Intimate partner violence (IPV) against women is a global public health and human rights concern. Despite a growing body of research into risk factors for IPV, methodological differences limit the extent to which comparisons can be made between studies. We used data from ten countries included in the WHO Multi-country Study on Women's Health and Domestic Violence to identify factors that are consistently associated with abuse across sites, in order to inform the design of IPV prevention programs.Standardised population-based household surveys were done between 2000 and 2003. One woman aged 15-49 years was randomly selected from each sampled household. Those who had ever had a male partner were asked about their experiences of physically and sexually violent acts. We performed multivariate logistic regression to identify predictors of physical and/or sexual partner violence within the past 12 months.Despite wide variations in the prevalence of IPV, many factors affected IPV risk similarly across sites. Secondary education, high SES, and formal marriage offered protection, while alcohol abuse, cohabitation, young age, attitudes supportive of wife beating, having outside sexual partners, experiencing childhood abuse, growing up with domestic violence, and experiencing or perpetrating other forms of violence in adulthood, increased the risk of IPV. The strength of the association was greatest when both the woman and her partner had the risk factor.IPV prevention programs should increase focus on transforming gender norms and attitudes, addressing childhood abuse, and reducing harmful drinking. Development initiatives to improve access to education for girls and boys may also have an important role in violence prevention. Intimate partner violence (IPV) against women is a global human rights and public health concern. The WHO Multi-Country Study on Women's Health and Domestic Violence documented the widespread nature of IPV , with liDesigning effective IPV prevention programmes involves identification of risk factors--both those that are direct causes of IPV, and those that point to common characteristics of victims and/or perpetrators thus allowing appropriate tailoring and targeting of services. Studies in various countries have identified a range of factors that influence IPV risk -13, but It is difficult to make comparisons between settings using existing individual studies as differences in identified risk factors may either be methodological artefacts or a real reflection of contrasting phenomena. Selected Demographic and Health Surveys ,15 have We use population-based data from the WHO Multi-Country Study on Women's Health and Domestic Violence, which was specifically designed to better understand the factors associated with violence in different settings. Comparability of data was maximised through use of a standardised questionnaire, standardised interviewer training and data-collection procedures across all participating sites, and a rigorous set of quality control procedures. We drew on current models of IPV risk, including those of Heise ,18 and JDetails of the study methods, sampling, response rates, and prevalence of different types of partner violence in each setting have been reported elsewhere  see Add. BrieflyTrained female interviewers completed interviews with one randomly selected woman aged 15-49 from each sampled household. 24,097 women were interviewed in total, using a standardised questionnaire which was developed by the study team and translated into 14 languages.Specially developed ethical guidelines emphasised the importance of ensuring confidentiality and privacy, both to protect the safety of respondents and field staff and to improve the quality of the data . Ethical1 The analysis compared women who reported having experienced any act of physical and/or sexual violence in the past year  with women who did not report any partner violence ('current' versus 'never'). Those who had experienced partner violence during their lifetime but not in the past year were excluded from the analysis so as not to dilute associations.Currently- or previously-partnered women were asked a series of questions about whether they had ever experienced specific violent acts  between early-life experiences and later IPV. Clustering of outcomes in each site was 'small'  ; hence wa priori) across the site-models except for the addition of certain relationship characteristics (polygamy and bride price/dowry) that were only relevant in some sites. As our overall aim was to identify similarities and differences in patterns of association between settings, we did not attempt to fit the most parsimonious model for each site. Neither did we place too much emphasis on the statistical significance of individual associations. Instead we focused on exploring the extent to which, keeping all other features of the model constant, patterns of associations were similar or different between sites.We included the same variables  between 0.95 > OR < 1.05 as indicative of no association, ORs of 1.05 or greater as risk-factors for IPV, and ORs of 0.95 or less as protective-factors for IPV. We use the terms risk- and protective-factors loosely to indicate the direction of association with IPV rather than to imply causality, as we are analysing cross-sectional data. Statistical significance is considered at the 5% level.19,517 women reported having ever had a partner and were thus asked about partner violence. In total, having excluded women reporting lifetime but not past-year experience of violence, and those with missing data for key variables in the models, 15,207 women were included in the 'prior to relationship' analyses, and 15,058 in the 'current situation' analyses . Achieving secondary education  by either the woman or her partner was associated with decreased IPV in almost two thirds of the sites (3 significant for each partner), when compared to situations where neither the woman nor her partner completed the level. However, the most consistent protective effect against IPV was observed where both the woman and her partner had completed the relevant schooling level . This most highly educated exposure group also had the lowest ORs for IPV in 10 out of 14 sites, compared to couples where one or both had not completed the level.A history of abuse was strongly associated with the occurrence of IPV, with reports of abuse of the woman's mother, her partners' mother, or both (compared to no known reported abuse of either mother) being associated with increased risk of IPV in all sites . ORs for IPV tended to be highest where women reported that both their mothers and their partners' mothers experienced abuse (observed in 10/15 sites). Evidence from bivariate analysis in most sites showed that women who did not know whether their partners had histories of abuse were also at increased risk of IPV compared to those who reported their partners did not have these experiences.Other experiences of violence were also associated with past year IPV, with a history of childhood sexual abuse of the woman, childhood beatings of her partner, or both consistently associated with increased risk of IPV, compared to no reports of abuse by either partner . Women in relationships where both she and her partner were abused in childhood are at the highest risk of IPV (true in 11/14 sites), . A similar pattern was seen in bivariate analysis for partner's age but this variable was excluded from multivariate models due to its strong correlation with the woman's age. In contrast, associations between IPV and an age-gap of at least 5 years between the woman and her partner were weak in most settings and the direction of the effect was context dependent. Older age of the woman was often associated with increased risk of IPV, but in only three out of fifteen sites was older age of the partner associated with increased risk of IPV. Weak associations were also seen in the other direction for age-gaps favouring either the woman or her partner.There was some suggestion that inequality in educational level between a woman and her partner may increase her risk of experiencing IPV. This was true in nine out of 15 sites where the woman had the higher level of education (1 significant), and the same where her partner had the higher level. Associations tended to be weak, however, and some were also observed in the opposite direction.There was no consistent pattern of association between IPV and relative employment status. Compared to couples in which both partners work, couples where just the man works appear to experience slightly lower levels of IPV in some settings . In some settings women who work when their partners do not may be at increased risk of IPV . There is some evidence that women in relationships where neither she nor her partner work are at increased risk of IPV . However, non-significant associations in opposite directions are also observed for these variables.Higher socioeconomic status (SES) was associated with decreased IPV in fourteen sites (significant in 8 sites when comparing the highest status group to the lowest). This variable was more strongly associated with IPV before adjustment for other variables that may confound or mediate the effects of socioeconomic status on IPV risk.In almost all sites, women who had attitudes supportive of a husband beating his wife had increased odds of IPV .In all sites odds of IPV were higher in relationships where one or both partners had problems with alcohol, compared to relationships where neither of them did . In the majority of sites frequent drunkenness among men yielded higher ORs for IPV than problematic drinking by the woman (8/11), and in ten of the eleven sites ORs were higher when both had problems with alcohol.Both a woman's experience of non-partner violence and her partner's involvement in fights with other men emerged as strong risk factors for IPV. Women's experiences of non-partner physical or sexual abuse over the age of 15 emerged as a risk-factor for IPV in almost all sites . Likewise, women whose partners were involved in a fight with another man in the past year experienced higher levels of IPV than those with partners who did not fight (significant in 13/15 sites). These factors were more strongly associated with IPV risk in the bivariate analysis. It is likely that both IPV and non-partner violence share common antecedents, such as CSA in the case of women, or a history of antisocial personality and alcohol abuse among men, which may account for all or part of this association ,24Women with children from previous relationships were at increased risk of experiencing IPV in most sites . Women whose partners had had relationships with other women during their relationship also experienced higher levels of IPV than women with faithful partners (significant in 14/15 sites). Lack of knowledge/disclosure about a partner's involvement with other women was also associated with increased IPV in most sites.Women who were cohabiting with a partner without being formally married were at increased risk of IPV . By contrast, women not living with their partners experienced lower levels of IPV . There was some suggestion that those in newer relationships were at increased risk of IPV, with higher levels of IPV in relationships of less than five years compared to longer relationships, in half of the sites (mostly non-significant). There were also several sites where weak associations in the opposite direction were seen for the newest relationships (5).A woman's participation in her choice of husband was associated with IPV differently across sites. In 6 out of 15 sites her lack of participation was associated with higher levels of IPV (3 significant), while in 8 sites it was associated with decreased IPV (1 significant).Payment of dowry and bride price  was associated with IPV in some sites, though patterns of risk were difficult to interpret. In the 6 sites where dowry was paid, it was associated with higher levels of IPV in 4 sites (3 significant) and lower IPV in 1 site (not significant). Bride price was associated with decreased IPV in 4 sites (2 significant) and increased IPV in two sites (neither significant).Women whose husbands had more than one wife were at increased risk of IPV in all 6 sites where polygamy is practised . The same was true for women who reported not knowing whether their husbands had other wives, compared to those who knew.Despite the wide variations in the prevalence of IPV across the study sites, many risk factors appear to affect IPV risk similarly, with secondary education, high SES, and formal marriage offering protection, and alcohol abuse, cohabitation, young age, attitudes supporting wife beating, outside sexual relationships, experiencing childhood abuse, growing up with domestic violence, and perpetrating or experiencing other forms of violence in adulthood, increasing the risk of IPV. We also found that the strength of the association was greater when both the woman and her partner had the risk or protective factor, suggesting the possibility of achieving greater prevention impact through targeting programs to couples most at risk.Overall, our analysis demonstrates far more consistency in risk and protective factors across sites than reported by Hindin and Kishor in their analysis of violence among couples from 10 recent Demographic and Health Surveys (DHS) . Among tOur analysis confirms that completing secondary education has a protective effect on IPV risk, whereas primary education alone fails to confer similar benefits . StudiesHigher socioeconomic status is generally associated with lower levels of physical and/or sexual partner violence. Even if it is not an independent or proximate risk factor but one that is partially confounded by or mediated through other factors , socioeconomic status of households should be taken into account when designing and targeting IPV intervention programmes .Early life experiences of abuse  emerge as consistently strong risk factors for IPV. In order to intervene in this inter-generational cycle of abuse, interventions must address childhood abuse and respond appropriately to children who have witnessed IPV against their mothers. Although the importance of the sexual abuse of children and the witnessing of marital violence by children has been documented in other studies, the potential importance of the physical abuse of boys has received less attention and merits further exploration. The consistent association between IPV and other forms of violence against women also point to the need for integrated responses to violence across sectors and programmes ,31. For Male behaviours commonly associated with 'traditional' masculinity , such asProblematic alcohol use, among both women and their partners, is consistently and strongly associated with IPV. While it is difficult to establish the temporality of the observed associations, this relationship has been repeatedly been demonstrated in studies of IPV ,34-36. HImportantly, not all variables demonstrated consistent relationships with IPV across sites, suggesting that policymakers should be cautious about any 'one model fits all' approach to IPV prevention. For example, risk associated with age disparity among partners, a woman working where her partner does not, and a woman taking an active role in choosing her partner, varies by setting. What constitutes empowerment in one setting may represent an unacceptable transgression of gender norms elsewhere. Jewkes highlights that transgression of gender norms and failure to fulfil cultural expectations of good womanhood and successful manhood are among the most important triggers for intimate partner violence . She argThe primary strength of our analysis is that it is based on fully comparable data from 15 culturally, economically and socially diverse sites. This type of comparison has not been possible to date in the field of IPV research, with the exception of the less tightly controlled DHS surveys. Obviously, the cross-sectional nature of this study limits the extent to which we can draw conclusions regarding temporality or the causal nature of observed associations. However, by distinguishing between early life and current characteristics, we do separate out those factors where temporality is clear from those where it is less certain.A further limitation is that the study interviewed only women, and hence relies on women's reports of their partner's characteristics. The data on partner characteristics refers to the woman's current or most recent partner, who in some cases may not be the perpetrator of the reported violence. Since the analysis considers only past year IPV, however, the number of cases where the reported violence was perpetrated by a more distant partner is likely to be small. Any resulting misclassification would bias results towards the null rather than invalidate observed associations.The multi-faceted nature of the factors that influence partner violence highlights the need for a multi-sectoral response that combines development activities, including improved access to secondary education for girls and boys, with initiatives to transform gender norms and attitudes, address prior histories of abuse, and reduce harmful drinking. Since risk of IPV is highest in younger women, schools are also an important setting for primary prevention activities, with potential to address issues of relationships, gender roles, power and coercion within existing youth violence and bullying programmes. Although there is no magic bullet to reduce partner violence, the consistency of our findings across sites suggests that a prevention strategy, once validated and refined, might have relevance in a wide range of settings. Initiatives to reduce partner violence require commitment and vision--by the international community, local governments and civil society. The time to act is now. As highlighted in the recent UN Campaign against violence against women--Women Won't Wait--such responses are urgently needed.IPV: intimate partner violence; CSA: childhood sexual abuse; DHS: Demographic and Health Survey; SES: socioeconomic status; WHO: World Health Organisation; UN: United Nations;The authors declare that they have no competing interests.CG-M, HAFMJ, ME, LH and CHW all participated in the study design and implementation. CG-M was the study coordinator. HAFMJ set up and supported data collection and processing in the countries and managed the central database. TA carried out the statistical analysis for this paper and drafted the manuscript. LH and CW helped draft the manuscript. KD and LK provided support with the statistical analysis and helped draft the manuscript. CG-M reviewed a draft of the manuscript. All authors read and approved the final manuscript.1Women were defined as ever partnered if they had ever been married or lived with a partner (and therefore had been at risk of intimate partner violence). In practice, this definition varied slightly between countries in accordance with local notions of partnerships.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/109/prepubPrevalence of physical and/or sexual intimate partner violence among ever-partnered women, by site. Prevalence data on lifetime and past-year experience of physical and/or sexual intimate partner violence among ever-partnered women for each of the sites included in the WHO study. These data are among those core study findings previously published in the Lancet :1260-1269.Click here for file


Serious forms of violence against women include Female Genital Mutilation (FGM) and Intimate Partner Violence (IPV). The aim of this study was to determine if FGM is associated with IPV, using data obtained from the Demographic and Health Survey (DHS) 2012 in Ivory Coast.Participants for this study were drawn from the 2011-12 Ivory Coast Demographic and Health Survey (CDHS), a nationally representative sample of 10060 women aged 15 to 49 years. The analysis of this paper is restricted to the sample of women who responded to the FGM and domestic violence modules (N = 5005).The lifetime prevalence of physical violence was 24.8%, sexual violence, 5.7%, and emotional violence, 19.0%, and the prevalence of any lifetime IPV was 32.1%. In all, 40.6% reported female genital cutting or mutilation (FGM). Women reporting FGM were two times as likely to experience sexual IPV , while other subtypes of IPV were higher in women reporting FGM but they were not significant. Of the socio-demographic covariates, urban residence and having a primary education were associated with most subtypes of IPV, while being a Muslim seemed protective from any type, sexual and emotional IPV. Having seen the father beating the mother was positively associated with most IPV subtypes, and having been diagnosed with a sexually transmitted infection (STI) in the previous 12 months was associated with physical and sexual IPV.Significant rates of FGM and IPV were found among this sample of Ivorian women calling for the need for multiple strategies to reduce FGM and IPV. Female genital mutilation (FGM) – defined by the World Health Organization (WHO) and the United Nations (UN) agencies as “the partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons” is a deeply rooted tradition in many communities in 28 countries in Africa and in some countries in Asia and the Middle East , rangingAccording to WHO  the globTwo previous studies in Egypt and Mali have shown a positive association between FGM and intimate partner violence (IPV) ,9. SalihParticipants for this study were drawn from the 2011-12 Ivory Coast Demographic and Health Survey (CDHS), a nationally representative sample of 10060 women aged 15 to 49 years. The 2011/12 CDHS employed a two-stage stratified sample, where systematic sampling with probability proportional to size was applied [The questionnaire included demographic variables such as age, formal education, work status, residence, marriage type, religious denomination and wealth status, a composite index based on the household’s ownership of consumer items such as television, car, drinking water, toilet facilities, etc.Female Genital Mutilation (FGM) was assessed from the survey item ‘Respondent Circumcised,’ which was a dichotomous (Yes/No) variable. Further, those who indicated that they had been circumcised were asked several items regarding circumcision, including ‘flesh removed from the genital area’, ‘genital area just nicked without removing any flesh’ and ‘Genital area sewn closed’ and the timing of circumcision [umcision .The domestic violence module of the Ivory Coast DHS includes 11 items that capture violence committed by a male partner or spouse. From these questions, IPV was categorised into three main subtypes: physical, sexual and emotional. Physical violence referred to any exposure to one or several of the following acts against women by a current or former husband or partner ever: i) pushing, shaking or throwing something at her; ii) slapping her or twisting her arm; iii) punching or hitting her with something harmful; iv) kicking or dragging her; v) strangling or burning her; vi) threatening her with a weapon (e.g. Gun or knife); and vii) attacking her with a weapon. Sexual violence referred to any exposure to one or several of the following acts against women by a current or former husband or partner ever: i) forced sexual intercourse; and ii) other sexual acts when undesired. Emotional IPV was assessed with two items, ‘ever humiliation’ and ‘ever threatened harm’, and was defined as a woman’s report of ever experiencing an act of emotional violence by a partner. Exposure to each of these types of violent acts were scored as 1 (any experience of violence ever) and 0 (no experience of violence ever).Women were further categorised as those who experienced one type of IPV and those who experienced two or more types of IPV ,9.In addition, several risk factors for IPV were assessed, including increased risk of HIV/STI  and witnData analysis was performed using STATA software version 11.0 . The analysis in STATA took into account the multilevel stratified cluster sample design of the study. Frequencies as estimation of prevalence of IPV were obtained. Logistic regression analysis was conducted to estimate the association between relevant predictor variables including FGM and IPV. Adjusted odds ratios are reported for selected predictor variables  while considering IPV as a dependent variable. In the analysis, weighted percentages are reported. The reported sample size refers to the sample that was asked the target question. The two-sided 95% confidence intervals are reported. The p-value less or equal to 5% is used to indicate statistical significance. Both the reported 95% confidence intervals and the p-value are adjusted for the multi-stage stratified cluster sample design of the study.Overall, 5005 women were administered the domestic violence and female genital cutting modules of the 2012 Ivory Coast DHS. Their demographic characteristics are provided in Table The adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for the association between FGM and IPV are shown in Table The lifetime prevalence of IPV and its subtypes in the Ivory Coast seem lower than the average in the WHO African region . The preThe study findings show that FGM was only partially associated with IPV, namely with sexual violence only, while having witnessed interparental violence in childhood was found to be associated with most IPV subtypes; the latter was also found in a DHS survey in Bolivia . TherefoFurther, the study found that having been diagnosed with a sexually transmitted infection (STI) in the previous 12 months was associated with physical and sexual IPV. IPV has been identified to increase the risk of HIV/STI . Of the Caution should be taken when interpreting the results of this study due to certain limitations. Since this was a cross-sectional study, causality between the compared variables cannot be concluded. A further limitation was that some factors known to be contributing to IPV were not assessed .Significant rates of FGM and IPV were found among this sample of Ivorian women calling for the need for multiple strategies to reduce FGM and IPV.The authors declare that they have no competing interests.KP performed the analysis and drafted the manuscript. SP developed the idea of the analysis and provided comments on the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/13/prepub


To examine correlates of perpetration and victimization of intimate partner violence (IPV) under and not under the influence of a substance, we conducted a study among women in Russia.In 2011, a cross-sectional survey was conducted among patients receiving services at a clinic for sexually transmitted infections in St. Petersburg, Russia. Multinomial logistic regression was used for analysis.Of 299 women, 104 (34.8%) and 113 (37.8%) reported a history of IPV perpetration and victimization, respectively. Nearly half (47.1%) of perpetrators and 61.1% of victims reported that the latest IPV event  was experienced under the influence of a substance. Factors independently associated with IPV victimization under the influence of a substance were alcohol misuse and a higher number of lifetime sex partners, whereas only experience of childhood abuse  was independently associated with IPV victimization that did not occur under the influence of a substance. Childhood physical abuse, lower age of first sex, sensation seeking, and alcohol misuse were independently associated with IPV perpetration under the influence of a substance, while only childhood abuse  was independently associated with IPV perpetration that did not occur under the influence of a substance.IPV under and not under the influence of a substance had different correlates . Despite the strong association between substance use and IPV, experience of childhood abuse is an important predictor of IPV perpetration and victimization in Russia, above and beyond substance use. Intimate partner violence (IPV) has been a significant public concern worldwide due to its high prevalence and wide range of adverse health consequences such as injury, chronic pain, sexually transmitted infections (STIs) and mental health problems Although a variety of studies revealed that a number of factors are associated with IPV Experience of childhood abuse, particularly physical abuse, is another key factor that has been found to be consistently associated with IPV perpetration in different studies, including a cross-sectional study using data collected from a large representative U.S. national sample of couples  and a 20-year longitudinal study Sensation seeking is another factor associated with IPV. This association is less consistent in the literature partly because IPV is a complex phenomenon which may not be fully explained by a single factor or simple model Substance use, particularly alcohol and drug use, is an important public health problem in Russia, and has been associated with several negative outcomes including IPV and HIV risk behaviors This study used multinomial logistic regression to simultaneously investigate three levels of outcome: IPV under the influence of a substance, IPV not under the influence of a substance, and no IPV. The primary purpose of the present study was to examine correlates of perpetration and victimization of IPV under and not under the influence of a substance (each compared to no IPV) among women receiving health services in St. Petersburg, Russia. We hypothesized that: (1) IPV under and not under the influence of a substance has different correlates; (2) experience of childhood abuse is associated with IPV perpetration and victimization with and without the influence of a substance; and (3) sensation seeking is associated with IPV perpetration independently of whether it occurs under the influence of a substance.Consecutive adult patients (aged 18 years and older) who required STI services in a dermatovenereology dispensary (STI out-patient clinic) in St. Petersburg, Russia were invited to participate in a cross-sectional study which aimed to examine factors associated with female reproductive health from May 2011 to November 2011. A total of 502 patients agreed to participate in and completed a computer-assisted interviewer-administered questionnaire. Written informed consent was obtained from all participants and the study was approved by the institutional review boards of the Biomedical Center in St. Petersburg, Russia and Yale University, CT, USA. Of the 300 women recruited into the study, 299 answered the questions about intimate partner violence and therefore comprised the final analytic sample. The decision to include only women in the present analyses was made to reduce the complexity of research questions because women and men had different recruitment criteria. Eligibility for women’s participation included: (1) age between 18 and 50; (2) sexually active during the past 6 month; (3) not trying to get pregnant; and (4) biologically able to have children.A questionnaire was used to collect information including demographic and health characteristics, alcohol and illicit drug use, sexual behaviors, sensation seeking and experience of violence including history of childhood abuse and IPV. The questionnaire was constructed in English, translated to Russian, and then translated back to English to ensure the integrity of the syntax and meaning. Demographic information included age at survey, marital status, level of education, employment status and income level.Alcohol and illicit drug use: Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT) which includes 10 questions with a total score that ranges from 0 to 40 Sexual behaviors: Participants were asked the age of their first sexual experience and the number of sexual partners in their lifetime. Considering that some participants had a much higher number of sexual partners, this variable was dichotomized according to the median value.Sensation seeking: The Brief Sensation Seeking Scale (BSSS-8) developed by Hoyle et al. was used to measure sensation seeking History of childhood abuse: We assessed experiences of childhood abuse from two aspects, emotional abuse and physical abuse, respectively, based on two questions: “How often did your parent or caretaker insult, swear or threaten you” and “How often did your parent or caretaker push, grab, pinch or beat you” during their first 18 years. Although we asked a question related to childhood sexual abuse, “How often did your parent or caretaker touch you in a sexual way or had you touch him/her in a sexual way,” only one woman had such an experience. Thus, childhood sexual abuse was not included in the present analysis. These questions were adapted from the Conflict Tactics Scale (CTS) and the response categories were never, rarely, frequently and way too frequentlyPerpetration and victimization of IPV: IPV perpetration was defined as having ever (a) insulted, sworn at, or threatened a sexual partner; (b) pushed, grabbed, slapped, punched, beaten up, or choked a sexual partner; or (c) physically forced a sexual partner to have sex or do something sexually that he or she did not want to do. IPV victimization was defined as having ever been the target of the aforementioned actions by a sexual partner. These partner violence items were adapted from the CTS and have been successfully used in Russia to measure intimate partner violence p<.05 and the data were analyzed using SAS software version 9.1 .Chi-square tests and ANOVA  F-tests were used to examine group differences by last IPV status  for categorical and continuous variables, respectively. Multinomial logistic regression was used to determine significant correlates of IPV under and not under the influence of a substance. None of the demographic characteristics were significantly associated with either IPV perpetration or victimization in the multinomial logistic regression; therefore they were not included in the final models. The significance level was defined as p = 0.01). Other characteristics were not significantly different across status of last IPV victimization.The mean age of the participants was 28 years (standard deviation = 7.8), ranging from 18 to 50 years. Nearly 50% of the participants were married, 42% were never married and the rest were divorced, widowed or separated. About 49% of the participants had completed university or higher education. The majority (57%) of the participants were full-time employed and 43% had monthly incomes below 15,000 rubles (about 500 U.S. dollars). None of these demographic characteristics differed by status of last IPV perpetration . When these demographic characteristics were compared by status of last IPV victimization , however, age of the participants was significantly different . Among 190 women who had experience of childhood abuse, 118 (62.1%) only had experience of childhood emotional abuse and 72 (37.9%) had childhood physical abuse experience with 70 of 72 reporting both experiences.Both IPV perpetration and victimization were common. Of the women in the study, one did not answer IPV questions; 104 (34.8%) reported a history of IPV perpetration and 113 (37.8%) reported a history of IPV victimization, with 75 (25.1%) reporting both perpetration and victimization experiences in their lives. More specifically, the percentages of women who experienced verbal, physical and sexual IPV were 32.1, 18.1 and 11.0%, respectively; the percentages of women who perpetrated verbal, physical and sexual IPV were 28.4, 21.4 and 2.7%, respectively. Of 104 women who had ever perpetrated IPV, 49 (47.1%) reported last perpetration under the influence of a substance. Among 113 women who had ever been a victim of IPV, 69 (60.6%) reported last victimization under the influence of a substance.p-values ranging from <.0001 to 0.001 , in which couples with experience of IPV had higher sensation seeking scores than those without IPV experience As with most studies, our study is not without limitations. First and foremost, our data may be subject to recall bias. The measurement of experience of childhood abuse and last IPV under and not under the influence of a substance was based upon self-reporting. It is possible that participants may not accurately recall their exposure to violence in their childhood and exposure to substance if the last IPV occurred many years ago. The misclassification resulting from recall bias is likely to attenuate the observed association. Second, the measurement of IPV may also be subject to social desirability bias. As a result, IPV may be underreported. Furthermore, some participants may use substances as an excuse for their IPV acts even in a situation where no substance was actually involved in their last IPV episode. However this possibility should be low since the proportion of IPV under the influence of a substance in the present study is consistent with results from other studies In conclusion, IPV under and not under the influence of a substance had different correlates  and experience of childhood abuse can be an important predictor of IPV perpetration and victimization, above and beyond substance use. The findings also support the growing body of work suggesting that, in addition to childhood physical abuse, childhood emotional abuse only can be a risk factor of IPV which warrants more research and clinical attention.


Intimate partner violence (IPV) is widely prevalent in Tanzania. Inequitable gender norms manifest in men's and women's attitudes about power and decision making in intimate relationships and are likely to play an important role in determining the prevalence of IPV. We used data from the RESPECT study, a randomized controlled trial that evaluated an intervention to prevent sexually transmitted infections in a cohort of young Tanzanian men and women, to examine the relationship between couples' attitudes about IPV, relationship power, and sexual decision making, concordance on these issues, and women's reports of IPV over 12 months. Women expressed less equitable attitudes than men at baseline. Over time, participants' attitudes tended to become more equitable and women's reports of IPV declined substantially. Multivariable logistic regression analyses suggested that inequitable attitudes and couple discordance were associated with higher risk of IPV. Our findings point to the need for a better understanding of the role that perceived or actual imbalances in relationship power have in heightening IPV risk. The decline in women's reports of IPV and the trend towards gender-equitable attitudes indicate that concerted efforts to reduce IPV and promote gender equity have the potential to make a positive difference in the relatively short term. Intimate partner violence (IPV) is a major public health and human rights concern in Tanzania . AccordiIt is widely accepted that gender inequities, perpetuated by cultural norms regarding gender roles and manifest in men's and women's ideas about power and decision making in relationships, have a profound impact on the perpetration and experience of IPV . SeveralSurvey data lend support to the observation that both men and women in Tanzania condone IPV as a normal part of an intimate relationship , 13. AccAlthough research has explored men's and women's attitudes about IPV, few studies have empirically examined the association between these attitudes and IPV risk . For exaTo our knowledge, the association between couples' attitudes towards IPV, couple concordance in attitudes and IPV risk has not been examined in Tanzania. Using data from the Rewarding STI Prevention and Control in Tanzania (RESPECT) study, we examined men's and women's attitudes about IPV, relationship power, and sexual decision making and couples' concordance on these issues, and whether these attitudes were associated with women's experience of IPV at baseline and over time. The year-long RESPECT study was a randomized controlled trial designed to evaluate whether conditional cash transfers (CCT) promoted safe sex and reduced the incidence of sexually transmitted infections (STIs)  and perpetration of IPV (men). They also underwent STI and HIV counseling and testing. Participants in the CCT arms received cash payments for every 4 monthly negative STI laboratory test result. All enrolled individuals were invited to group counseling sessions that focused on relationship and life skills training based on the Stepping Stones curriculum . The analysis is guided by a social-ecological framework, which posits that IPV risk is shaped by the interplay of a host of individual, community, and societal factors, including individual beliefs and practices within an intimate relationship as well as community and societal norms regarding gender and power . It is aIn this analysis, we considered attitudes toward IPV as proximate determinants, and gender norms as a key underlying, distal determinant of IPV. For example, women's access to education and employment is limited in social and cultural environments that are highly patriarchal, increasing their economic dependence on male partners, which is a known risk factor for IPV  . SimilarWe outlined our hypotheses about the causal relationships between all variables in a Directed Acyclic Graph  and used the DAG to determine the minimum variables necessary to include in multivariable analyses to remove confounding of the main effects. Our primary hypothesis is that men's and women's attitudes about IPV, relationship power, and sexual decision making (including couple concordance/discordance on these attitudes) are proximate determinants of women's experience of IPV. Specifically, we proposed that women's and men's espousal of inequitable gender attitudes would be associated with greater experience of IPV at baseline and over time. We also hypothesized that couples' discordance on these issues would be associated with a heightened risk of IPV at baseline, and that this relationship would persist over time. We further hypothesized that the very fact of discordance between couples is more important than the nature of that discordance; that is, we proposed that lack of agreement between a woman and her partner (regardless of which partner held the more inequitable attitudes) would be associated with a higher risk of IPV than if she agreed with her partner. This finding would be consistent with earlier studies that have found that women themselves often exhibit highly inequitable attitudes about IPV as a way of fitting in with their communities and protecting themselves from violence , 25. Study protocols were approved by institutional review boards in Tanzania and the United States. All study participants gave written informed consent to participate in the study. Couples were interviewed separately at a study station that was set up on the outskirts of the village, and care was taken to ensure privacy and confidentiality. Study interviewers received in-depth training on interviewing techniques, gender and reproductive health, and the study protocols. A study liaison was identified in each village to help participants gain access to further information, counseling services, and study personnel. In addition, study counselors received training on how to offer psychosocial support and were equipped with information on domestic violence-related services.The outcome of interest—women's self-report of intimate partner violence over the previous 4-month period—was measured using a dichotomous variable based on four questions from the RESPECT questionnaire: “have you been hit, kicked, or beaten by your partner and/or a family member for any reason during the last 4 months?”, “Has your partner or another family member done any of the following during the last 4 months: humiliated you in front of others, insulted you, tried to scare you, threatened to hurt you or someone you care about?”, “Have you been physically forced to have sexual intercourse when you did not want to during the last 4 months?”, and “Did you, during the last 4 months, have sexual intercourse when you did not want to because you were afraid of what your partner might do?”. Participants who responded “yes” to one or more of these questions were coded as having experienced violence, while those who responded “no” to all four questions were coded as not having experienced violence. The RESPECT questionnaire did not ask women about lifetime experience of violence; at all rounds, women were asked about their experience of violence in the previous four months. Although the RESPECT questionnaire asked similar questions regarding male participants' perpetration of violence against their partners, couples did not always agree on violence within their relationships (data not shown). Given this disagreement and our primary interest in examining women's experience of IPV during the course of the study, we decided to focus on women's report of violence as the outcome measure. Our analyses focused on the association between women's reports of IPV and women's and men's attitudes about IPV, relationship power, and sexual decision making and couples' concordance. Men's and women's attitudes towards IPV and opinions about power within relationships were assessed using four exposure variables. The first question (“is a husband justified in beating his wife if…”) measured the acceptability of physical IPV in five hypothetical situations: if a wife goes out without telling her husband, if she neglects the children, if she argues with her husband, if she refuses to have sex with her husband, or if she burns the food. A binary variable was created to measure acceptability of IPV, coded as “1” if a participant responded in the affirmative to any of these five situations and coded as “0” if the participant did not agree that violence was justified in any of these situations. The second question assessed the acceptability of IPV as a response to a wife refusing to have sex with her husband: “if a woman refuses to have sex with her husband when he wants her to, he has the right to: get angry and reprimand her, refuse to give her money or other means of financial support, use force and have sex with her even if she doesn't want to, or go and have sex with another woman.” A binary variable (yes/no) was created on the basis of whether participants thought IPV was acceptable in response to a wife's refusal to have sex. For each of these questions, couples were coded as having concordant responses if both partners shared the same binary response.Our third and fourth exposure variables of interest assessed participants' opinions about power within their relationship. These were ascertained using the following two questions: “who usually has more say about whether you have sex?” and “in general, who do you think has more power in your relationship?” Participants were given the response options “myself”, “my partner”, or “both people equally.” Couples were determined to be concordant if they shared the same response about which partner had more to say about having sex or had more power in the relationship, regardless of which partner this was or whether they agreed that they shared these decisions equally. Other covariables we considered included age (measured as a continuous variable), education status , and socioeconomic position . We also examined differences in reported IPV by study arm.Analyses were conducted using data from the subset of heterosexual couples who were enrolled in the study together. All couples were included in the baseline data analysis, and couples on whom data were available for a minimum of two out of the four rounds were included in the longitudinal analyses. For each round, couples were included in the analysis as long as there were no missing data on the variables of interest. t-tests. Next, we looked at changes in women's reports of IPV as well as changes in participant's attitudes about IPV and relationship power during the follow-up period. We conducted tests for trend to determine whether changes were statistically significant. Preliminary analyses focused on the cross-sectional relationships between age, education, and socioeconomic position and ever having experienced IPV at baseline using contingency tables, Chi-square analyses, and Student's To examine the independent relationship between the exposure variables (women's and men's attitudes towards IPV and relationship power and partner concordance on attitudes) and IPV, we fit separate logistic regression models for each indicator. We also ran a multivariable logistic regression model to examine the association of each main exposure variable and IPV, adjusting for socioeconomic status, age, and education. Finally, to examine the longitudinal relationship between the exposure variables of interest and women's experience of IPV, we used multivariable random effects logistic regression models . These mSocioeconomic position, age, education, and round of data collection were included in the models as confounders. Interactions between these confounders and the exposures of interest were also considered. However because they were not statistically significant, they were not included in the final model. We examined three “families” of hypotheses: based on women's attitudes and opinions, men's attitudes and opinions, and couple concordance. We believed that an individual hypothesis within each family would have to be considered in light of the additional tests performed on other hypotheses within the subgroup. Since each family of hypotheses included four exposure variables, we determined that an appropriate significance level  for each hypothesis test would be set at 0.05/4 or 0.0125. Out of a total of 2,399 individuals enrolled in RESPECT, 567 couples were identified and included in this analysis. A comparison of individuals who reported being married or living together as married and who did not enroll as a couple and those who did enroll as a couple indicated that there were no statistically significant demographic differences between the two groups. A total of 26 couples were lost to follow up: seven after the baseline round and an additional 19 between rounds 2 and 4. Additionally, at each round, between two and four couples were missing data on one or more variables and were excluded from the analysis. Couples who were lost to follow or excluded due to missing data did not differ in terms of demographic characteristics or women's reports of IPV (data not shown). Participant characteristics at baseline including demographic background, experiences of IPV, attitudes about violence and opinions about sexual decision making and relationship power are shown in P < 0.0005) and was not associated with demographic characteristics or study arm. In addition, at 12 months, fewer women and men noted that violence against a wife was acceptable, and a larger proportion of participants reported that sexual decision making was shared by both partners  decreased steadily over time from 20.5% at baseline to 11.8% at 12 months (data not shown). The decrease was statistically significant . This longitudinal analysis suggests that couples' attitudes towards violence and opinions about sexual decision making and relationship power are proximate determinants of women's experience of IPV. The study also provides some evidence that discordance among couples on these issues may heighten women's risk of experiencing IPV. Our observation that gender inequitable attitudes were more commonly reported by women than men is consistent with findings from other studies . It is pIt is encouraging to note that men and women tended to express more gender equitable attitudes by the end of the study. The fact that attitudes about the acceptability of IPV changed far more than opinions about sexual decision making and power within participants' relationships suggests that the changes could have been partly a result of social desirability bias. However, reported 1PV declined steadily over the course of the study from 20% at baseline to 12% at the end of one year of followup, and were not associated with demographic characteristics or intervention/control status. Since we have data on levels of IPV only from RESPECT study participants, we cannot determine whether this result reflects a declining trend in IPV in this region. However, to our knowledge, no major interventions on IPV occurred during this time period and it is unlikely that such a substantial reduction in IPV could be explained in this fashion. The reduction in women's reports of IPV—despite improved rapport between participants and study staff (which may have improved IPV disclosure)—suggests that changes in men's attitudes and behaviors may have resulted from study participation. Given that the proportion of individuals who participated in the group counseling sessions on relationship and life skills was low (data not shown), and that STI/HIV counseling did not explicitly address relationship issues, we hypothesize that repeated exposure to survey questions on relationship dynamics and the opportunity to participate in the study as a couple may have contributed to these shifts. Engaging men and women—as individuals, couples, and community members—is widely accepted as an important component of IPV prevention efforts worldwide , 29. At Results of the longitudinal regression analyses point to the potential benefits of promoting notions of equity in relationships. Women who reported that they shared sexual decision making and relationship power with their partner were consistently less likely to report IPV. In contrast, IPV was reported more frequently when men and women espoused inequitable attitudes or reported that women had more decision making control in the relationship although few of these associations were statistically significant. These findings underscore the need to better understand the delicate balance of power in intimate relationships and the role that perceived or actual imbalances in power  have in heightening women's risk of IPV. Further qualitative research may shed light on the dynamics of power, conflict, and violence within relationships in which partners hold similar or differing views.The association between couples' concordance on attitudes about IPV and relationship power and women's experience of violence also merits further investigation. Our study had limited statistical power to investigate the relationship between different types of concordance/discordance and IPV risk. Thus, we were unable to examine whether IPV risk differed depending on who held more equitable attitudes within a relationship. For example, future research should explore whether risk is higher among women who feel IPV is unjustified and whose partners feel it is justified. Previous research has suggested that discordance within a couple arising from perceived or actual gains in power by women can result in backlash, including IPV by men , 29, 30.Overall, much remains to be learned about how women and men perceive and engage with ideas of greater equity in intimate relationships. Gender norms and values are dynamic, and their relationship with individual behaviors and experiences is complex. Further in-depth examination of young women's and men's evolving ideas about gender, identity, and relationships is needed. Several questions merit study. For example, do young men and women perceive their relationship to be “healthy”? Do they desire greater equity and how do they define equity in a relationship? Are these views—and concordance/discordance in views within a couple—associated with how partners communicate with each other, handle conflicts, and experience or perpetrate IPV? A better understanding of these questions will further illuminate the ways in which gender norms and relationship dynamics influence women's risk of experiencing of violence and help identify entry points for IPV prevention efforts.Our study has additional limitations. First, the decision to measure IPV as a binary variable without accounting for frequency or type of IPV, while providing us with more statistical power, may have prevented us from observing crucial differences in the associations between attitudes and IPV risk. Second, it is especially difficult to draw strong conclusions about the heightened risk of IPV among couples holding discordant attitudes without a finer understanding of how the composition of this discordance might differently impact women's experience of IPV. Third, the decision to use only partnered couples in these analyses also raises issues of potential selection bias. It is possible that partners who both chose to participate in the RESPECT study differed in important ways from participants whose partners chose not to be in the study, including on attitudes about the acceptability of IPV. Finally, it is possible that women who experience IPV are more likely to report that violence is justified. Despite its limitations, this research provides some new insights on the role of women's and men's attitudes toward IPV and relationship power, including the role of partner discordance, in influencing women's experience of IPV. Unlike most previous research in Tanzania, this study prospectively examined the relationship between attitudes about gender relations and IPV among young couples. The widespread acceptance of IPV and inequitable power within relationships in this population highlights the urgent need for programs that help young people acknowledge, understand and challenge gender-based hierarchies. Greater understanding of young people's perceptions of “gender equity”—by focusing on women and men who do not condone IPV and who share power within their relationship—will facilitate the development of antiviolence programs. Furthermore, couple-based programs for HIV testing and treatment have been successful in sub-Saharan Africa and offer a foundation for antiviolence efforts . The dec


Intimate partner violence (IPV) is associated with increased risk of HIV among women globally. There is limited evidence and understanding about IPV and potential HIV risk pathways among sex workers (SWs). This study aims to longitudinally evaluate prevalence and correlates of IPV among street and off-street SWs over two-years follow-up.Longitudinal data were drawn from an open prospective cohort, AESHA  in Metro Vancouver, Canada (2010–2012). Prevalence of physical and sexual IPV was measured using the WHO standardized IPV scale (version 9.9). Bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE) were used to examine interpersonal and structural correlates of IPV over two years., 387 SWs had a male, intimate sexual partner and were eligible for this analysis. One-fifth  experienced recent physical/sexual IPV at baseline and 26.2% over two-years follow-up. In multivariable GEE analysis, factors independently correlated with physical/sexual IPV in the last six months include: childhood (<18 years) sexual/physical abuse , inconsistent condom use for vaginal and/or anal sex with intimate partner , <daily prescription opioid use , providing financial support to intimate partner , and sourcing drugs from intimate partner .At baselineOur results demonstrate that over one-fifth of SWs in Vancouver report physical/sexual IPV in the last six months. The socio-structural correlates of IPV uncovered here highlight potential HIV risk pathways through SWs’ intimate, non-commercial partner relationships. The high prevalence of IPV among SWs is a critical public health concern and underscores the need for integrated violence and HIV prevention and intervention strategies tailored to this key population. Male-perpetrated intimate partner violence (IPV) is a pervasive human rights violation and public health concern, with substantial negative impacts on morbidity and mortality, including poor sexual and reproductive health outcomes, HIV, and sexually transmitted infections (STIs) Immediate consequences of IPV include injuries and death from physical assault, unintended pregnancies, HIV/STIs, and psychological distress In North America, male-perpetrated IPV is associated with a significant burden. In the U.S., the 2010 National Intimate Partner and Sexual Violence Survey indicated that 30% of women experience physical IPV and 17% sexual IPV in their lifetimes Other studies from around the world have documented the association between partner violence and gender inequality with increased risk of HIV Despite growing data on the magnitude and correlates of IPV among the general population of women of reproductive age globally Qualitative and ethnographic research among marginalized groups of women  has documented the pervasiveness of controlling and abusive boyfriends, providing some contextual understanding around the power imbalances and associated violence that directly influences women’s agency and ability to safeguard against risky sexual and drug-using behaviors, making these populations particularly vulnerable to transmission of HIV/STIs There is a critical need for research on IPV among marginalized groups, including SWs. The objectives of this study were therefore to examine the prevalence of physical and sexual IPV against a cohort of SWs in Vancouver, Canada and to describe the socio-structural correlates of IPV.Data for this study were drawn from AESHA , an open prospective cohort of female SWs (2010–2012) who conduct sex work in both street (public) and off-street (indoor) settings. Eligibility criteria for AESHA participants at baseline includes being female , older than 14 years of age, having exchanged sex for money within the last 30 days, and providing written informed consent. This analysis is restricted to AESHA participants who reported having at least one intimate partner, which is defined as having a sexual, non-commercial, male partner in the last six months, at baseline.In the context of hard-to-reach populations, SWs were recruited through time-location sampling and community mapping strategies. Day and late night peer-outreach was used to identify both outdoor sex work locations  and indoor sex work venues  across Metro Vancouver. In addition, online recruitment was used to reach SWs working through online solicitations spaces.At enrolment and on a bi-annual basis, participants complete an interview-administered questionnaire by a trained interviewer and HIV/STI/HCV (hepatitis C virus) serology testing by a project nurse. The main interview questionnaire elicits responses related to socio-demographics , sex industry work , clients , intimate partners , trauma and violence , and drug use patterns (injection and non-injection). In addition, a clinical questionnaire is administered relating to overall physical, mental and emotional health, sexual and reproductive health, and HIV testing and treatment experiences. SWs have the option to visit one of two study offices or complete the questionnaire and nursing component at a safe location identified by them, including work or home locations. All participants receive an honorarium of $40CAD at each bi-annual visit for their time, expertise and travel.The AESHA study holds ethical approval through Providence Health Care/University of British Columbia Research Ethics Board and has a community advisory board of over 15 agencies.Recent IPV was measured using an abridged version of the WHO Standardized IPV Scale Version 9.9 Study variables for potential correlates of IPV were selected based on the literature and available data collected for the AESHA cohort between 2010 and 2012. Fixed variables considered at baseline included demographic variables such as: age (continuous), sexual minority , being of Aboriginal/Indigenous ancestry , and being a migrant/new immigrant worker (versus Canadian born). Historical exposure to childhood physical and/or sexual abuse (<18 years of age) was also included. Individual variables including frequency of use of injection and non-injection illicit drugs  were time-updated, and based on the last six months at each follow-up.The study participants provided all information relating to their partners, as the partners themselves were not interviewed. Partner-level data were time-updated, co-variates were collected at baseline and each follow-up visit for the primary intimate sex partner, and included inconsistent condom use for vaginal/anal sex with intimate partners, condom refusal by intimate partner, cohabitating with intimate partner, sourcing drugs  from intimate partner, and financial support provided to or by an intimate partner. Whether or not intimate partners had other sexual partners  was also included.Analyses were restricted to AESHA participants who reported having at least one recent intimate  male sex partner (last six months). Socio-demographic variables  were considered fixed variables. All other variables were considered time varying, and were updated to reflect their occurrence within the last six months. All time-updated variables were measured at the same time period as the outcome. Correlates of IPV were examined using bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE), with a logit link for dichotomous variables. To adjust the standard error and account for correlations arising from the four repeated measurements on the same participant over the two-years follow-up period, an exchangeable correlation matrix was used. GEE accounts for missing data using the GEE estimating equation, that substitutes data from non-missing pairs into the estimators of the correlations matrix. Variables significantly associated with IPV at the p<0.05 level in bivariate screening were subsequently fitted into a multivariable GEE model to adjust for potential confounding. The multivariable model was constructed using Quasi-likelihood Information Criteria (QIC) selection, which has been used successfully in past research by our group Of the total cohort (n = 652), our analyses were restricted to participants who reported having at least one male, intimate sexual partner in the past six months for a sample of 387 street and off-street SWs. At baseline, one-fifth  of women reported experiencing moderate or severe physical and/or sexual IPV in the last six months. The median age of all participants was 34 , with those who reported recent IPV being slightly younger than those who did not: 32 (IQR: 25–39) vs. 35 (IQR: 28–42) (p = 0.003). Most women (76.2%) were Canadian-born, and 39.0% self-identified as being of Aboriginal ancestry. Almost one quarter (24.3%) of participants reported being a sexual minority. The majority (66.7%) of SWs reported physical and/or sexual abuse before age 18 and this was higher among those who had experienced recent IPV compared to those who had not (84.3% vs. 61.8%) (p<0.001). Baseline socio-demographic and partner-level characteristics of participants who experienced IPV in the last six months compared to those who did not are displayed in Regarding drug use, 72.1% of SWs at baseline had used non-injection illicit drugs and 40.8% had injected drugs in the last six months. At baseline, the number of SWs who reported using prescription opioids (POs) less than daily was 63 (16.3%), which was higher among those with IPV (28.9%) than those without (12.8%) (p = 0.003). Non-injection and injection drug use by intimate partners was reported at 63.6% and 21.2%, respectively, and 37.5% of participants reported sourcing drugs from their intimate partners. In the last six months, 39.0% of SWs were living with their intimate partners and 13.7% of intimate partners had other sex partners.Bivariate and multivariable odds ratios for correlates with recent IPV are displayed in In the multivariable GEE analysis, factors independently correlated with recent physical/sexual IPV over the last six months include: childhood physical and/or sexual abuse <18 years , inconsistent condom use for vaginal and/or anal sex with intimate partner , less than daily PO use , providing financial support to intimate partner , sourcing drugs from intimate partner  and younger age .Our longitudinal study demonstrates that over one-fifth of SWs in Metro Vancouver report moderate or severe physical and/or sexual IPV in the last six months. Experiencing recent IPV was independently associated with early childhood exposure to physical and/or sexual abuse, while partner-level factors emerged as key correlates over the course of follow-up, including inconsistent condom use, economic dependence of male intimate partner on sex worker, and sourcing drugs from an intimate partner.The high prevalence of recent IPV among street and off-street SWs in our study is a critical and neglected human rights and public health concern and underscores the pressing need to focus on marginalized and hidden populations. Our results support existing literature documenting elevated levels of violence faced by SWs in Vancouver The overlap between gender inequality and heightened risk of HIV plays an important role in the context of IPV against SWs. It is estimated that SWs have more than 13-times increased odds of having HIV compared to the general female population Among drug-using women in particular, power dynamics with their intimate partners often favour traditional gender roles where men exert significant control over the relationship, including negotiating sexual risk-reduction behaviours. Bi-directional temporal relationships between sexual and physical IPV and risk of HIV/STI transmission have been demonstrated among drug-using women in the U.S, where inconsistent/no condom use and requesting partners to use condoms was significantly associated with IPV Qualitative research among substance-using women in survival sex work underscores the role of structural violence and gendered power inequities in shaping HIV and the need to facilitate enabling environments This study’s findings that childhood abuse is positively associated with recent IPV, often referred to as “re-victimization”, is consistently documented in many settings Although violence between partners occurs at the interpersonal-level, the larger macro-level context plays an important role in sustaining cultures of complacency that tolerate gender-based violence, including against SWs. The criminalized nature of the sex industry in Canada drives a culture of stigma among SWs that leads to a cycle of violence that is ultimately fuelled by power inequity. Laws that further marginalize SWs not only constrain their choices occupationally, but also undermine their health in general: stigma associated with sex work prevents SWs from accessing health care services needed for violence treatment and prevention Implementing screening instruments for IPV in reproductive/primary health care and low-threshold support settings for marginalized populations, may help to more accurately detect IPV and direct focus toward SWs’ often overlooked non-commercial relationships. However, there continues to be debate around the extent to which screening effectively improves health outcomes for women This study has a number of strengths and limitations that should be considered in the interpretation of our study. The longitudinal design and analytic methods (GEE) are considered strengths of this study, increasing the number of observations, and allowing for average estimates of the correlates of IPV over a two-year period. However, as our analyses did not allow for temporal associations, we were unable to determine causality between the study variables and IPV. Many of the variables examined in our study were sensitive  and IPV is a highly stigmatizing topic, which may have resulted in under-reporting or respondent-driven reporting biases in violence by our participants. However, the WHO Standardized IPV Scale used in this study was designed to ask a limited number of questions pertaining to common acts in violent partnerships rather than requiring respondents to identify themselves as abused – an approach that has been shown to encourage greater disclosure of violence The magnitude of physical and/or sexual IPV reported by SWs in our study demonstrates a critical need to focus on marginalized and stigmatized SW populations. SWs remain entrenched in a cycle of violence that often started in childhood and continues to impact their current intimate relationships. Our findings highlight key factors associated with IPV, including childhood exposure to physical or sexual violence, inconsistent condom use with intimate partners, economic dependence and sourcing drugs from an intimate partner, as well as PO use among SWs. The correlates of IPV uncovered here highlight important socio-structural factors that intersect with violence within SWs’ intimate, non-commercial partner relationships and underscore the need for further prevention and intervention strategies tailored to this key population, who continue to experience a disproportionate burden of violence.


In Tanzania like in many sub-Saharan countries the data about Intimate Partner Violence (IPV) are scarce and diverse. This study aims to determine the magnitude of IPV and associated factors among ever partnered women in urban mainland Tanzania.Data for this report were extracted from a big quasi-experimental survey that was used to evaluate MAP (MAP - Men as Partners) project. Data were collected using standard questions as those in big surveys like Demographic and Health Surveys. Data analyses involved descriptive statistics to characterize IPV. Associations between IPV and selected variables were based on Chi-square test and we used binary logistic regression to assess factors associated with women’s perpetration to physical IPV and Odds Ratio (OR) as outcome measures with their 95 % confidence intervals (CI).The lifetime exposure to IPV was 65 % among ever-married or ever–partnered women with 34, 18 and 21 % reporting current emotional, physical and sexual violence respectively. Seven percent of women reported having ever physically abused partners. The prevalence of women perpetration to physical IPV was above 10 % regardless to their exposure to emotional, physical or sexual IPV.IPV towards women in this study was high. Although rates are low, there is some evidence to suggest that women may also perpetrate IPV against their partners. Based on hypothesis of IPV and HIV co-existence, there should be strategies to address the problem of IPV especially among women. There is multiplicity of definitions for intimate partner violence. Nevertheless, the common understanding of IPV includes all physical, sexual, or psychological harms aggravated by a current or former partner. IPV includes also threats of acts and coercion or arbitrary deprivations of liberty that may occur in public or someone’s private life perpetrated by the partner . AlthougIn Tanzania, the reported life-time prevalence of IPV ranges between 15 and 60 % . A multiFactors associated with violence, specifically against women, are diverse and always inter-woven. For that matter, an integrated ecological framework to understand violence against women has been developed . With thChanneling Men’s Positive Involvement in a National HIV/AIDS Response to train men and women on reducing HIV risk, improving reproductive health outcomes and to increase gender-equitable norms and behaviors. We further selected two wards .The United Republic of Tanzania is a union between the mainland and the Archipelago of Zanzibar and Pemba. Tanzania mainland has a total population of 43.6 million of which 33.9 and 33.0 % of the rural population aged between 25 and 50 years are males and females respectively . By the Data for this report are extracted from a cross-sectional study to evaluate CHAMPION’S (MAP - Men as Partners) project in which the study design was quasi experimental – two arms . This design was applied because of its simplicity to implement. Due to logistical challenges, the two groups  were not assigned randomly. However, in both groups, we conducted the pre-test to both groups before conducting the training to the experimental group only. Then, a post-test was performed to assess if there were any behavior changes between and within the study groups.We estimated a sample of 1,620 independent (not pairs) adults (aged between 25 to 50 years) women and men. Eligibility criteria included having been ever-partnered. This sample size was calculated for a quasi experimental design in order to detect at least a 10 % difference between study arms with 80 % power, a 95 % confidence interval, and accounting for a 10 % loss to follow-up. Although the main focus was men, a ratio of one woman to 2 men per site  was used in order to gather information related to women and men. Therefore, in each ward we selected streets randomly and then we systematically (based on the number of households) selected a household targeting eligible women and men in a zigzag pattern (left and right of the street) to get two men and one woman until the required sample size is attained. For the purpose of this paper, we use a sub-sample of women only.Each respondent was invited to participate after signing the consent form. We ensured safety of both study participants and of the interviewer. Also, participants were assured of a respectful and non-threatening participation and freedom to withdraw from participating in the interview participation was voluntary and a participant can withdraw at any time. No personal identifiers were collected from any study participant. Also to enhance freedom of expression, all interviews were sex-matched; a female participant was interviewed by a female interviewer. All interviews were conducted in a strict private room close to or in the house of a study participant with a calm environment to allow both freedom of expression and to enhance confidentiality.Variables that were collected included background information  of the respondent and reported incidences of intimate partner violence . The components for the assessment of IPV were threats and actual physical violence, sexual and emotional violence by a partner: currently (within past one month) and beyond one month but within past three months. The lifetime violence was measured by asking whether the woman ever experienced violence from the current or any previous partner. Furthermore, since also men are potentially victims of IPV, we asked if the woman ever physically hit or slapped or did anything that could harm her partner even when the partner was not already abusing them.The questionnaire with structured questions was used to capture information on IPV among partners. Key questions on IPV were adopted from the standard Demographic and Health Survey (DHS) tool with minor modifications to suit the setup. For example:Does or did the partner ever:Say or do something to humiliate you in front of others?Threaten to hurt or harm you or someone close to you?Insult you or make you feel bad about yourselfIf yes, how many times did it happen within the one past month? The tool was translated and back-translated to and from Kiswahili, the language of communication in Tanzania. We pre-tested the tool in a similar setting as those planned for the survey to make sure questions are understandable and carry the intended meaning.Main data analyses involved descriptive statistics to characterize IPV . Looking for the association of each of the three components of IPV with selected variables, the test involved Chi-square. We used the logistic regression model to assess independent predictors of women reporting physical violence towards men perpetrated by their partners with three women’s demographic factors  as independent variables. Since IPV behaviors may not be quite independent from one household to the other , we used robust estimation of variances to account correlation between IPV rates in similar settings. The level of significance used was alpha = 0.05.Study participants with complete data were 471 females. The majority, 317 (67.3 %) were married or cohabiting, only 115 (24.4 %) had at least secondary education. Their mean age was 32.2 (SD = 7.7) years. Other background characteristics are presented in Table Out of all women interviewed, 308 (65.4 %) , reported having experienced some form of IPV. Among those reporting to have experienced any form of IPV, 137 (46.1 %) reported recent (within one month) violence. The highest reported lifetime form of IPV was emotional violence, 238 (50.5 %) . While 212 (45. 0 %)  reported lifetime physical violence, 137 (29.1 %)  of women reported lifetime sexual violence. Similarly, the reported current prevalence of physically, sexual and emotional violence was 17.6 % , 21.1 %  and 33.8 %  respectively  were affirmative that they ever physically abused their partners. Of these, five (15.6 %) reported recent (within past six months) physical abuse.In Table In Table In this paper, we assessed intimate partner violence (IPV) directed to women and men as reported by women in urban areas of mainland Tanzania. The consequences of IPV are diverse; including social, physical, mental outcomes and death , 22. FurWe found a relatively high (65 % for lifetime and 45 % for current) of reported any form of IPV towards women. Almost the same proportion has been reported among women in Southwest Ethiopia in 2012 ; higher In this study, 45 and 29 % of women report exposure to intimate partner physical and sexual violence. These rates are slightly higher than those from one of the previous studies in Tanzania (DHS) that reports 36 and 21 % respectively . DiffereAlthough literature on physical violence perpetrated by women towards men is scanty , in urbaIn this study we did not find any association between the prevalence of IPV and demographic characteristics. Lack of associations suggests that IPV incidents are common in many settings and among many women and men regardless of their age, education status and their marital status. Other studies have found association between IPV and age, education and marital status. For example, several studies including Andersson et al., WHO and Iliyasu et al., found links between IPV with age, education level and marital status , 14, 34.In this study, we have a couple of potential limitations. First, we used face-to-face interviews rather than a self-administered tool. By using this technique, it is possible to introduce information bias because respondents might have been offering socially desirable answers. Second, although we tried to examine independent factors associated with IPV, the selected factors were not exhaustive and missed several social factors like alcohol consumption that has been documented elsewhere . Third, To conclude, IPV is still a public health problem especially putting more women at risk. It should be more comprehended more hurting to find perpetrators of violence being one partner. In this study a substantial proportion of women report experiencing current and lifetime forms of IPV. More resources and programs should be mobilized by policymakers, public health experts and researchers are needed to address the problem of IPV. Furthermore, more data are required in this area so as to set up evidence-based strategies required for prevention and response to IPV.Channeling Men’s Positive Involvement in a National HIV/AIDS Response; CI, confidence intervals; DHS, Demographic and Health Survey; IPV, intimate partner violence; MAP, Men as Partners; OR, Odds Ratio; USAID, United States Agency for International DevelopmentCHAMPION,


Various risk factors of intimate partner violence (IPV) have been found to vary by gender. South Korea has one of the highest prevalences of IPV in the world; however, little is known about potential risk factors of IPV and whether gender influences this relationship.Using data from the 2006 Korea Welfare Panel Study, 8,877 married participants  aged ≥30 years were included. Reported IPV was categorized as verbal or physical IPV and the association between IPV and related factors was assessed by multivariate logistic regression analysis.Women were significantly more likely than men were to report IPV victimization . Wor odds of physical perpetration than women satisfied with their family. Moreover, alcohol intake was significantly associated with IPV perpetration and victimization in both genders.Significant gender-specific differences were found among factors related to perpetrating violence and being a victim of violence among adults in heterosexual relationships in South Korea. Intimate partner violence (IPV) is a worldwide public health problem as well as a serious social problem in South Korea -3. IPV iIPV causes a wide range of negative effects on the health of women -7 and chThe prevalence of reported partner violence varies greatly 15%-71%) among various countries 5%-71% am,15. In SIPV typically results due to gender inequality and is frequently considered a form of gender-based violence . ViolencFactors associated with IPV victimization among women include pregnancy, depressive symptoms, smoking, alcohol consumption, low socioeconomic status, experiencing IPV during childhood, and witnessing IPV perpetration against their mother -28. TumwIn addition, lacking a social network, emotional support, and having low perceived life satisfaction were found to be related with IPV among men and women ,33-37. FAlthough the aforementioned studies identified some factors associated with IPV, the limited sample size, lack of gender-specific analyses, and a lack of consideration for IPV perpetration among women and IPV victimization among men warrant further study. Furthermore, previous research has not considered factors related to each type of IPV . To this end, we investigated whether gender-specific differences exist in the prevalence of IPV as well as the type of the violence that was perpetrated or experienced.Data from the nationally representative 2006 Korea Welfare Panel Study (KOWEPS) performed by the Korean Institute of Social and Health Affairs in conjunction with Social Welfare Research Institute of Seoul National University were used for this study. Details of this study have been published elsewhere ,39. BrieIn the 2006 dataset, 18,856 men and women were recruited. Of them, 16,084 (85.29%) men and women aged 19 or older participated in the survey. For our analyses, only those who were older than 30 years old and married were included leaving 9,667 men and women. The 16 participants who were younger than 30 and married were excluded from our analysis because, according to the National Statistical Office in South Korea, the average age of marriage among males and females was 32.1 was and 29.4 in 2012, respectively . By limiDuring data collection, participants were asked 13 questions pertaining to the level and type of violence experienced in their marriage over the past 12 months. Verbal IPV was assessed by asking how often in the past 12 months their spouse was (1) insulting, (2) made a malicious remark, or (3) threatened them. Physical IPV was assessed across ten violent activities. Respondents were asked how often in the past 12 months their spouse perpetrated the following physically violent activities at him/her: (1) threw something, (2) pushed, (3) slapped, (4) kicked or punched, (5) used an object to hit, (6) beat, (7) threatened using a weapon like a knife, (8) choked, (9) caused a sprain or bruise, or (10) caused him/her to be hospitalized after a violent encounter. These questions were adopted from the Conflict Tactics Scale . In addiThe statistical models used in this study were created based on variables reported in previous studies ,41. NineParticipants were divided into five age groups, 30–39, 40–49, 50–59, 60–69, and ≥70 years, for the analysis. In addition, education level was stratified into three groups based on the highest level of education achieved as elementary school, middle or high school, or university or higher. Income was calculated according to the equivalized household income equation as the sum of the total household income from all sources including earned income, income from assets, and miscellaneous income divided by the square root of the number of household members. The equivalized income was then divided into quartiles [p-value >0.05 was considered statistically significant.Descriptive statistics were used to describe participant characteristics and report the number and percentage of participants for each variable. In addition, the prevalence of IPV was calculated for all variables. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to measure the strength of the association between IPV and all possible IPV-related factors in this study population. Multivariate logistic regression models, with IPV as the dependent variable, were used to calculate gender-specific ORs. Fully adjusted ORs were calculated after controlling for all potential confounders . Sampling weights were also added to aid in generalizing our findings to the entire population of South Korea. All statistical analyses were performed using SAS version 9.2 , and a Gender-specific data on the characteristics of the study population and the prevalence of IPV are shown in Tables The majority of men reported working full time (47.6%), had at least a middle or high school education (47.2%), were non-smokers 51.7%), and moderate drinkers (30.4%). For men, the prevalence of verbal IPV was 24.4% for victimization and 25.3% for perpetration. The prevalence of physical IPV was 3.4% for victimization and 5.1% for perpetration  and had at least a middle or high school education (47.7%). In addition, most women were nonsmokers 98.2%) and nondrinkers (69.9%). For women, the prevalence of verbal IPV was 28.2% for victimization and 26.7% for perpetration. The prevalence of physical IPV was 6.9% for victimization and 3.4% for perpetration . In addition, women tended to perpetrate verbal violence against their spouse more often than men were (26.7% vs. 25.3%). However, 5.1% of men and 3.4% of women reported perpetrating physical violence against their spouse. A similar proportion of men and women reported male-to-female violence, yet more women than men reported female-to-male violence.Women were significantly more likely than men were to report being a victim of IPV  for verbal IPV victimization, 5.49 (95% CI: 2.91-10.37) for physical IPV victimization, 2.54 (95% CI: 1.74-3.71) for verbal IPV perpetration, and 4.68 (95% CI: 2.66-8.27) for physical IPV perpetration. However, the adjusted OR among men who were dissatisfied with their personal life was 1.76 (95% CI: 1.39-2.22) for verbal IPV victimization, 3.07 (95% CI: 1.79-5.26) for physical IPV victimization, 1.69 (95% CI: 1.34-2.13) for verbal IPV perpetration, and 2.51 (95% CI: 1.60-3.95) for physical IPV perpetration when compared to men who were satisfied with their personal life. Among the measured health behaviors, men reporting high alcohol intake were more likely to have experienced verbal IPV victimization, physical IPV victimization, verbal IPV perpetration, and physical IPV perpetration. Compared with non-drinkers, the adjusted OR of heavy drinkers was 2.06 (95% CI: 1.65-2.58) for verbal IPV victimization, 2.54 (95% CI: 1.49-4.31) for physical IPV victimization, 2.00 (95% CI: 1.60-2.50) for verbal IPV perpetration, and 2.81 (95% CI: 1.84-4.30) for physical IPV perpetration , 1.53 (95% CI: 1.13-2.08), and 2.15 (95% CI: 1.21-3.83), respectively. Moreover, women with a high level of family and life satisfaction were less likely to report verbal IPV victimization, physical IPV victimization, verbal IPV perpetration, and physical IPV perpetration; these findings are similar to that among men. Compared with women who were satisfied with their family relationships, the adjusted ORs among women dissatisfied with their relationships were 3.17 (95% CI: 2.23-4.52) for verbal IPV victimization, 6.68 (95% CI: 4.23-10.56) for physical IPV victimization, 2.78 (95% CI: 1.95-3.96) for verbal IPV perpetration, and 9.46 (95% CI: 5.21-17.19) for physical IPV perpetration. Moreover, the adjusted ORs among women dissatisfied with their personal life was 1.96 (95% CI: 1.55-2.49) for verbal IPV victimization, 2.52 (95% CI: 1.64-3.89) for physical IPV victimization, 2.36 (95% CI: 1.85-3.00) for verbal IPV perpetration, and 2.23 (95% CI: 1.22-4.08) for physical IPV perpetration when compared to women who reported being satisfied with their personal life . In addition, women reported a lower rate of experiencing male perpetration than that of experiencing victimization. However, the rate of female perpetration was roughly aligned with the rate of victimization that was reported by men. One interpretation for this discrepancy may be that men underreported IPV perpetration due to a social desirability bias. Similar disparities in reporting have been found in studies conducted in other countries .The majority of research surrounding IPV has addressed violence against women, examining prevalence estimates of female victimization and male perpetration. In the current study, rates of verbal IPV victimization among females (28.2%) fell within the range of previous estimates (24.6%-55.0%) ,48, althAmong men, low education level was positively associated with perpetrating verbal violence; however, among women, low education level was positively associated with both victimizing and perpetrating verbal IPV. Previous studies have reported similar associations and have strongly suggested that future violence prevention programs should aim to increase levels of education and understanding about IPV .Our results also confirm the finding of other studies that IPV victimization and perpetration are likely to occur regardless of one’s drinking habits ,47. HoweOur study has important limitations. First, the prevalence of IPV was measured over the previous 12 months; therefore, these data may have underestimated the actual prevalence of IPV in this study population. Second, the KOWEPS dataset did not measure experiences with IPV during childhood such as any exposures to domestic violence or witnessing IPV perpetration among their parents. Third, the KOWEPS dataset did not ask participants who were married whether they live with their spouse. We cannot assume that all married couples live with their spouse and this factor may influence the prevalence of IPV; therefore, future studies should investigate whether this factor is associated with IPV. Fourth, IPV related to sexual abuse was not included in the KOWEPS survey. Last, the confidence intervals estimated in our analyses were wide; therefore, future prospective studies with large sample sizes are needed to better understand these relationships.In this nationally representative study, we found that the prevalence of IPV and its associated factors were gender specific. In particular, alcohol intake, family, and life satisfaction were strongly associated with both verbal and physical IPV among men and women. In addition, the prevalence of IPV victimization was significantly higher among women than among men. Moreover, older men who were dissatisfied with their family and personal life as well as heavy drinkers were more likely to be victims of physical IPV than their counterparts were. Furthermore, older women who were dissatisfied with their family and personal life as well as heavy drinkers were more likely to perpetrate physical IPV than their counterparts were. Large, prospective studies are needed to understand the etiology of these factors for the proper implementation of preventative measures to reduce IPV in South Korea.Worldwide, gender differences in IPV have been reported and, among those countries, South Korea has one of the highest prevalences of IPV. However, the factors related to IPV in Korean adults are unknown.We found significant gender-specific differences among the factors related to IPV. In addition, the prevalences for each the type of violence perpetrated and victimized varied significantly by gender.This is the first study to utilize nationally representative data to investigate the prevalence and risk factors of IPV in South Korea. This study measured IPV as a self-reported experience over the previous 12 months, yet further data such as sexual IPV and violence during childhood were not collected; therefore, further studies are needed.IPV: Intimate partner violence.The authors have no conflicts of interest to disclose.ML developed the research question and performed the analysis, ML and KMS drafted the manuscript and interpreted the data, ML and ECP participated in the design and planning of the study and ECP is guarantor. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/415/prepub