental disorder among active duty and veteran military personnel. There is a need for greater consistency in IPV measurement to allow meta-analyses of the findings of different studies. Future research should consider the impact of IPV victimisation in order that gender differences can be better understood.Supplementary material 1 (DOCX 43 kb)Below is the link to the electronic supplementary material.


First, we examined the level of inter-partner agreement in reporting of men’s physical, sexual, emotional and economic IPV against women in the last three and twelve months prior to the survey, ever in the relationship, and during pregnancy. Second, we conducted a convergent validity analysis to compare the relative efficacy of men’s self-reports of perpetration and women’s of victimization as a valid indicator of IPV against Tanzanian women using logistic regression models with village-level clustered errors. We found that, for every violence type across the recall periods of the last three months, the last twelve months and ever in the relationship, at least one in three couples disagreed about IPV occurrences in the relationship. Couples’ agreement about physical, sexual and economic IPV during pregnancy was high with 86–93% of couples reporting concordantly. Also, men’s self-reported perpetration had statistically significant associations with at least as many validated risk factors as had women’s self-reported victimization. This finding suggests that men’s self-reports are at least as valid as women’s as an indicator of IPV against women in Northern Tanzania. We recommend more validation studies are conducted in low-income countries, and that data on relationship factors affecting IPV reports and reporting are made available along with data on IPV occurrences. Keywords: Intimate partner violence; measurement; validity; survey research; Tanzania.In recent years, major global institutions have amplified their efforts to address intimate partner violence (IPV) against women—a global health and human rights violation affecting 15–71% of reproductive aged women over their lifetimes. Still, some scholars remain concerned about the validity of instruments used for IPV assessment in population-based studies. In this paper, we conducted two validation analyses using novel data from 450 women-men dyads across nine villages in Northern Tanzania.  Intimate partner violence (IPV) is a global health and human rights problem affecting 15–71% of reproductive-aged women worldwide over their lifetime. DefinedRecently, IPV has evolved into an important area of intervention and investigation among practitioners and academics. Major global health and development organizations have escalated their commitment to address IPV in low-income countries. For example, since 2013, the United States’ (USAID and the Department of State) support for global gender-based violence (GBV) programs totaled approximately $153 million per year . During and the perpetrator, scholars showed poor inter-partner agreement in IPV reporting. Regardless of gender, victims report up to 50% more IPV occurrences than perpetrators, depending on context [However, some scholars remain concerned about the validity of instruments used for IPV assessment, questioning whether IPV instruments are effective in accurately classifying women as exposed or not exposed to IPV –16. Data context –20.First, we examined the level of inter-partner agreement in the reporting of physical, sexual, emotional and economic IPV against women in the last three and twelve months prior to the survey, ever in the relationship, or during pregnancy, using novel data from 450 couples across nine villages in Northern Tanzania. Second, we conducted a convergent validity analysis to compare the relative efficacy of men’s self-reported perpetration and women’s self-reported victimization as a valid indicator of IPV against women in Tanzania. Using logistic regression models, we examined whether and to what extent male and female partners’ IPV self-reports were associated with men’s self-reports on validated risk IPV factors, namely, men’s inequitable attitudes about gender norms and relations, traumatic childhood experience, condom non-use, multiple sexual partners, and substance use.In this paper, we conducted two validation analyses. This study makes important contributions to IPV research in low-income countries. First, since self-reports will dominate IPV research for years to come , rates oGender-based stratification is a central feature of society in Tanzania, an East African country with an estimated population of 47.4 million and per capita income of $865 . With a Discordant reporting of IPV by couples occurs when (a) the man reports no violence perpetration, but the woman reports victimization : Cell 2;Scholars attribute couples’ discordant reporting to a number of social and methodological factors. Social factors include social desirability and norms of victim blaming , 30. MetSocial desirability is often considered a determinant of couples’ discordant reporting and perpetrators’ under-reporting of IPV , 21. DefIn Tanzania, social desirability will likely produce couples’ discordant men-to-women IPV reporting in the form portrayed in Cell 3 more commonly than that in Cell 2 . As statConversely, Tanzanian women may not disclose victimization fearing blame, shame, divorce, abandonment, and loss of the custody of children. McCleary-Sills and colleagues (2016) explain, “… at the core of this is a sense that women are at fault for any violence they experience because they have somehow provoked their partners into beating them” (p. 229). Women fOn methodological factors, couples’ discordant IPV reporting may be attributable to definitional differences. A difficult construct to operationalize, IPV tends to be private  and subjective . Men’s knowledge about what is or is not IPV may be lower than women’s, creating discordant reporting of IPV. Such gender gaps may exist because men only recently started participating in violence prevention programs , whereas women’s participation in such programs has been ongoing for many years .Finally, couples’ discordant IPV reporting may stem from questionnaire design and implementation . Men andFor convergent validation analysis, the IPV risk factors considered include men’s inequitable gender attitudes; exposure to childhood trauma; multiple sexual partners; condom non-use; and alcohol or drug use. Support in prior literature informed inclusion of these IPV risk factors.Men’s excessive alcohol consumption is associated with IPV against women. Working as a trigger, alcohol influences violence by disinhibiting behavior in individuals with aggressive tendencies and encouraging sexual-risk taking , which may lead to jealousy, perceptions of partners’ infidelity, transmission of sexually transmitted infections, and marital conflict and violence , 46. MenChildhood exposure to traumatic experiences, especially when untreated, can influence individuals’ violent treatment of others later in life , 57. ChiFinally, men’s IPV perpetration is believed to be a consequence of the gender system that entitles men to more rights, privileges and power, resulting in gender inequalities at the societal and relational levels. This inequality limits women’s educational attainment and wage employment, leading to women’s economic dependence on men and vulnerability to and acceptance of male control and abuse of power , 64, andKaratu District, one of seven districts in the Arusha region of Tanzania. Our selection of this region and district was based on the high prevalence (>1 in 3) and acceptance (1 in 3) of IPV in Arusha (NBS & ICF Macro 2016), as well as the implementation of an ongoing savings groups (known as LIMCA) with women implemented by our partner, World Education Inc./Bantwana. These groups aimed to empower women participants through savings and credit activities to increase their economic independence and expand social networks. The groups also aimed to improve women’s knowledge about the physical, mental and emotional harms of IPV on women, men and children.For this analysis, we used the baseline survey data from 450 couples who participated in a three-arm cluster-randomized controlled trial (RCT) to evaluate the effectiveness of an intervention (entitled Together to End Violence against Women (TEVAW)) in reducing men’s IPV perpetration in Tanzania. We conducted this cluster-RCT in We recruited a non-probability sample of 450 of 604 women LIMCA members and their male partners. Women LIMCA members were briefed about the study during regular LIMCA meetings. We invited women-men dyads who were eligible. Eligibility criteria for women included being aged 18 years or above, living with a male partner, providing written consent to participate in the study and consents in writing to her male partner to participate. Eligibility criteria for men included being aged 18 year or above, living with a woman LIMCA group member, and providing written consent to participate in the study. We included in the study the first 450 men-women dyads deemed eligible. Baseline data were collected in June-July 2015 via face-to-face interviews. Women and men were interviewed separately in a private location by trained interviewers of the same gender. Ethical approval was obtained from Boston University and the Tanzania National Institute of Medical Research Institutional Review Boards.For IPV by type, we adopted questions from three instruments: Men’s Health and Relationship Study , WHO MulWe created a dummy variable of whether a man (woman) had perpetrated (been victimized of) IPV against women. We considered that a man had perpetrated physical violence against his female partner in last three months, last 12 months, ever in the relationship, and during pregnancy if, for each of these time intervals, he reported perpetrating once, a few times or many times any one of the following: slapped a partner or thrown something at her that could hurt her; pushed or shoved a partner; hit a partner with a fist or with something else that could hurt her; kicked, dragged, beaten, choked or burned a partner; or threatened to use or actually used a gun, knife or other weapon against a partner. We considered that a woman had experienced physical violence from her male partner if she reported experiencing once, a few times or many times any one of these acts. The same parameters were used for men’s perpetration and women’s experience in the four time points mentioned of the following acts of sexual violence , emotional violence , and economic violence . Questions on physical, sexual, or economic IPV during pregnancy were about victimization of any acts of physical, sexual or economic IPV during any pregnancy.Gender inequitable attitudes was measured using an 18-item scale on attitudes toward gender norms in intimate relationships, known as the GEM (Gender Equitable Men) Scale . For eacExposure to childhood trauma was measured using a 13-item scale, a modified version of the Child Trauma Questionnaire . For eacCondom non-use was measured using men’s reports on how often  they used condoms when having sex in the last year. On condom non-use, men received the value of 1 if they reported never; else, they received a zero. Multiple sexual partners was measured using men’s reports on the question: “Including stable partners and occasional partners, how many people have you had sex with in the last year?” Options include: 1 person; 2 or 3 people; 4–10 people; 11–20 people; more than 20 people; and none. Men received 1 if they reported having sex with more than one person within the last year; otherwise, they received a zero. Finally, alcohol or drug use was measured using men’s reports on two questions: “How often do you drink alcohol?” and “How many times have you used drugs in the last 12 months?” For both questions, options include: every day or nearly every day; weekly; once a month; less than once a month; and never. Men received a zero if they reported never on both questions; otherwise, they received a one.Finally, male and female partners’ age was measured with self-reported age in years; highest level of schooling attended was measured using self-reports.We estimated the crude percentage agreements and chance-corrected agreements between couples’ reports of physical, sexual, emotional, and economic violence in the last three and twelve months prior to the survey, ever in the relationship, and during pregnancy. We cross-tabulated men’s reports (Yes/No) of physical, sexual, emotional and economic violence perpetration in the last three and twelve months prior to the survey, ever in the relationship, and during pregnancy and women’s reports (Yes/No) of victimization. Further, we estimated the chance-corrected agreements between couples’ reports of each of the 48 violent events considered in the analysis (see Measures).Next, for convergent validity analysis, we estimated the following equation:ii. Y is 1 if the log odds of reporting IPV by men or women iX refers to risk factors for IPV perpetration, namely, men’s gender inequitable attitudes, exposure to childhood trauma, condom non-use, multiple sexual partners, and alcohol or drug use; iM refers to men’s age and highest level of education attained; and, iW refers to women’s age and highest level of education attained. We fit a logistic regression model with village-level clustered errors, controlling for male and female partners’ age and highest level of education attained.kappa) between couples’ reports of IPV in last three months were low ranging between 0.04  and 0.09 ; kappa estimates for couples’ reports of IPV in the last twelve months and ever in the relationship were also low ranging between 0.06  and 0.18  and between 0.02  and 0.17 (economic IPV), respectively.For every violence type across the recall periods of last three months, last twelve months and ever in the relationship, at least one in three couples disagreed about IPV occurrences in the relationship  and 14% (economic IPV)  between couples’ reports of men-to-women perpetration of each of the 48 acts of IPV considered in this analysis. The kappa estimates were low: for physical IPV acts, these estimates ranged between -0.01 and 0.03, 0.02 and 0.19 and 0.03 and 0.14 for last three months, twelve months and ever in the relationship, respectively; for sexual IPV acts, these estimates ranged between -0.02 and 0.06, 0.03 and 0.09, and 0.01 and 0.05 for last three months, twelve months and ever in the relationship, respectively; for emotional IPV acts, these estimates ranged between 0.01 and 0.07, 0.03 and 0.12, and -0.04 and 0.12 for last three months, twelve months and ever in the relationship, respectively; and, finally, for economic IPV acts, these estimates ranged between 0.05 and 0.14, 0.08 and 0.14, and 0.09 and 0.18 for last three months, twelve months and ever in the relationship, respectively.Finally, in or women (Block 3) were 15–45% higher than those estimated using women’s reports (Block 2); 76–308% higher than those estimated using men’s (Block 1). Prevalence rates estimated using reports by men and women (Block 3) were 51–87% lower than those estimated using women’s reports (Block 2), and 27–60% lower than those estimated using men’s reports (Block 1).Of five IPV risk factors, three  had significant associations with men’s self-reported physical IPV perpetration in the last three months ; and, three  had associations with women’s self-reported victimization (Panel 1: Model 2). The magnitudes of association were relatively small; directions generally were as expected. Men’s odds (aOR = 1.10) of reporting perpetration increased with a unit increase in their childhood-trauma scores. Alcohol or drug users had higher odds (aOR = 2.01) than non-users; condom non-users (aOR = 0.55) had lower odds than users. Next, men who reported agreement with more gender-inequitable attitudes had higher odds (aOR = 1.05) of being reported as perpetrators by their female partners. The same pattern of association was evident for men who experienced more trauma during childhood (aOR = 1.08). Finally, alcohol or drug users had higher odds (aOR = 1.65) of being reported as perpetrators compared to non-users.Of five IPV risk factors, two  had significant associations with men’s self-reported sexual IPV perpetration ; none had associations with women’s self-reported victimization (Panel 2: Model 2). Men who reported multiple sexual partners were three times more likely to report sexual IPV perpetration than men who reported one or none. Men who reported alcohol or drug use had higher odds (aOR = 1.56) than men who reported non-use.On emotional IPV (Panel 3), three  of five IPV risk factors had significant associations with men’s self-reported perpetration (Model 1); one  had an association with women’s self-reported victimization (Model 2). Men who reported more traumatic childhood had higher odds (aOR = 1.18) of reporting perpetration. Condom non-users had lower odds (aOR = 0.56) than users; alcohol or drug users had higher odds (aOR = 2.77) than non-users. Further, alcohol or drug users had higher odds (aOR = 1.62) of being reported as perpetrators by women than non-users.On economic IPV (Panel 4), four  of five IPV risk factors, had significant associations with men’s self-reported perpetration (Model 1); one  was associated with women’s self-reported victimization (Model 2). Men who reported agreement with more gender-inequitable attitudes (aOR = 1.06) and more childhood-trauma (aOR = 1.12) had higher odds of reporting perpetration. Condom non-users had lower odds (OR = 0.54) than users; alcohol or drug users had had higher odds (OR = 2.20) than non-users. Further, alcohol or drug users had higher odds (aOR = 1.44) of being reported as perpetrators by their female partners.or economic IPV perpetration in the last three months (Model 1). None had associations with women’s odds of reporting victimization (Model 2).All five IPV risk factors (Panel 5) had significant associations with men’s odds of reporting of physical, sexual, emotional Further, we estimated associations with five IPV risk factors of IPV occurrences reported by men or women (Model 3) and by both men and women (Model 4). Of five IPV risk factors, four  were associated with physical IPV, none with sexual IPV, three with emotional IPV , two each with economic IPV  and any one form of IPV , when IPV against women was measured using IPV occurrences reported by men or women (Model 3). Additionally, of five IPV risk factors, two  were associated with physical IPV, one (childhood trauma) with sexual IPV, three  with emotional IPV, two  with economic IPV, and three  with any one form of IPV, when IPV against women was measured using IPV occurrences reported by both men and women (Model 4).and the perpetrator are believed to mitigate reporting biases .In recent years, the Government of Tanzania has amplified its effort to redress the consequences faced by the victims of intimate partner violence in the country. These efforts, albeit important, may become those of limited impact if assessment tools are neither specific nor sensitive in correctly classifying women as victims or otherwise. Self-reports by the victim are commonly used for IPV assessment. Yet, self-reports are prone to reporting bias. The validity of self-reports by the victim is contingent on victims recognizing an act as violent as and when it happens, remembering when violence occurs in the relationship, and not concealing violence. Self-reports by the victim In this paper, using data from 450 Tanzania couples, we examined the level of inter-partner agreement in the reporting of physical, sexual, emotional, and economic IPV against women in the last three months prior to the survey, last twelve months, ever in the relationship, and during pregnancy. Further, we examined the relative association of men’s self-reported perpetration and women’s self-reported victimization with validated risk factors, namely, men’s gender inequitable attitudes, exposure to childhood trauma, condom non-use, multiple sexual partners, and alcohol or drug use. We used men’s self-reports to measure risk factors.In IPV reporting, we found poor agreement between partners within the couple in Northern Tanzania. We found that, for every violence type across the recall periods of last three months, last twelve months and ever in the relationship, at least one in three couples disagreed about IPV occurrences in the relationship. The level of partner disagreement in the reporting of lifetime physical IPV in the current analysis (42%) is comparable to findings (35%) by Yount and Li (2012) using the 1995–96 and 1996–97 DHS data from 943 randomly selected couples from Assiut and Souhag, Egypt .prima facie support to our argument. Norms of victim blaming should similarly affect IPV reporting by women LIMCA members and their male partners, and cannot explain discordant reporting. Social desirability bias is less likely to be a factor: gendered motivation to conceal or disclose IPV occurrences are likely slim in the gender-stratified context of Northern Tanzania, where IPV is perceived as normal and met with acceptance by both genders. That the extent of couple disagreement remains comparable across the recall periods of last three months, last twelve months is suggestive of the fact that men and women were equally prone to recall bias.We argue that, in the context of Northern Tanzania, definitional differences have contributed to discordant reporting more than norms of victim blaming, social desirability, or recall bias. Compared to women LIMCA members trained in child protection and gender-based violence, men may be less capable of recognizing acts as those of violence due to training gaps, potentially resulting from men’s non-participation in any structured IPV training. That the level of couple disagreement is higher in the reporting of emotional violence (48%) than it is in the reporting of physical violence (36%) provides some A vast majority of couples agreed that physical (92%), sexual (93%), and economic (85%) abuse did not occur during pregnancy. Such high concordance rates were contrary to expectation, given language ambiguity in the questions of interest. These questions do not ask about abuse in reference to a specific pregnancy, requiring each partner in the couple of multiple pregnancies to decide for him/herself which pregnancy to recall in his/her answer. Specifying pregnancies in questions about abuse during pregnancy will further improve data quality.Convergent validity findings via logistic regression models with village-level clustered errors were somewhat contrary to expectation. Compared to women’s self-reports, men’s had significant associations with at least as many IPV risk factors. This implies that men’s self-reports are as valid as women’s self-reports as an indicator of men’s perpetration of physical IPV against women, and more valid than women’s self-reports as an indicator of men’s perpetration of sexual, emotional, and economic IPV in the context of Northern Tanzania.Further, validation findings suggest that some women may have reported sexual, emotional, or economic IPV when there were none. Over-reporting  may steThe validation analysis results should be interpreted in light of the limitations as follows. The sample of 450 couples was not randomly selected, suggesting current results may or may not be generalizable to all couples whose female partners are engaged in income-generating activities in Tanzania. Further, more importantly, we used men’s self-reports to measure all five risk factors for IPV perpetration in men. Therefore, the unbiasedness of validation results are conditional on five risk factors being: (a) true risks in the context of Tanzania; and, (b) free of measurement errors. Future studies should replicate current analyses using different data.In conclusion, the use of retrospective self-report questionnaires has revolutionized the way we collect data on violence perpetration and victimization, allowing production of a great deal of knowledge about the causes and consequences of interpersonal violence against women. However, the lone use of retrospective self-reports is believed to have created controversies . Research attempting to resolve these controversies, as part of research on the operationalization of IPV, is more prevalent in high- vs. low-income countries. We recommend this gap be addressed urgently. In the meantime, researchers and practitioners may modify current data-collection practices in low-income countries. For instance, in addition to collecting data on IPV occurrence, researchers and practitioners should collect data on factors affecting the quality of IPV reports and reporting. These factors include: satisfaction level, a desire to exact revenge for prior mistreatment, the degree of investment in the relationship, among other relationship factors. Valid assessment is imperative to mitigating IPV adversities on maternal and child health.S1 Dataset(ZIP)Click here for additional data file.


Little research has assessed the impact of emotional intimate partner violence (IPV) and economic IPV on women’s mental health. Using cross-sectional data from the Stepping Stones and Creating Futures intervention trial baseline, in eThekwini Municipality, South Africa we assess three questions. First, whether emotional IPV and economic IPV make independent contributions to mental health outcomes; second what matters, severity, variety, or absolute experience? and third, are some items more important in driving mental health impacts than others? We assess associations between past 12-month emotional IPV, past 12-month economic IPV, and past week depressive symptoms and past four-week suicidal ideation. We describe the prevalence of each mental health outcome by individual items, including never/ever and frequency, and combined emotional IPV, and economic IPV, reporting depression scores and percentage of suicidal ideation and 95% confidence intervals (CI). Second, we created four-level categorical variables for combinations of emotional, economic, sexual and physical IPV, and present its frequency, and the mean/% and 95% CI for depression symptomatology and suicidal ideation. 680 women (aged 18–30) were enrolled. High levels of past year emotional IPV, economic IPV were reported. 45.3% reported clinically relevant symptoms of depression, and 30.0% past four-week suicidal ideation. All measures of emotional IPV and economic IPV showed a consistent positive correlation with CESD scores, and suicidal ideation. For all four-level categorical constructs the highest depression scores, and prevalence of suicidal ideation, were for combinations of emotional IPV or economic IPV with physical and/or sexual IPV. For depression in 17/18 combinations this was significantly different compared to women reporting no IPV. For suicidal ideation this was significant in 6/18 combinations all related to economic IPV. Emotional IPV and economic IPV have independent associations with women’s mental health, beyond physical IPV and sexual IPV, and also have distinct patterns between each other.NCT03022370. Registered 13 January 2017, retrospectively registered. A decrease in emotional intimate partner violence (IPV) is now an indicator of progress for the Sustainable Development Goal 5.2. This indicator is one of 230 indicators assessing progress on the 17 global goals established by the UN to assess development progress by 2030 . The lacThe lack of focus on emotional and economic IPV in research to date emerges for a number of reasons. First, there is a lack of consensus on best practices for measuring these constructs, which can manifest in myriad and culturally diverse ways e.g. , 8, in cFinally, there is also a lack of conceptual clarity about what constitutes emotional IPV and economic IPV. For emotional IPV, this is apparent in the multitude of terms for the same or similar phenomena, including psychological violence, or abuse. For clarity and a working definition in this paper, emotional IPV includes verbal abuse and humiliation, and threats of violence or other acts to scare a woman . While eThere is emerging evidence that the view that emotional and economic IPV have less health impact than physical or sexual IPV may be wrong. A review of research on IPV and suicide found two studies showing increased suicidal ideation and suicide attempts following emotional IPV, specifically Bangladeshi women were 2–3 times more likely to report suicidal ideation if they had experienced emotional IPV . In a loThere are even fewer studies exploring the health impacts of economic IPV, but those that do show that economic IPV also negatively impacts mental health. In Palestine, a nationally representative cross-sectional study showed women who experienced economic IPV were more likely to report depression and anxiety . The natWhile research on health impacts remains limited, it is clear that both economic and emotional IPV are widespread. A systematic review of emotional IPV in pregnancy in Africa estimated that 24.8% to 49% of pregnant African women experienced emotional IPV . In the There are a number of questions about how best to define and measure emotional and economic IPV, and no clear standard has yet emerged. The three major international surveys that have measured these constructs show slight, but important, variations. The WHO Multi-Country Study on Domestic Violence (WHO MCS), and the UN Multi-Country Study on Men and Violence in Asia and the Pacific (UNMCS) and the current Domestic Violence Module (Jan 2017) of the Demographic Health Survey (DHS) vary in the number of items used, and the focus and wording of questions .Just as there is no consensus on the measurement of emotional and economic IPV, there is likewise no consensus on coding and analysis of responses to questionnaire items; this creates further complexities in understanding the prevalence and unique health impacts of these constructs. Some studies treat emotional and economic IPV as separate constructs, while others treat it as one construct –21. FurtIn this paper, we argue that through looking at the health impact of emotional IPV, and economic IPV, juxtaposed with the impact of physical and sexual IPV, we can begin to answer many of the central questions in the measurement of emotional and economic IPV. Building this understanding is important for understanding the relative health impact of different forms of IPV, developing and evaluating IPV prevention interventions, and understanding what is most useful to track for monitoring progress towards the SDG. We seek to answer three central questions. First, do economic and emotional IPV, make important, independent contributions to self-reported depressive symptomology and suicidal ideation? Second, if they are important, what matters in their measurement? Is it the number of types, number of episodes, or the overall severity of the IPV? Finally, are some items more important in driving health impacts than other items?Between September 2015 and September 2016, 680 young adult women were recruited to participate in the Stepping Stones and Creating Futures cluster randomized control trial in urban informal settlements surrounding Durban, South Africa. 34 clusters were identified and community leaders approached for inclusion. In each cluster between 19 and 21 women were enrolled into the trial . These aParticipants were aged between 18 and 30 and out of school. Further eligibility criteria included residence in the informal settlement and ability to understand the informed consent process. Participants were not blinded to study arm, those enrolling in the intervention arm received R100 (~US$7) and those in the control arm received R300 (~US$21) for completion of questionnaires. The structured questionnaires were self-completed on cellphones, with built in logic checks and skip patterns. Questionnaires were available in Zulu, Xhosa and English. Research staff matched to the participants by age and gender were available to clarify meaning or assist if literacy or technology posed an issue.Participants provided informed written consent to participate. Ethical approval for the study was received from the University of KwaZulu-Natal, and the South African Medical Research Council. Further details on ethical procedures and research methods are described elsewhere .The content of the questionnaires was almost entirely based on surveys previously used and validated for use in South Africa. Our two key outcomes for this analysis were past week depressive symptomology and past month suicidal ideation.We assessed depressive symptoms using the 20-item The Centre for Epidemiologic Studies Depression Scale (CES-D) scale , which hTo measure past 4 week suicidal ideation, we asked a single item asked whether “the thought of ending your life been in your mind?” This approach has been used widely to assess suicidal ideation . A binarWe assessed women’s experiences of four types of IPV in the past year: physical, sexual, emotional and economic. Questions on physical IPV were taken from the widely used South African adaption of WHO’s MCS survey . Past yeEmotional IPV in the past year was assessed using the five items from the WHO MCS survey  and adapEconomic IPV was assessed using the four items from the UNMCS survey for women , which wData were uploaded and compiled into a dataset for analysis in Stata IC 14.1. Because of self-completion on cellphones, and inbuilt logic checks, there was very little (<1%) data missing in the sample and no corrections were undertaken for this. Descriptive analyses took into account the clustered nature of the sample, and the 95% confidence intervals (CIs) were calculated using Taylor linearization. Taylor linearization corrects standard errors for the clustered nature of the sample, and provides wider CIs . For eacTo describe associations between the emotional and economic IPV and our chosen mental health outcomes, we first described the prevalence of individual items of emotional IPV and economic IPV. For each item of the emotional and economic IPV scales we report the prevalence of, i) never/ever in the past 12 months, ii) two or more times in the past 12 months versus none or 1, and iii) the frequency of experience . We also report the prevalence of none versus any emotional or economic IPV and two or more versus none or one report of emotional or economic IPV. For each type of IPV described we present the mean and 95% CI for depression scores and the percentage and 95% CI for suicidal ideation.To assess the associations between the four types of IPV exposures and depression/suicidal ideation, we first created a series of four-level categorical variable for a variety of combinations of emotional, economic, sexual and physical IPV and present variation in mental health outcome. For instance, we created a four-level variable for no exposure to violence, one or more emotional IPV exposures only, any emotional IPV and any physical IPV exposure, and physical IPV exposure only. This enabled the creation of ‘clean’ reference categories for each type of exposure, where typically there is overlap between types of violence that is not accounted for in analyses. We developed different permutations of this violence variable with physical IPV, sexual IPV, economic IPV, combined economic and emotional IPV and then examined if the effects were different if we considered never/ever exposures and higher versus lower frequency of exposure (two or more exposures). For each violence variable we present its frequency and the mean/% and 95% CI for depression symptomatology and suicidal ideation.A total of 680 women were interviewed . Women wAll forms of IPV measured were highly prevalent . Almost Two-thirds (66.5%) of the women reported two or more instances of emotional IPV in in the past year, while just under half (43.7%) reported two or more experiences of economic IPV in the past year. Three-quarters (76.3%) reported two or more experiences of emotional and/or economic IPV in the past year.The mean CES-D score of women in the sample was 21.2. Almost half the sample (45.3%) reported potentially clinically relevant depression (a score of ≥ 21 ), while Tables The most frequently reported form of economic IPV was “your partner spent money on alcohol, tobacco or other things for himself when he knew you did not have enough for essential household expenses” (38.4%) and the least frequent was taking a woman’s earnings against her will (9.9%) . ApproxiAll measures of emotional and economic IPV we examined showed a consistent positive association with mean CESD-D scores Tables  and 3. FA similar pattern was observed for economic IPV, whereby for all individual items any vs none, and two or more vs none or one comparisons were significantly different with no overlaps of 95% CI. In addition, women reporting many experiences of any individual item had significantly higher depressive symptoms compared to none, while the few category was marginal or non-significant.All measures examined for each of emotional IPV, and economic IPV ‘full constructrs’  were significantly associated with increased CES-D scores.The overall pattern of associations between emotional IPV, economic IPV, and self-reported suicidal ideation in the last four weeks were similar to those for CES-D scores, but differences were less often significant Tables  and 3. TInteresting differences emerge in looking at the emotional IPV or economic IPV only categories vs the physical and/or sexual IPV only categories. For 15 out of the 18 categorical variables tested, the category of emotional IPV or economic IPV only was associated with higher mean CES-D scores than the category of physical and/or sexual IPV only, the only exception being cases B4-6, looking at multiple events of economic IPV vs multiple events of physical and/or sexual IPV. Cases B4 and B5 also represent the only combinations where physical or sexual violence was significantly different from the no IPV referent, but the variable definition for these cases meant the women who had experience emotional IPV (but not economic) were coded in this group, and so these cases ultimately affirm the importance of emotional IPV as a correlate of CES-D score.This is further affirmed by looking at cases C4-6, which show that the combined category for emotional and/or economic IPV only, associated with significantly higher mean CES-D scores than the categories for physical and/or sexual violence only. Further evidence for the importance of emotional IPV in mean CES-D score is found in case A5, where emotional IPV alone is associated with significantly higher CES-D scores than no IPV .Our analysis clearly highlights the importance of emotional IPV and economic IPV in driving significant mental health impacts for women, and that these extend beyond those found with the current, narrower focus on physical and/or sexual IPV alone. While there is a small, but growing body of research on the health impacts of emotional IPV, and its differential impacts compared to physical and/or sexual IPV , 12, 26,The analysis supports the hypothesis that emotional IPV and economic IPV, have distinct health impacts in themselves. For both economic IPV and emotional IPV the frequency of exposure Tables  and 3 inThere were also differences between the mental health impacts of emotional IPV and economic IPV, despite them being strongly inter-related concepts, they did function as distinctive constructs and should be considered as such. While both emotional IPV and economic IPV had similar patterns around associations with depressive symptomology, there were stronger and more consistent associations between economic IPV and suicidal ideation Tables –5, compaThis analysis suggests that emotional IPV and economic IPV should not be regarded as ‘lighter’ less ‘important’ forms of IPV when compared to physical and/or sexual IPV, in terms of mental health outcomes. Women in this study who experienced only emotional, or economic IPV reported more depressive symptoms and were more likely to report suicidal ideation than those who experienced physical or sexual IPV only. Major depressive disorders (MDD) for women are common globally, with an estimate past year prevalence of 5.5%, and are associated with increasing death related to physical injuries, self-harm and suicide . MoreoveFinally, the analysis showed that the highest levels of depressive symptoms and prevalence of suicidal ideation, were seen amongst women who experienced emotional IPV or economic IPV, combined with physical IPV or sexual IPV Tables  and 5, sThere are several important implications of the analysis presented here for policy, and for research and evaluation. First, we do not need to measure all forms of emotional IPV and economic IPV to see a mental health impact. The addition of multiple items to questionnaires has often been considered as overly burdensome for studies, and not capturing any distinct impact on women’s health, beyond what has already been captured through assessing physical and sexual IPV. Given the very high prevalence of any emotional IPV and economic IPV and overlaps of types, the returns on measuring additional forms will not yield high returns when viewed in terms of having many more women being ‘exposed’. As has been shown, emotional IPV and economic IPV have distinct mental health impacts over and above physical and sexual IPV. As such their inclusion is important, but the analysis shows that a relatively small set of items can lead to capturing of these health impacts, particularly when combined with other forms of IPV.Second, we do not need large numbers of indicators in scales to capture health impacts. As shown, measures of ever/never exposures, and in particularly two or more exposures (compared to none or one) capture the majority of mental health impact for women for emotional IPV or economic IPV. As such, it should be possible to derive a smaller sub-set of items that capture the majority of burden that women experience in terms of emotional and economic IPV.Finally, given that emotional IPV and economic IPV have distinctive outcomes in terms of mental health, as well as being clear indicators of severity of impact, when combined with physical and sexual IPV, it is critical that these are included as trial outcomes in interventions seeking to prevent IPV. At a practical level reducing all forms of IPV that have an impact on mental health is crucial, and therefore as emotional IPV and economic IPV have a distinct and separate impact to physical and/or sexual IPV, the impact of interventions on these should be assessed. In addition, other studies have hinted that interventions may have different impacts on different forms of IPV. For instance, an evaluation of Oportunidades in Mexico showed a reduction in physical IPV amongst female recipients, but increases in emotional IPV and increases in threats of violence, however these were not statistically significant .This paper has a number of limitations. First, data is cross-sectional and as such temporality of relationships cannot be ascertained, and there is evidence that the relationship between IPV and depression is bidirectional , 37. SecThe role of emotional IPV and economic IPV in driving health impacts of women is rarely considered, although there is growing interest in emotional IPV, specifically around its consideration as an SDG indicator. The paper clearly highlights that the different forms of IPV  while strongly overlapping also have distinctive health outcomes that need to be considered in research, intervention and policy as such. It is very important that this research is replicated in other datasets and a view on the main findings across multiple settings is reached as this can substantially advance knowledge and understanding of this important area of women’s experience of IPV.S1 Table(DOCX)Click here for additional data file.S1 File(CSV)Click here for additional data file.


The growth in Intimate Partner Violence (IPV) cases among couples in Nigeria has been significant in recent years. Victims, which are often females, face numerous health challenges, including early death. I examined the linkages between spousal age differences and IPV in Nigeria.n = 6765). Intimate partner violence was measured using 13-item questions. Data were analyzed using the logistic regression model (α = .05).The couples recode data section of the 2013 Nigeria Demographic Health and Survey was used  and 1.35  higher in households where the spousal age difference was 0–4 and 5–9 years respectively, than the likelihoods among those with a spousal age difference ≥ 15 years, but the strength of the association weakens when other variables were included in the model.The mean spousal age difference was 8.20 ± 5.0 years. About 23.5, 18.0, 13.5 and 4.7% of couples surveyed had experienced some form of IPV, emotional, physical and sexual violence respectively. Also, IPV prevalence was 27.0, 23.7, 22.0 and 18.7% among couples with age differences of 0–4, 5–9, 10–14 and ≥15 years respectively; this pattern was exhibited across all domains of IPV. Among women who experienced physical violence, 20.5% had only bruises, 8.0% had at least one case of eye injuries, sprains and/or dislocations, and 3.7% had either one or more cases of wounds, broken bones or broken teeth. The identified predictors of IPV were: family size, ethnicity, household wealth, education, number of marital unions and husband drinks alcohol. The unadjusted likelihood of IPV was 1.60 (C.The level of IPV was generally high in Nigeria, but it reduced with increasing spousal age difference. This study underscores the need for men to reach a certain level of maturity before marriage, as this is likely to reduce the level of IPV in Nigeria. Violence against women 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” . IntimatLiterature on IPV in low-income countries has focused largely on Asia –6 and soSpousal healthy relations and a successful married life are the result of many factors. One salient factor, which usually goes unnoticed is spousal age difference. Spousal age difference refers to the difference between the ages of wife and husband. The tradition of male dominance in marriage is still prevalent in Nigeria, where, apart from a few exceptions, men marry women that are younger than they are . This coWomen bear the overwhelming burden of IPV in Nigeria. The 1993 United Nations General Assembly resolution recommends the promotion of research, especially regarding domestic violence, relating to the prevalence of different forms of violence against women, and encourages research on the consequences of violence against women [A growing number of research has been conducted into the factors associated with IPV and its three domains , 12, 13.In sub-Saharan Africa, the IPV prevalence ranges from 30.5% in Nigeria to 43.4% in Zimbabwe, 45.3% in Kenya, 45.5% in Mozambique, 53.9% in Zambia and 57.6% in Cameroun . A studyIn order to understand IPV within a family violence structure, different frameworks have been used by sociologists. The family violence perspective views conflict between family members as universal and inevitable, and holds the view that most family violence is not the result of individual pathology but that it is a “normal part of family life in most societies” . Straus A nested ecological theory by Dutton and Nicholls states that more precise variables are viewed as ‘nested in’ broader variables . This thThis study was conducted in Nigeria, a country in the West African sub-region. By geographic definition, Nigeria is predominantly a rural country and the level of illiteracy is high. A national survey found that the median age at first marriage for men and women was 18.1 and 27.2 years respectively .The study was cross-sectional population-based and used weighted 2013 Nigeria Demographic and Health Survey data, with a focus on the couple recode section of the data. It was a nationally representative sample, with participants selected across all the states in Nigeria. The survey used as a sampling frame the list of enumeration areas (EAs). Administratively, Nigeria is divided into 36 states and a Federal Capital Territory (FCT). These states are subdivided into 774 LGAs, and each LGA is divided into localities. Each locality was subdivided into EAs. The EAs, which were the primary sampling units (PSU), were used as a cluster with a minimum size of 80 households. The sample was selected using a stratified three-stage cluster design, consisting of 904 clusters, 372 in urban areas and 532 in rural areas. A complete listing of households and a mapping exercise were carried out in each cluster, with the resulting lists of households serving as the sampling frame for the selection of households. All regular households were listed. Global Positioning System (GPS) receivers were used to calculate the coordinates of the sample clusters. A fixed sample of 45 households was selected per cluster. In this study, a sample of one eligible woman in each household was randomly selected to be asked questions regarding domestic violence .Only couples with complete information on variables that were used for the generation of IPV and age difference were included in the study. A small number of cases, where women were older than their husbands, were excluded. Thus, the total sample of couples included in the study was 6765. Intimate partner violence was created using information on the following items:The items 1–3, 4–10 and 11–13 above constitute the emotional violence (EV), physical violence (PV) and sexual violence (SV) domains respectively, as measured by the demographic health and survey . In ordeThe main independent variable was spousal age difference, which was generated by subtracting the ages of the women from the ages of their husbands. These age gaps were later categorized as 0–4, 5–9, 10–14 and ≥15 years with a view to examining which spousal age gap inhibits or promotes IPV, other than using age difference as a continuous variable in the analysis. Other independent variables include the following: number of living children, residence, ethnicity, religion, household wealth, education, marriage type, husband drinking alcohol, husband’s education, number of marital unions and empowerment.p-value cut-off point of 0.25 was included in the first model. In the iterative process of variable selection, covariates were removed from the model if they were not significant  and not a confounder. At the end of the iterative process of deleting, refitting, and verifying, the final model was fitted.Data were analyzed using t-test, Chi-square and logistic regression at 5% level of significance. The t-test was used to determine the mean age difference by IPV. The Chi-square was used to examine the association between IPV, EV, PV, SV and socio-demographic characteristics, including spousal age difference. Due to the dichotomous nature of each of the dependent variable, we used the logistic regression model to identify the predictors of IPV and other domains of violence. The selection of variables into the logistic regression was done by running a bivariate analysis of the dependent variable and an independent variable. Thereafter, any statistically significant variable based on the Wald test from logistic regression and a Two models (unadjusted and adjusted) were used to examine the relationship between age difference and IPV, EV, PV, SV. The unadjusted models Eq.  were the0, βpi are the regression parameters, xi are the independent variables, and pi represents the proportion of women who have experienced IPV in the ith category of a particular variable.βIn Table p < 0.001) and 27.0%-to-18.7% (p < 0.001) respectively. In the case of sexual violence, the pattern was different from the patterns exhibited by IPV, physical, and emotional violence. The percentage of women who had experienced sexual violence was 4.6%, 4.9%, 4.7% and 4.2% among couples with the age differences of 0–4, 5–9, 10–14 and 15+ years respectively (p > 0.05).Figure The data as shown in Fig. p < 0.001).The data presented in Table Ethnicity and religion were significantly associated with all the domains of violence. In the main religious groups in Nigeria, the data show that Igbo women experienced more IPV (28.0%), emotional (24.0%) and sexual violence (4.3%) than did women in the Yoruba and Igbo ethnic groups, but Yoruba women (17.2%) experienced the physical violence among the three ethnic groups. A higher proportion of Christian women than Muslim women experienced IPV (33.8% vs 15.8%), emotional (25.4% vs 12.4%), physical (22.6% vs 6.6%) and sexual violence (5.7% vs 4.0%). The data further show that emotional violence was the only violence domain that was not associated with household wealth. A slight disparity existed between the percentage of women who experienced any type of IPV, physical or sexual violence among those who come from middle-income and rich households, but the margin was wider between middle-class and poor households. The percentage of women who experienced IPV forms a U-shape, with women with no formal education and those with higher education having previously experienced lower levels of violence from their intimate partner than did women who had primary and secondary education. For instance, the prevalence of IPV was 16.0%, 32.5%, 29.6% and 19.0% among those with no formal, primary, secondary and higher education respectively. This was also the pattern exhibited based on the husband’s level of education. Surprisingly, IPV was found to be higher among highly empowered women than those in low level of empowerment.The percentage of women who reported that they had experienced violence from their intimate partner was strikingly higher among spouses of men who drink alcohol. With regard to previous experiences of any type of IPV, the percentage of women was 45.4% among women whose husbands drank alcohol, compared to 18.5% among women whose husbands did not drink alcohol. In the case of emotional violence, it was 35.1% and 14.1% among women whose husbands drank alcohol and whose husbands were non-drinkers respectively. In the case of physical violence, 33.2% of women whose husbands drank alcohol had experienced such violence, compared to 9.1% of women whose husbands did not drink alcohol.I = 1.30–1.98, p < 0.001), 1.35  and 1.23  higher in households where the spousal age differences were 0–4, 5–9 and 10–14 respectively, than among those with a spousal age difference of at least 15 years. In particular, being in spousal age difference groups 0–4 , 5–9 , and 10–14  years seemed to predispose women to physical violence than among couples where the age difference was 15 years and above. Spousal age difference was not found to be significantly related to sexual violence.The data as presented in Table I = 1.65–2.63, p < 0.001), 2.87  and 2.46  times more likely among couples who had given birth to 1–2, 3–4 and ≥5 children respectively than among couples who have no children; this pattern was similar to the emotional and physical violence experienced. Among all the types of violence, only the sexual domain shows a significant relationship with place of residence. In this case, the likelihood of sexual violence was found to be higher in the rural areas  than in the urban areas. In terms of the relationship between ethnicity and IPV, the odds of IPV, emotional violence and physical violence were lowest among Hausa/Fulani women and highest among Igbo women. However, Yoruba women experienced lower sexual violence  than Hausa/Fulani women. In addition, women who practiced the Islamic religion were less likely to experience IPV or any of IPV domains than their Christianity counterparts were. The data further show that the risk of any violence type was significantly higher in households where the husbands drank alcohol. Moreover, the likelihood of IPV, emotional violence and physical violence was 1.48 , 1.39  and 1.50  higher among women with a high empowerment status than among women with a low empowerment status, although there was no significant relationship between empowerment status and sexual violence.The risk of IPV was higher among couples who have at least one child than among those without any children. In particular, the odds ratio of IPV was 2.09 , 2.37  and 2.15  higher among couples who had 1–2, 3–4 and 5+ living children respectively, than among those who had never had any children. This statistically significant pattern was also exhibited by physical, emotional violence and number of living children. The Igbo and Yoruba women were more likely to have experienced IPV, emotional and physical violence than were Hausa/Fulani women. The odds of experiencing IPV was 1.80  and 1.93  higher among Igbo and Yoruba women respectively than among their Hausa/Fulani counterparts. With regard to previous experiences of physical violence, Yoruba women had a higher risk  than did Hausa/Fulani women. Also the chance of sexual violence was higher among Igbo women  than among Hausa/Fulani women. Having been married more than once  furthermore predisposes Nigerian women to a higher risk of sexual violence than was the case among those who had only been married once.The likelihood of IPV was 1.78c  times higher among women whose husbands drank alcohol; this pattern was found across the three domains of violence. The likelihood of IPV, physical violence and sexual violence falls consistently with increasing level of household wealth. While the data showed no significant difference between women with no formal education and those who had a higher level of education with regard to the violence they had experienced, whether IPV, sexual or emotional violence, the risks were significantly higher among women with a primary and secondary level of education than among those with no formal education. The likelihood of IPV was 1.57  and 1.55  higher among women with primary and secondary education respectively than among those with no formal education. For sexual violence, the chance was 1.60  and 1.70  higher among women with primary and secondary education than among those with no formal education.The likelihood of IPV was 2.25 (C.Intimate partner violence is a problem that potentially affects every family, although its severity level varies across socio-cultural characteristics , 12. In The study revealed that the average spousal age difference was 8.20 ± 5.0 years, and the mean difference was lower among households where wives have experienced some form of IPV. This implies that men who commit IPV are much older than their wives. Traditionally, men marry women who are younger than they are; the persistent harsh economic conditions that have lasted for about four decades in Nigeria have led to men only marrying later in life, which further widens the age gap between couples. The expectation is that IPV should reduce where the spousal age difference is wider, because in such instances, the man is expected to be more mature than his wife, and thus should be able to tolerate some inadequacies of his wife in terms of behavioral attitudes. However, it seems that this expectation is not correct, as reviewed in the theoretical framework in the background section of this paper. Although the odds of IPV significantly reduced as spousal age difference increases, spousal age difference was not found to be a predictor of IPV. This finding is consistent with the outcome of the study conducted in America .In this study, about one in every four women had experienced IPV, while emotional violence was found to be the most prevalent of the domains of IPV, followed by physical and sexual violence in that order. This variation pattern in the prevalence of IPV and its domains echoes the findings of studies previously conducted in Nigeria and some parts of Africa , 11, 14.The number of years that couples had been married appeared to be important to IPV . The shaThe chance that a woman would experience violence from her intimate partner was found to increase, as the family size increased; it was lowest among couples who did not have children. The prolonged harsh economic conditions in Nigeria, combined with the high levels of unemployment, which has caused the failure of some men to discharge their responsibilities as head of the household could be responsible for this finding. All things being equal, under the current economic condition in Nigeria, it is assumed that families with a lower number of children may find it easier to meet their immediate needs than families with a larger number of children. Where resources are lacking and when facing numerous family needs that are echoed by the wife, the husband may resort to violence . This isThe cultural environment is important when discussing issues relating to IPV . In marrEducation is a way of breaking the prevalence of male dominance in marriage, irrespective of the spousal age difference. It is known that women who are more educated are also more likely to be aware of their fundamental human rights and thus more empowered within the household in terms of their involvement in family issues/decisions than women who have received less education. The tussle for power and the non-compliance or disagreement of women with some of the rules laid down by the husband may trigger violence within the marriage. As one of the important predictors of IPV in this study, the positive relationship between level of education and IPV, where increasing the level of education was found to be non-protective of IPV, has been established in the literature  but the This study had some limitations. Firstly, it is likely that IPV cases are under-reported, because women are often afraid or reluctant to report it, particularly among low-income groups. It is also likely that some communities may have reservations about reporting IPV in general. These certainly will have an implication on the prevalence of IPV found in this study. Therefore, our results may not be representative of all cases of IPV and may be biased towards populations with more sensitization towards IPV or a greater awareness of programmes relating to IPV. According to the findings of this study, however, more efforts are needed to reduce the level of IPV, as stipulated by the SDGs. Secondly, it is also likely that the number of IPV cases was grossly under-reported because women who were hospitalized as a result of experiencing violence during the course of the survey, were not captured due to the population-based nature of this study. Thirdly, the cross-sectional nature of this study suggests that causality cannot be clearly established, and therefore the readers of this article should interpret the findings with caution. Lastly, family arrangement has a direct relation to IPV, but that has not been covered because the data did not capture information that could be used for such analysis.The level of IPV found in this study was high; it appeared to reduce with increasing spousal age difference. Spousal age difference is not a predictor of IPV, but a higher spousal age difference was found to be protective of IPV. Therefore, this study recommends that men need to be sufficiently mature before entering into marriage, as this will reduce the level of IPV in Nigeria. Strategies to eradicate IPV in Nigeria should target couples with lower age differences as well as families where the husband drinks alcohol. While the age difference may not really be an important factor in examining IPV amidst other covariates, the predictors of IPV found in this study were: family size, ethnicity, household wealth, education, marital duration and husband’s alcohol consumption. These factors should be taken into consideration when designing frameworks on reducing IPV in Nigeria. The findings underscore the risk associated with the influence of spousal age difference on IPV. Context-specific qualitative studies are needed in Nigeria to explore the relationship between partner age differences and IPV further.