Evidence-based interventions are essential in the prevention of violence against women (VAW). An understanding of risk factors for male perpetration of VAW using population-based research is crucial for developing such interventions. This study is a baseline assessment of a two-arm unmatched cluster randomised controlled trial (C-RCT), set up to assess the impact of a Rural Response System (RRS) intervention for preventing violence against women and girls in Ghana. This study aims at assessing past year prevalence and risk factors for sexual or physical intimate partner violence (IPV) perpetration among men.The population-based survey involved 2126 men aged 18 and above living in selected communities in 4 districts in the central region of Ghana. Logistic regression techniques were used to determine risk factors for sexual or physical IPV perpetration. All models adjusted for age of respondent and took into account the study design.Half of the men had perpetrated at least one form of violence against their intimate partners in their lifetime while 41% had perpetrated sexual or physical IPV. Majority (93%) of the men had been in relationships in the 12 months preceding the survey, and of these, 23% had perpetrated sexual or physical IPV. Childhood factors associated with sexual or physical IPV included witnessing abuse of mother (aOR:1.40(1.06–1.86)), and neglect (aOR:1.81(1.30–2.50)). Other major risk factors for IPV perpetration were: having multiple partners (aOR:1.76(1.36–2.26)), ), substance use (aOR:1.74(1.25–2.43)) and gender inequitable attitudes (aOR:0.94(0.91–0.97)).Childhood violence experience and witnessing, risky behaviour  and gender inequitable attitudes are major risk factors for sexual or physical IPV perpetration. Perpetration of sexual or physical IPV tend to co-occur with non-partner violence and emotional IPV perpetration. Interventions targeting these factors are critical in reducing IPV. Intimate partner violence (IPV), which refers to aggressive or coercive behaviours among marital, dating or cohabiting partners, remains a global public health concern due to its adverse health consequences to the victims, which are often women . Strong Prevalence estimates for women’s IPV experience in Ghana is high. The Ghana Demographic Health Survey 2008 (GDHS) showed that two in five women had experienced either emotional, physical or sexual IPV, and one in five women had experienced physical IPV in their lifetime. The same survey found that one in five women had experienced sexual or physical IPV in the 12 months preceding the survey . AnotherStudies amongst men have shown some consistent risk and protective factors for IPV perpetration. Prominent risk factors for IPV perpetration by men include childhood experience of violence  or exposure to violence (e.g. witnessing abuse of mother at the hands of father or boyfriend) and having permissive attitudes towards violence against women (VAW), while having gender equitable attitudes has been found to be protective against IPV perpetration , 13–17.Substance abuse and mental health issues have also been found to be key risk factors of IPV perpetration by men. Studies have found cumulative risk of depression and post-traumatic stress disorder symptoms and substance abuse to be associated with intimate partner violence perpetration –20. StudMost LMIC, including Ghana, have patriarchal sociocultural values that condone abuse of women’s rights, and have attitudes that make IPV against women acceptable and culturally normal and reinforcing traditional symbolic structures of male dominance and control over women , 24–26. In Ghana, despite legislation and advocacy work to reduce the levels of IPV victimisation/perpetration, the effects of such interventions have been inadequate due to limited inclusion of men in such work. Furthermore, most interventions and studies in Ghana have concentrated on women and not included men. The 1998 study by the Gender Studies and Human Rights Documentation Centre (Gender Centre) recommended that the responsibility for men’s perpetration of violence against women and children needs to be shifted to society as a whole rather than put it solely on women . The stuThis paper examines prevalence of sexual or physical IPV perpetration among men and its associated risk or protective factors in central region of Ghana. It is part of a larger intervention study aimed at promoting gender equitable social norms and attitudes in communities, with the overall aim of reducing violence against women. A number of studies have advanced for interventions that promote gender equitable attitudes among men. These studies have also advanced for interventions that promote positive parenting, and that address normalisation of violence against women and children.The data reported in this paper were drawn from a baseline survey of an unmatched cluster randomised controlled trial evaluating the Rural Response System (RRS) intervention to reduce VAW in Central Region of Ghana. The RRS intervention is focused on both men and women, however for the purpose of this paper only baseline data collected from men is presented.The baseline survey was done in four districts located in the Central Region of Ghana. These districts include two which are along the coastline of Ghana and another two inland districts. The Central region has an adult literacy rate of about 50%, with literacy rate among men being higher than that of women (69.8% vs 46.3%). The unemployment rate among men in the region is however slightly lower than that of women (8.0% vs 8.2%) [The baseline survey used clusters listed by the Ghana Statistical Service (GSS) and were used in the Ghana Demographic and Health Survey (DHS). A multistage stratified cluster random sampling process was used to select participants in line with the design for the on-going cluster-Randomised Control trial. Initially, clusters (communities) were randomly selected within each district, after which we randomly selected enumeration areas (EAs) within the selected clusters, and then selected households within the selected EAs using systematic random sampling. We used probability proportional to size (PPS) to select number of EAs within clusters and number of households within EAs. Different EAs were drawn for the men’s survey, separate from those for the women’s survey in each district. A total 10 clusters were selected in each district. An average of 82 households were selected in each of the 10 clusters in each district and an adult male (≥ 18 years) and who is deemed to live (sleep and eat) in the household, and who has lived in the community for at least a year, was invited to participate in the survey. A total of 2126 men were interviewed.Interviews were conducted in English, Twi or Fante, depending on the participant’s language preference, and data was gathered through face to face interviews and recorded on Personal Digital Assistants. Additional details of the trial design can be found in the study protocol which is registered on Clinical Trials.gov (Identifier: NCTo3237585).The main outcome in this paper is self-reported physical or sexual violence perpetration against an intimate partner in the past 12 months. This dichotomous outcome is derived from 5 physical violence perpetration outcomes and 3 sexual violence perpetration items . These wOther forms of violence measured were emotional IPV (measured using 4 items), single item economic IPV measure and non-partner violence.Some of the protective or risk factors, based on previous literature, measured in the baseline survey included childhood experience or exposure to violence in the home, having gender equitable attitudes and relationship practices, being involved in other forms of violence perpetration (fights with other men or violence against non-partners). Other risk factors measured were sexual behaviours, mental health and substance use as well as partner characteristics.Gender equitable attitudes were measured using the 8-item Gender Equitable Men (GEM) scale adopted from the WHO Multi-Country Study on Women’s Health and Domestic Violence against Women, and look at the extent to which men agree with separate roles for men and women or agree with equality between men and women . Some ofFactor analysis was done to assess the reliability and consistency of the GEM scale in the Ghana context  and GEM score was created as an additive scale with higher scores representing more equitable attitudes.Permissible attitudes towards VAW were measured using two items from the gender attitudes scale. These items were: i) “There are times when a woman deserves to be beaten”, ii) “A woman should tolerate violence in order to keep her family together”. Participants who agreed (agreed or strongly agreed) to either of the two statements, were considered to have permissible attitudes towards VAW.We also measured individual and community gender norms using 9-item gender relationship scales, adopted from the Stepping Stones/Creating Future study in South Africa . ExampleRelationship Control 8-item scale was used to measure the controlling behaviour of the men towards their intimate partners, done with the purpose of exerting power. Items in this scale include: “I won’t let my partner wear certain things”, “I tell my partner who she can spend time with” and “I want to know where my partner is all of the time”. These items were measured on a 4-point Likert scale. The scale had good internal consistency . An additive score as a measure of the overall controlling behaviour, with high scores indicating more controlling behaviour.Childhood exposure to violence (experienced or witnessed before the age of 18 years) was measured using the Childhood Trauma Scale (CTQ). We used a modified version of the short form of the Childhood Trauma Questionnaire which had a four point Likert scale . HoweverWe used the Centre for Epidemiological Studies Depression Scale (CES_D) to measure level of depression amongst participants . The CESParticipants were asked if they had in the course of their life experienced some traumatic events such as ‘witnessing murder of friend or relative’, ‘being victim of armed robbery’ or ‘witnessed someone being raped’. The trauma exposure was measured using an adapted Life Event Checklist from the PTSD checklist (8 items). We created a dichotomous measure from the binary responses and a participant was considered to have experienced or witnessed a traumatic event if they responded positive to at least 1 of the items.Participants were asked if they use drugs or drink alcohol. On alcohol use, participants indicated how often they take drinks containing alcohol . We then dichotomised the responses based on whether someone ever drinks or not and a combined measure of drug and alcohol use was created.Sexual behaviour risk factor included having multiple sexual partners and being involved in transactional sex. Participants were asked about the number of main and other partners they had had sex with the past year. Involvement in transactional sex was derived from 5 questions that assessed whether a participant had had sex where the partner expected to get monetary or material support. Partner characteristics that were measured include age of partner, employment status, earning disparity and their education level.We analysed various social and demographic factors that in previous research have been found to be associated with IPV perpetration such as education level, marital status, employment status, household food security and age of participant , 14, 37.Ethics approval for the trial was obtained from the South African Medical Research Council Ethics Committee (EC031-9/2015) and the Institutional Review Board at the Noguchi Memorial Institute for Medical Research at the University of Ghana (# 006/15-16). Eligible participants were given information about the purpose of the study, procedures involved, participants’ rights, risks and benefits of participating in the study in the language of their choice and were enrolled in the survey voluntarily. A researcher was present during the initial informed consent process to ensure that participants understood the information, study procedures and their rights. The informed consent process was done in English, Twi or Fante, depending on the participant’s language preference. Written consent was then sought from all eligible participants prior to commencement of the interview. For safety and confidentiality reasons, only one participant was interviewed in each selected household and interviewers ensured that interviews were done in complete privacy. All participants were given unique identification number and their names were not recorded on the questionnaire. This was done to ensure anonymity of the process. Participants were reimbursed with 10 Ghanaian Cedis (~ 3USD) for their time and inconvenience completing the questionnaire.In all analysis procedures, we took into account the multistage sampling design of the survey, with stratification by district and the enumeration areas being the lowest level clusters. We assessed whether there was any relationship between non-response to these respective partner characteristic variables and our outcome variable .Descriptive statistics were presented as mean (with standard deviation) or as frequencies (with percentages). We calculated 95% Confidence Intervals using Taylor linearization. Bivariate relationships between sexual or physical violence perpetration and attitudinal, behavioural and demographic variables were examined using the Pearson’s Chi-Square test for categorical variables and t-tests for continuous variables. We also examined the relationship between childhood experience of violence or exposure to violence and other potential risk factors of IPV perpetration.To investigate potential risk factors associated with physical or sexual IPV perpetration, we first conducted a bivariate analysis using maximum likelihood logit models. All factors associated with IPV perpetration in the bivariate analysis  were put in the multivariate model. We also included any factors which were marginally significant , which we considered as potential meaningful risk factors. The multivariate logistic regression model adjusted for age of participant. To account for clustering, we used generalised linear mixed modelling, with enumeration areas as random effects.We also examined the model for multi-collinearity using VIF, and dropped variables that were highly correlated. For example, we found that individual gender attitudes were highly correlated with perceived community gender attitudes (VIF>10). However, individual gender attitude score had a stronger relationship with IPV perpetration than the perceived community gender attitude score. Thus, in final multivariate logistic model we did not include the perceived community attitude score. We further investigated the effect of including perpetration of non-partner violence and perpetration of emotional violence as risk factors.Of the 2126 participants interviewed, 1973 were married or had a partner/girlfriend in the 12 months preceding the survey. This was the denominator used for our outcome . However, all men interviewed had been in some relationship in their lifetime and were all considered for descriptive analysis on lifetime perpetration of IPV. Due to an error in the skip pattern in the questionnaire, respondents that were not living with their partners/girlfriend did not respond to questions on partner characteristics. In order to utilise information on partner characteristics in the modelling, we created a dummy level in all partner characteristic variables . Apart from partner characteristics, all other variables had very little or no missing data. With very little or no missing information in the explanatory variables, we used listwise deletion in multivariate logistic regression modelling. All analyses were conducted using Stata SE Version 13.Lifetime perpetration was at 27.7% (589/2126), with ‘slapping”, “pushing or shoving”, also being the most common acts. A total of 328 (16.6%) men had perpetrated some form of sexual violence in past 12 months, with their lifetime prevalence at 27.8%. Overall, a fifth of the men (454/1973) had perpetrated physical or sexual violence against an intimate partner in the 12 months preceding the survey. Almost one- third of the 454 men who had perpetrated sexual or physical IPV, had perpetrated violence against non-partner, and over half (261/454) perpetrated emotional IPV in past year. The prevalence of emotional IPV only was 13%.Experience of any form of childhood abuse was associated with IPV perpetration, with men who had experienced physical neglect being three times more likely to perpetrate IPV , and men who had experienced sexual abuse were two times more likely to perpetrate IPV . Similar risks were observed in those that had experienced physical abuse  or emotional abuse . Witnessing abuse of mother was also strongly associated with IPV perpetration .We also found very significant association between experience of violence or exposure to violence in childhood and having attitudes that endorse VAW. Men who had witnessed abuse of their mother were three times more likely to have attitudes that endorse VAW (OR = 3.3 CI: 2.5–4.3). There were significant associations between permissible attitudes towards VAW and childhood neglect or physical abuse (OR = 1.7 and OR = 1.3 respectively). Childhood experience or exposure to violence was also highly associated with substance use. Men who had witnessed abuse of their mother were two times more likely to use alcohol or drugs.Men who perpetrated sexual or physical IPV were more likely to perpetrate sexual violence against a non-partner , and were more likely to perpetrate emotional violence against their intimate partner .Having risky sexual behaviour was also highly associated with IPV perpetration. Men with multiple partners in the past 12 months were three times more likely to have perpetrated sexual or physical IPV . Similarly, men who had been involved in transactional sex or had had sex with sex workers were three times more likely to have perpetrated sexual or physical IPV (OR = 3.23 CI: 2.58–4.05).Use of alcohol or drugs was also associated with IPV perpetration, with men who drink or use drugs being twice more likely to perpetrate IPV (OR = 2.41 CI: 1.94–3.00). Risk of IPV perpetration increased with increase in depression score . Having experienced some traumatic events was also highly associated IPV perpetration (OR = 2.98 CI: 2.38–3.73). However, having post-traumatic stress disorder was partially associated with IPV perpetration . Substance use was highly associated with having multiple partners (OR = 1.7 CI: 1.3–2.1), being involved in transactional sex (OR = 2.4 CI: 1.9–3.1) and having experienced/witnessed some traumatic events (OR = 1.6 CI: 1.3–1.9).Having attitudes that condone VAW was also a strong risk factor for IPV perpetration. Men with permissible attitudes towards VAW were two times more likely to perpetrate IPV . Having gender equitable attitudes reduced a man’s likelihood of perpetrating IPV (OR = 0.91 CI: 0.88–0.94). However, there were no significant differences in what the respondents indicated were community gender norms between perpetrators and non-perpetrators. Controlling behaviour was also found to be significantly associated with IPV perpetration, with the odds of IPV perpetration increasing with increase in controlling behaviour (OR = 1.06 CI:1.02–1.09).Of the men who provided information about their partner, partner unemployment and partner education were most significant factors associated with IPV perpetration. Men with partners who were more educated than them were more likely to perpetrate IPV compared to men who had the same education levels with their partners (OR = 1.75 CI: 1.24–2.47). Most of the men (181/206) with more educated partners had junior secondary school level or lower. A man with an unemployed partner was two times more likely to perpetrate IPV than a man whose partner was employed (OR = 1.70 CI:1.30–2.22).In the multivariate logistic regression , childhoOur findings show high levels of sexual or physical IPV perpetration in the selected communities in Ghana with one in five men having perpetrated sexual or physical IPV in the 12 months preceding the survey, and one in ten men having perpetrated physical IPV in 12 months preceding the survey. Sexual IPV prevalence was higher than physical IPV prevalence, and not all perpetrators used all types of violence. However, there was some overlap between sexual and physical IPV, with 6% of the men perpetrating both sexual and physical IPV in the 12 months preceding the survey. Findings from the UN Multi-country study showed variation in the occurrence of sexual or physical IPV with some countries having higher prevalence of sexual IPV than physical IPV and other countries having higher physical IPV prevalence compared to sexual IPV . There aFor lifetime prevalence rates, almost one in every three men had perpetrated some form of physical IPV. Our lifetime prevalence rates are far much higher than findings by Kishor and Bradley, who using data from nationally representative Demographic and Health Surveys in Ghana found a lifetime physical IPV perpetration of 16.3% . HoweverIn this paper, we found that having witnessed abuse of one’s mother increases the risk of IPV perpetration in adulthood. The very significant association between witnessing inter-parental violence and having attitudes that endorse VAW bridges the link between exposure to violence in childhood and IPV perpetration later in life. This is consistent with other studies that have looked at inter-generational transmission of VAW , 41–43. In the crude bivariate analysis, both gender attitude measure from the GEM scale and individual attitudes score were strongly associated with IPV perpetration and perceived community gender attitudes was marginally significant. In the multivariate analysis, only individual attitudes were significantly associated with IPV perpetration. However, there was a very strong positive correlation between GEM score and individual gender attitudes score, which might explain the non-significant relationship between GEM score and IPV perpetration in the multivariate model. Our findings are in line with several studies that have found a relationship between gender attitudes and IPV perpetration or experience , 14, 27.Field and colleagues found alcohol consumption was a more influential predictor of IPV perpetration than permissible attitudes towards violence . Apart fBivariate analysis further showed a strong relationship between IPV perpetration and woman’s education level relative to their partner’s education level, with men whose partners were more educated than them having high likelihood of perpetrating IPV. In a study done in India, Ackerson and colleagues found increased likelihood of IPV experience among women with no education but also in women who were more educated than their partner .Findings from the Ghana 2008 DHS showed that women with tertiary education had decreased likelihood of experiencing IPV. HoweverOur study found strong association between risky sexual behaviours  and IPV perpetration, a finding consistent with that of other studies that have looked at risk factors for IPV perpetration/experience and generally interpreted these as indicator variables for a more patriarchal, sexually entitled masculinity , 17, 28.Having an unemployed partner increased men’s likelihood of perpetrating IPV. Several studies have shown that female empowerment through education or income is generally protective against IPV , 13. HigA major limitation of our study is the non-response to partner’s characteristics. Information on partner characteristics would have helped in linking IPV perpetration with women’s characteristics relative to men’s. Another limitation of our study is the unavailability of data at community level that could have helped us understand society-level drivers of IPV perpetration. The findings of this study cannot to be generalised to the whole of Ghana, but provide much needed empirical evidence on which primary VAW prevention interventions can be based, and act as a reference level for the Rural Response System (RRS) intervention to reduce gender-based violence currently ongoing in the districts where the survey was conducted. Based on the cross-sectional study design, we are also mindful that it is not possible to infer causal relationships between IPV perpetration and the risk factors examined in our paper.The study contributes important evidence about factors associated with men’s IPV perpetration in Ghana, and complements findings from studies conducted amongst women. Findings of this study emphasise the urgent need for primary prevention interventions that can address inter-generational transmission of violence and address learned gender inequitable attitudes and norms that condone men’s control and dominance over women. Interrupting the cycle of violence is very critical in reducing men’s perpetration of VAW. Context-specific evidence is critical for designing appropriate and relevant interventions and policies. We also argue that it may be necessary for VAW primary prevention interventions to take into account contextual challenges like poverty and unemployment .S1 File(CSV)Click here for additional data file.


Intimate partner violence (IPV) is exceedingly common in conflict and post-conflict settings. We first seek to describe factors associated with past 12 month IPV amongst currently married women in Afghanistan, focused on the factors typically assumed to drive IPV. Second, to describe whether IPV is independently associated with a range of health outcomes.Cross-sectional analysis of currently married Afghan women, comprising the baseline study of a trial to prevent IPV. We use multinomial regression, reporting adjusted relative-risk ratios to model factors associated with the different forms of IPV, comparing no IPV, emotional IPV only, and physical IPV and emotional IPV. Second we assessed whether experience of emotional IPV, and physical IPV, were independently associated with health outcomes, reporting adjusted ß coefficients and adjusted odds ratios as appropriate.Nine hundred thirty five currently married women were recruited, 11.8% experienced only emotional IPV and 23.1% experienced physical and emotional IPV. Emotional IPV only was associated with attending a women’s group, greater food insecurity, her husband having more than one wife, experiencing other forms of family violence, and more inequitable community gender norms. Experiencing both physical IPV and emotional IPV was associated with attending a women’s group, more childhood trauma, husband cruelty, her husband having more than one wife, experiencing other forms of family violence, more inequitable community gender norms, and greater reported disability. Emotional IPV and physical IPV were independently associated with worse health outcomes.IPV remains common in Afghanistan. Economic interventions for women alone are unlikely to prevent IPV and potentially may increase IPV. Economic interventions need to also work with husbands and families, and work to transform community level gender norms.NCT03236948. Registered 28 July 2017, retrospectively registered. Intimate partner violence (IPV) is common in both conflict and post-conflict settings, but there remains little evidence about the extent of IPV in such settings , 2. For Global research on risk factors for IPV have focused on individual characteristics, partner characteristics, poverty, and community attitudes . IndividCharacteristics of women’s male partners are important in shaping women’s vulnerability to IPV. Men who are more controlling, who are more patriarchal in their attitudes and practices , 16, andHousehold economic position is also important in women’s experiences of IPV. Household food insecurity is often a key marker of IPV vulnerability, even in high-income countries , 21. OthFinally, community level analyses have consistently shown that where IPV is normative at the community level, women are more likely to experience IPV . But, inIPV is associated with women’s poor health. Women who experience IPV are more likely to be depressed, suicidal, have post-traumatic stress disorder (PTSD), and have overall worse health , 25. TheThis paper has two aims. First, to describe the factors associated with recent IPV amongst a group of currently married women in Afghanistan, focused on the factors typically assumed to drive IPV. Second, to describe whether IPV is independently associated with health outcomes amongst these married women.Data are drawn from currently married women participating in the baseline assessment of the Women for Women International (WfWI) intervention trial, in Afghanistan, enrolled between September 2016 and March 2017. The study comprised six villages in Kabul and Nangarhar Provinces.Women were aged 18 to 49. The study aimed to recruit among the poorest women in villages, and those without much formal education, and not currently working or earning much money. In the main study, women were recruited no matter their marital status, but in this analysis only married women are included, as it is not possible to ask about IPV to women who are not currently married.Women were randomized at the individual level to intervention and control arms, and were aware of arm allocation when completing questionnaires. For questionnaire completion, women in the control arm received US$10, while women in the intervention received no compensation (however they did receive the intervention). The intervention was delivered after baseline data collection, and seeks to strengthen livelihoods and social empowerment , 32. EthStructured paper and pencil questionnaires were completed through face-to-face interviews. Fieldworkers were women trained in quantitative interviewing. Interviews were conducted in training centres in villages, a space only women could enter, where auditory privacy could be ensured.Data was double-entered into a database. Discrepancies between the databases were resolved through manual checking of the original questionnaire. Missing data was imputed for scales. The mean of the item for the overall sample was used to impute data and no more than two items were imputed per individual, per scale. If three or more items were missing from a scale for an individual, the scale was set to missing for that person.The primary outcome was past year IPV and only married women were asked these questions. Emotional IPV and physical IPV were assessed using scales based on the WHO Multi-Country study on Domestic Violence , adaptedSocio-demographic questions were asked, including ethnic group, age, marital status and education level. Women were asked a single item about participation in a women’s group, specifically “Do you attend a group where women meet together to do something to earn money or to improve the community or for social reasons in the village?” Women’s gender attitudes were assessed using 11 items, on the gender equity scale, modified for use in Afghanistan (α = 0.87), with a typical item being “I think girls in my family should go to school”. Items were summed together (range 14–32), with higher scores indicating less gender equitable attitudes. Childhood traumas were assessed using 12 items based on the childhood trauma scale  adapted Poverty was assessed in two ways. Household food insecurity was assessed with three items of the Household Hunger Scale (α = 0.94), assessing past month food insecurity, which was summed (range 3–12) . One iteHousehold relationships were assessed in three different ways. First women were asked whether they were their husband’s only wife. Second, a five-item scale assessed husband cruelty, with questions including “my husband is strict and controlling”. Responses were on a four-point Likert scale and summed . Finally, to assess violence in the home from other family members, women were asked three questions about violence experienced from other household members; mother-in-law, father, or a sibling, all in the past year. A positive response to any of these items led to women being classified as having experienced violence from another family member.Perceived community level gender attitudes were assessed using 11 items. Community level gender attitudes were assessed through the same questions as individual level gender attitudes, but instead of “I think”, questions were “In this community many people think” .Six health and wellbeing measures were assessed. Past week depression was assessed with CESD-20  and scorn = 17) had only experienced physical IPV, but not emotional IPV, and were excluded from analysis. For the categorical variables, proportions of the sample with each level of the variable by IPV category are presented. For continuous variables, the mean for each experience category are presented. We used Chi-square tests to compare distributions across categorical variables and present 95% confidence intervals (CIs) to enable comparison of means, as appropriate, by IPV category. All variables were selected based on an a priori hypothesis that they may be associated with IPV, based on previous research on risk factors for IPV, summarized in the introduction.We first describe the socio-demographic characteristics, livelihoods, and experiences of IPV of the sample used for the analysis with percentages and means. As there is significant overlap between the different forms of IPV, we created a three-level categorization; women experiencing no IPV; those experiencing one or more instances of emotional IPV ; and those who experienced both physical IPV and emotional IPV. Only 1.8%  we categorsied women’s experience of IPV in two ways. First, we considered the health impacts with IPV categorized as for the above model: no IPV, one or more experiences of emotional IPV only, and one or more experiences of physical IPV and one or more experiences of emotional IPV. In Table In total, 935 currently married women were recruited into the evaluation Table . Of thesThere were low levels of education, with two-thirds having attended no schooling, and 13% only madrasaIPV experience did not differ by age and education category Table . A higheAt the individual level, a higher percentage of women reporting emotional IPV, and those reporting physical and emotional IPV, reported being currently part of a savings group, or women’s group. Women reporting experiencing both physical and emotional IPV reported more inequitable gender attitudes and more experiences of childhood traumas, than those reporting no IPV, and the 95%CIs did not overlap. Women reporting emotional IPV only and physical and emotional IPV reported a higher mean score for food insecurity compared to those reporting no IPV, and 95%CIs did not overlap.At the family level, a larger proportion of women reporting their husband had more than one wife, reported emotional IPV, and physical and emotional IPV. Women reporting physical and emotional IPV reported higher means scores for husband cruelty, than women with no IPV experience. And a higher proportion of women reporting emotional IPV, and physical and emotional IPV, reported experiencing violence from another family member. Women who experienced emotional IPV, and physical and emotional IPV, reported higher gender inequitable community attitudes, than those reporting no IPV. For health related factors, women reporting only emotional IPV, and physical and emotional IPV, reported more depressive symptoms, and higher mean scores for disability, than those reporting no IPV, with no overlap with 95%CIs.In the multinomial regression Table , women oExperiencing physical and emotional IPV, compared to no IPV, was associated with participation in a women’s group, having higher levels of childhood trauma, reporting their husband had more than one wife, higher levels of husband cruelty, experiencing violence from another family member, and increased perceptions of gender inequitable attitudes at the community level. Women who reported greater levels of disability also reported more physical IPV and emotional IPV.Table In our sample, about a quarter of currently married women reported any physical IPV in the past year, and just over a third reported emotional and/or physical IPV in the past year. Almost all those who experienced physical IPV, also experienced emotional IPV. Factors associated with women experiencing emotional IPV only, and physical IPV and emotional IPV, were very similar in the multinomial model, where typically women reporting physical and emotional IPV experience, compared to emotional IPV only, had larger adjusted relative-risk ratios.Not all factors associated with women’s experience of emotional IPV, were associated with women’s experience of physical and emotional IPV. Specifically, food insecurity was only associated with experiencing only emotional IPV, but not physical and emotional IPV, and childhood traumas were only associated with experience of physical and emotional IPV, and not emotional IPV only. There are a number of potential reasons for this. Emotional IPV, while strongly overlapping with physical IPV, is a different construct , and as Women’s experience of both emotional IPV only, and physical IPV and emotional IPV, were associated with involvement in women’s groups outside the home. It may be women who experience IPV opt into women’s groups, more than women who do not experience IPV, as a way to build resources and social networks and work to ameliorate the impact of IPV, enabling resilience in the face of trauma . AlternaExperience of childhood traumas were associated with experiencing physical IPV and emotional IPV, but not emotional IPV only. The importance of childhood traumas in shaping IPV experience is recognised in a variety of contexts . AfghaniNo markers of poverty were consistently associated with IPV. Food insecurity was only associated with emotional IPV in the multinomial model. There was no evidence that earnings had any association with IPV. This is in contrast to much research that suggests poverty is a driver of women’s experiences of IPV . There aThe family structure and dynamics were important for women’s experience of IPV. Women reporting more husband cruelty, were more likely to experience physical and emotional IPV. This reflects the importance of male power in shaping women’s experiences of IPV , 43, andWomen reporting their husband had more than one wife were more likely to experience emotional IPV, and physical and emotional IPV. Qualitative research suggests multiple wives living under one roof, may experience increased levels of competition between wives, around positioning in the household structure, and men may struggle to manage this dynamic, increasing conflict . In addiThe importance of findings about household structure and dynamics and its relationship to IPV, is it questions the narrow focus on dyadic models of IPV (i.e. violence between husband and wives). The assumption IPV is a dyadic phenomenon emerges from research in high-income countries, with a narrow interpretation of social relationships within the home. It does not recognise that in many households there are multiple generations and that gender and age hierarchies shape relationships, and power is contested between women, and not only between women and men.Community level inequitable gender attitudes were associated with emotional IPV, and physical and emotional IPV. Studies elsewhere have shown that community level attitudes to gender and acceptability of IPV have an independent impact on women’s experiences of IPV . InterveSeverity of disability was a ‘driver’ of physical and emotional IPV and a consequence in this study. Disabled women globally experience increased vulnerability to IPV, because of gender inequalities, disability stigma and discrimination, and increased economic dependency on partners and caregivers , 49, butThe analysis showed women’s experience of emotional IPV had an independent association with a range of health outcomes, particularly when it was severe (two or more episodes) emotional IPV. This supports the limited body of evidence that shows emotional IPV has an independent impact on women’s health, over and above physical IPV , 30. Desn = 17) women had only experienced physical IPV and not emotional IPV, and these women were excluded from analysis. As data are cross-sectional temporal associations between factors are unclear. Women self-selected into the study, and therefore this is not generalizable to the population-level.The study has limitations. Very few (We show a complex picture about the appropriate nature of interventions to prevent IPV in Afghanistan. In contrast to reviews showing the importance of economic empowerment interventions to reduce women’s experiences of IPV , 50, our


Intimate partner violence (IPV) has been increasingly recognised as a major public health and human rights problem that cuts across all populations, irrespective of social, economic, religious or cultural groups.The objectives of this study were to determine the prevalence, pattern and correlates of IPV among women attending the General Out Patient Clinic of Aminu Kano Teaching Hospital, Kano, Nigeria. It was also designed to determine the pattern of health complications associated with IPV as well as the perception of women on intimate partner violence.This was a cross-sectional, hospital-based study. Three hundred and ninety-three women aged 15–49 years who were in or had ever been in an intimate relationship were recruited. An interviewer-administered questionnaire was used to collect data about their socio-demographic characteristics while information on IPV was obtained using the Composite Abuse Scale. The data were analysed using the Statistical Package for Social Science (SPSS) version 16.0.χ2 = 24.726, p = 0.000) and pregnancy reduced the risk of IPV , while polygamous family setting  and an extended family type  were associated with an increased risk of IPV. Alcohol consumption by the partner  was found to be a positive correlate as well as a complication of IPV. Other patterns of health complications that were significantly associated with IPV were depression , miscarriage  and the presence of physical injuries in the participants . One hundred and fifty-nine (40.5%) of the participants agreed that a husband is justified for beating or hitting his wife and neglecting the child was the reason given by most of the participants (26.7%) to justify IPV.The prevalence of IPV within the previous year was 42.0%. Of all the 393 participants recruited in the study, 46.6% had experienced emotional/psychological violence, harassment/controlling behaviour was present in 43.3%, physical violence was reported in 29.0%, sexual violence was present in 21.9% and 37.9% of the participants had experienced severe combined abuse. Being married (The high prevalence of IPV among women of reproductive age in this study shows that it is an important problem that women would rather not talk about or have accepted as a norm. It is associated with poor physical and mental health of women who are victims.It is therefore recommended that physicians routinely screen for IPV especially in patients with depressive symptoms, miscarriage and physical injuries. Screening will be a safe and cost-effective means for identifying women experiencing IPV, leading to appropriate interventions that will decrease further exposure to IPV and its adverse health consequences. Intimate partners may be cohabiting, but need not be.2 Violence against women is the most pervasive and yet under-recognised human rights violation in the world. It is also a profound health problem that saps women’s energy, compromises their physical and mental health, erodes their self-esteem and prevents them from achieving their full potential.3Intimate partner violence (IPV) has been defined as behaviours within an intimate relationship that cause physical, psychological or sexual harm to those in the relationship, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours.4 A cross-sectional study by Zungu et al. 2010 on IPV among women attending a public hospital in Botswana showed the lifetime and past-year prevalence of IPV to be 49.7% and 21.2% respectively.5In 48 population-based surveys from around the world, between 10% and 69% of women reported being physically assaulted by an intimate male partner at some point in their lives, and that 15% – 30% had been assaulted in the previous year.6 the northern part of the country, reported a prevalence of 31.8% among pregnant women, while Iliyasu et al. in Kano found a prevalence of 58.8% among female university students in Northern Nigeria.7 In a cross-sectional study carried out among a sample of women attending a primary health centre in Ile-Ife, south-western Nigeria, the prevalence of IPV in the previous 12 months was found to be 36.7%.8 A similar study on IPV among women of childbearing age in a primary health care centre in eastern Nigeria, reported a prevalence of 46.3% for the previous 12 months.9In Nigeria, studies on the prevalence of IPV have reported a wide range of values. A cross-sectional study by Envuladu et al. in Jos,1IPV is not simply a matter of family privacy, individual choice or inevitable facet of life. It is a complex problem related to patterns of thought and behaviour that are shaped by a multitude of forces within families and communities.10 There is a paucity of data on the pattern and extent of IPV in the region.In Nigeria, some women justify domestic violence perpetrated by husbands depending on the situation. In the 2003 Nigerian Demographic Health Survey, 64.5% of women and 61.3% of men were reported to support wife beating in at least one of the six scenarios described in the survey.This was a cross-sectional, descriptive, hospital-based study carried out between 1st August and 30th September, 2015, at the General Out-Patient Clinic (GOPC) of the Family Medicine Department of Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. The aim and objectives of the study were read to eligible participants, whence a voluntary, written informed consent was obtained from each participant.The study population consisted of all women aged 15–49 years who were in or had ever been in an intimate relationship, presenting to the GOPC of AKTH.8Through a systematic, random sampling 393 women were recruited for this study.11Sample size was calculated using the formula:n = Z2 p q /d2        [Eqn 1]n = the desired minimum sample size (when population is greater than 10 000), Z = the standard normal deviation, set at 1.96 which corresponds to 95% confidence interval, p = prevalence of IPV among women attending a primary health centre in Ile-Ife = 36.7%,8q = 1 – p = 0.633, d = level of precision usually set at 5% = 0.05.where n = (1.96)2 × 0.367 × 0.633/(0.05)2 = (1.96)2 × 0.2323/0.0025 = 0.8924/0.0025 = 356.96 ≈ 357 participants.Therefore, Ten per cent of the calculated minimum sample size (36 women) was added to account for attrition, missing or incomplete data. Thus, the number of women to be recruited for this study will be 357 + 36 = 393 participants.Participants were included if they consented and were aged 15–49 years, currently married, divorced, or involved in an intimate relationship. Women with known psychiatric illness were excluded because their concentration, memory and judgement could be impaired.12 The CAS consists of 30 items presented in a six-point format requiring respondents to answer ‘never’, ‘only once’, ‘several times’, ‘monthly’, ‘weekly’ or ‘daily’ in a 12-month period. A preliminary cut-off score of 7 divides respondents into abused and non-abused. Preliminary recommended cut-off scores for the individual subscales are as follows: Physical Abuse (I), Emotional Abuse (3), Harassment (2), Sexual abuse (1) and Severe Combined Abuse (I). Information on the perception of women on IPV was assessed using extracts from the 2003 Nigeria Demographic and Health Survey model questionnaire which has a number of questions about the perception of women on intimate partner violence.10 The Patient Health Questionnaire-2 (PHQ-2) was used to screen for depression among the respondents.A pre-tested, structured questionnaire was administered by the investigator to eligible women after obtaining informed consent from individual participants. Information on IPV was obtained using the Composite Abuse Scale (CAS).p-value of less than or equal to 0.05 was considered statistically significant.All data collected were analysed using Statistical Package for Social Science (SPSS) version 16.0 software. The Chi square test was used to assess the associations of demographic variables with type of violence. Logistic regression analysis was used to assess the correlates of intimate partner violence. A Ethical clearance for this study was sought and obtained from the Research Ethics Committee of AKTH, Kano, Nigeria.The age range of the study participants was between 16 and 45 years. The mean age was 27 (SD ± 6.29) years and the modal age group was 25–34 years (47.3%).Other socio-demographic characteristics of the study participants are as shown in Of all the respondents, 165 (42.0%) had experienced a form of violence in the preceding 12 months while 228 (58.0%) had not experienced IPV in any form.Harassment/controlling behaviour was the most common form of violence experienced by 71 (43.3%) of the participants. Forty-eight (29.0%) had experienced physical violence, 36 (21.9%) had experienced sexual violence while 10 (5.8%) had experienced emotional/psychological violence. Sixty-three (38.2%) participants had experienced severe combined abuse.χ2 = 3.693, p = 0.254), ethnicity , religion , occupation  and level of education  were not significantly associated with IPV. However, the correlates found to be significantly associated with IPV on bivariate analysis were:The age of the participants . Being married reduced the risk of IPV while divorced women were more likely to have experienced IPV.Marital status: IPV was significantly associated with marital status . However, on further analysis, there was no significant independent association .Pregnancy status: There was an association between pregnancy status and IPV on bivariate analysis .Type of family setting: The polygamous family setting was associated with increased risk of IPV .Type of family: Extended family setting was associated with increased risk of IPV .Physical injury: There was an increased risk of sustaining physical injury following assault from an intimate partner. This association was found to be statistically significant . Women were at an increased risk of having a miscarriage following assault from their partners.Miscarriage: Miscarriage was significantly associated with IPV .Substance use by the respondents: There was an association between the increased use of substances such as sleeping pills and IPV .Alcohol use by the partner: Alcohol consumption by the partner was significantly associated with IPV .Depression: IPV was significantly associated with depression in women . Being overweight or obese increased the risk of IPV.Body mass index: Overweight and obesity were associated with IPV .Blood pressure: IPV is significantly associated with the development of hypertension in women  of the participants agreed that a husband is justified for beating or hitting his wife for at least one of the reasons asked. Neglecting the child was the reason given by most of the participants, 105 (26.7%), to justify wife beating while cooking meals late was the reason given by the least, 40 (10.2%), participants to justify wife beating. Two hundred and thirty-four (59.5%) of the participants did not think IPV was justified for any reason. The perception of participants on IPV is summarised in Health professionals are often the earliest point of contact for survivors of violence. Family physicians, through effective case management, co-ordinated and continuing care, can alleviate some of the negative effects of partner violence on women suffering in silence. In addition, through publications of research findings, family physicians can create awareness of the burden of the problem and as such promote advocacy for women empowerment.1 It is also similar to the prevalence of 45.6% in Africa.3 In Nigeria, a similar prevalence of 46.3% was reported by Ilika and colleagues in a clinic-based study among the Igbo community in Neni, Anambra State.9 Okenwa and colleagues reported a prevalence of 29% among women of childbearing age in Lagos, South west of Nigeria.13 The lower prevalence in their study could be due to the differences in methodology and the socio-cultural characteristics of the study populations. The prevalence of IPV reported in this study could still be underestimated because of beliefs that issues concerning families and intimate relationships should not be discussed as it is seen as a ‘private matter’.14The prevalence of IPV within the previous year in this study was 42.0% which is within the range of global estimates of IPV prevalence of between 20% and 50%.The present study measured four different patterns of IPV among all the participants (393) involved in the study.15 It is fairly higher than the reports of physical violence from Eastern Nigeria by Ilika et al. in Anambra State (15.8%) and Okemgbo et al. in Imo State (20.1%).16 These differences could be due to differences in cultural characteristics of the study populations. Northern Nigeria has a distinct culture and tradition of female seclusion (‘Purdah’), practice of polygamy, forced marriages and desire for large families. In the Igbo tribe, it is culturally unacceptable to beat a pregnant or lactating mother.14 Based on comparison on studies about the association between pregnancy and IPV across the world, many studies reported that the association remains uncertain whether, in fact, the risk of IPV initiation or escalation increases, decreases or remains the same as a result of pregnancy. The reason that was advanced was that studies that examined the risk of IPV during pregnancy did not examine the patterns of IPV around the period of pregnancy through comparisons of IPV prevalence rates in the pre-pregnancy, pregnancy and post-pregnancy periods.18 IPV against women before pregnancy was a strong risk factor for abuse during pregnancy and after delivery, and abuse during a previous period was a strong indicator of subsequent abuse.18Physical violence: In the present study, 29.0% of the 393 participants experienced physical violence from their intimate partners. The result from this study is comparable with reports of physical violence by Iliyasu et al. in Kano (27.5%), and Gyuse and Ushie in Jos (26.5%).19 Although psychological violence was found to be the most prevalent form of IPV in the present study, it is still much higher than the 23.0% reported in a study by Okenwa and colleagues among women of childbearing age in Lagos, Nigeria, in which psychological violence was also the commonest form of IPV.13 Zungu et al. admitted the difficulty in measurement of psychological IPV due to diversity in cultures.5Emotional/psychological violence: In this study, 46.6% of the 393 participants experienced emotional violence which is comparable to the prevalence of 47.5% reported by Al-Nsour in Jordan and 50.8% reported by Iliyasu et al. among female university students in northern Nigeria.20 This wide range suggests a variation in the degree to which such behaviour is normative or acceptable in different cultures.Controlling behaviour/harassment: In this study, 43.3% of the 393 participants experienced controlling behaviour from their intimate partners. A study by Adebayo et al., in Lagos, Nigeria, found a higher prevalence (71.9%) among their study participants.1 The result is also consistent with prevalence rates reported in Imo state (21.3%), Kano (22.2%) and Lagos (21.0%).22 The prevalence in this study is higher than the prevalence reported from a study in Jos (10.7%), which was conducted among an obstetric population.15Sexual violence: In this study, 21.9% of the 393 participants experienced sexual violence which is within the range of 10% and 50% reported from the WHO Multicountry study.4 This may also be due to the patriarchal nature of Nigerian ethnic groups and religions.The differences in age, religion, ethnicity and educational level were not statistically significant in the present study. This may be related to the fact that IPV cuts across age, class, race, ethnicity, religion and national boundries.14 Another respondent in a focused group discussion by Odimegwu et al. among the Tiv in Nigeria was of the opinion that ‘if you are not yet beaten by your husband, then you do not know the joy of marriage and that means you are not yet married’.21 Thus, the perception of women to justify wife beating varies according to cultural norms and personal attributes, which suggests that designing an effective intervention to eliminate violence against women would require culturally acceptable programmes.This study revealed that a high percentage of the participants (40.5%) agreed that a husband is justified for hitting or beating his wife under the conditions examined in this study. The high level of support expressed for wife beating in this study confirms that violence against women is accepted as a cultural norm. A respondent from a focused group discussion by Ilika et al. among Igbo women of Ozubulu community in Anambra State was of the view that ‘a woman deserves beating if she talked back on her husband, refused him sex, presented a poorly cooked food, or late meal, and failed to care for the children’.This study revealed a high percentage (67.9%) of the victims of IPV sustained physical injuries such as bruises, red eyes, lacerations, etc, following assault from their partner. This is an expected finding given the high prevalence of IPV found in this study.4 IPV is an established risk factor for depression and depression has also been described as a health consequence of IPV.1 Thus, IPV can be conceptualised as a risk factor, correlate or outcome of substance use and depression. IPV being a significant cause of psychiatric illness in women, its exclusion in this study would tend to underestimate the prevalence that was reported. However, women with known psychiatric illness were excluded because their concentration, memory and judgement could be impaired, thus information obtained cannot be relied upon. Its exclusion is a limitation for this study.This study has found a significant positive association between IPV, depression and substance use among the victims of abuse. This finding is consistent with reports from similar studies within and outside Nigeria.This study found that women are at an increased risk of having a miscarriage following assault from their partners . This finding is consistent with the reports from the studies that showed that women with a history of physical or sexual abuse are also at an increased risk for unintended pregnancies, sexually transmitted diseases and miscarriages.1,The high prevalence of IPV among women of reproductive age in this study shows that it is an important problem that women would rather not talk about or have accepted as a norm. It is associated with poor physical and mental health of women who are victims.This study provides insight for policy makers, physicians and researchers who are attempting to tackle the global issue of IPV.It is therefore recommended that physicians routinely screen for IPV especially in patients with depressive symptoms, non-specific complaints, miscarriage and physical injuries on the face, trunk and upper limbs. Screening will be a safe and cost-effective means for identifying women experiencing IPV, leading to appropriate interventions that will decrease further exposure to IPV and its adverse health consequences.


Intimate partner violence (IPV) is a significant public health issue among married rural-to-urban migrant workers, the largest group of internal migrants in China. This study aims to explore the prevalence, patterns and associated factors of intimate partner violence against married rural-to-urban migrant workers in eastern China.A cross-sectional study was conducted in Zhejiang province in China between July 2015 and April 2016, and a total of 1,744 married rural-to-urban migrant workers ultimately took part in the study. Conflict Tactics Scales and several short demographic questions were applied. Data were principally analyzed with logistic regression.The majority of married rural-to-urban migrant workers were middle-aged couples with a low education level and a relatively long-term duration of migration in fixed migrant cities. Nearly 45% of married rural-to-urban migrant workers were experienced at least one incident of intimate partner violence during the past 12 months. The joint occurrence of multiple forms of violence is the most commonly reported features of intimate partner violence, especially three overlapping patterns of intimate partner violence. Some individual (education and age), relationship  and social (duration of migration and number of migratory cities) factors of the respondents, were negatively or positively associated with intimate partner violence against married rural-to-urban migrant workers.The results indicated that one out of two married rural-to-urban migrant workers experienced at least one incident of intimate partner violence during the past 12 months in China. Accordingly, there is an obvious demand of intervention and treatment activities to prevent and reduce the occurrence of intimate partner violence among the millions of migrant workers in China.The online version of this article (doi:10.1186/s12889-016-3896-x) contains supplementary material, which is available to authorized users. Intimate partner violence (IPV) is a serious and widespread problem worldwide. It is a domestic violence by a spouse or partner in an intimate relationship against the other spouse or partner , and theIPV has been shown to be the most common type of violence against married couples, especially among women groups. For example, a study, based on 48 population-based surveys from developing and developed countries and conducted by World Health Organization (WHO) in 2002, found that 13–61% of women in countries across the world reported having experienced IPV from their partners . AnotherMeanwhile, IPV affects physical health and mental health of IPV survivors and their families adversely through direct pathways, such as injury, humiliation and isolation, and indirect pathways, such as family function, attachment, marital satisfaction and other factors –13. A hiThese research not only have significantly advanced current knowledge concerning IPV among different groups, but also have motivated new important research questions. For instance, rural-to-urban migrant workers in china are now experiencing the largest mass migration of people from the countryside to the city in history . MigratiThe present study, based on those existing studies, aims to further explore IPV among married rural-to-urban migrant workers with making the following three specific efforts.First, we have chosen married rural-to-urban migrant workers as our subjects. In China, rural-to-urban migrant workers are a special group formed by Chinese peasants in the process of social transformation during the course of urbanization. They refer to farmers who move from rural to urban areas within China in pursuit of employment and better living standards, without no permanent urban residency (“hukou”). According to the National Bureau of Statistics, it was estimated that there were 277 million rural-to-urban migrant workers in 2015, accounting for about 20% of the total population. Among them, an estimated 203 million were married , 21, 22.Second, we focus on the prevalence and pattern of IPV among married rural-to-urban migrant workers. In China, the issue of IPV has received limited attention until the Fourth World Conference on Women (1995) was hosted in Beijing. In the past two decades, the relevant studies on IPV in China have mainly been conducted on theoretical mechanism of IPV. The first empirical and wide-scale study on IPV in china was carried out in 2000. It was found that 34.7% of 3,543 investigated women admitted that they had experienced physical, psychological or sexual violence . The folThird, according to the ecological model theory of violence, the causes of IPV are diverse and there is no single factor that explains further why some individuals are violent. Rather, violence is a result of individual, relationship and societal factors . TherefoThe aims of the present paper were to (1) examine prevalence and pattern of IPV among married rural-to-urban migrant workers in Eastern China and (2) identify the risk and protective factors for IPV at three levels: individual, relationship and societal level.In this study, rural-to-urban migrant workers were defined as those who were 18 years of age or older, possess a legal rural hukou , and have been granted the legal right to work temporarily in urban and prosperous coastal regions for at least six months . MigrantA cross-sectional study was conducted in Zhejiang province in China between July 2015 and April 2016, and a total of 1,744 married rural-to-urban migrant workers ultimately took part in the study. The final eligible participants were identified by the multistage probability sampling method as follows.In stage 1, four cities, Hangzhou, Ningbo, Wenzhou and Jinghua, were selected from Zhejiang Province in China, respectively. We chose these four cities of Zhejiang Province as our study cites since Zhejiang was one of the most economically developed provinces in China’s four economical zones with a migrant population of estimated 14 million in 2015, accounting for around one-thirds of the province’s population. Meanwhile, more than two-thirds of rural-to-urban migrant workers in this area are currently in Hangzhou, Ningbo, Wenzhou and Jinghua. In stage 2, three districts in each of the four study cities were randomly selected, and these districts represented the inner-city, suburban and urban fringe zone. In stage 3, two residential sub-districts with a high density of rural–urban migrants in each of the three studies districts were randomly selected. In stage 4, a quota-sampling procedure based on six occupational clusters was applied to ensure that the sample was representative of the migrant worker population in Zhejiang. According to the figures released by the National Bureau of Statistics of China in 2015, in Zhejiang, the proportions of migrant workers in six occupational clusters, manufacturing, wholesale and retail, construction, domestic service, transportation, and hotels and restaurants, were approximately 45, 13, 11, 9, 6, and 4%, respectively [Hence, 1,864 married rural-to-urban migrant workers were eligible for the study and consent with the study procedures, and then1,744 made valid replies, yielding a response rate of 93.56%. Details of socio-demographic characteristics of the sample are displayed in Table The present study consisted of the following two-steps procedure. First, in the pilot study, the pre-test was conducted with a convenience sample of 50 married rural-to-urban migrant workers from the target population to evaluate clarity, comprehensiveness, and acceptability of questionnaires. Some amendments were made prior to the initial delivering. Secondly, in the formal study, after fully understanding the purpose and the procedure of the study, the eligible participants signed the informed consent. With their agreement, one envelope with the questionnaire and instructions was handed to every participant. The instructions told them how to fill in the questionnaire. Participants filled out the 20-minute questionnaires in quiet and comfortable reading rooms in factory (one to six participants at one time), then placed the completed questionnaire inside an envelope and gave it back to the researchers. Third, at the end of the survey, each of participants received a leaflet detailing local support services or network counseling service for domestic violence, sexual abuse and other mental health problems. Fourth, upon completion, everyone was given a towel, a tooth brush and a tooth paste as a token of appreciation. The questionnaires were administered by trained researchers, including faculty members and postgraduate students from Wenzhou Medical University, who had been provided systematic training before formal study. The questionnaires were anonymous and all participants took part in the study voluntarily.This study was done in compliance with the Helsinki Declaration, and was reviewed and approved by the Ethics Committee of Wenzhou Medical University.A socio-demographic questionnaire consisted of three parts. The first part is the individual-level information including age, gender, education, region of origin (north vs. south), monthly income and other basic demographic information. The second part is the relationship-level information. In this study, relationship-level information focuses on marital information including marital status, lifestyle with your spouse (living together vs. living in separate places), marital satisfaction, premarital sex (yes vs. no) and extramarital affairs (yes vs. no). The third part is societal-level information. In this study, societal-level information focuses on migratory information including duration of migration and number of migratory cities.Intimate partner violence was measured by the Chinese version of short form of the revised Conflict Tactics Scales CTS2) , 30 . Firstly, psychological IPV was assessed by psychological aggression subscale of the Chinese version of short form CTS2. Specifically, the self-reported frequency of psychological abuse from the other spouse in the past year was recorded. Examples of psychological IPV include: insulted, swore, shouted, yelled by spouse and made me feel bad about myself; destroyed belongings or threatens to hit. The psychological IPV subscale consists of four items with high degree of internal consistency reliability among the Chinese participants (Cronbach’s α = 0.72) .Secondly, physical IPV was assessed by physical assault subscale of the Chinese version of short form CTS2. Specifically, the self-reported frequency of physical assault from the other spouse in the past year was recorded. Examples of physical IPV include: pushed, shoved, slapped, punched, kicked and beatin of the spouse. The physical assault subscale consists of four items with good degree of internal consistency reliability among the Chinese participants (Cronbach’s α = 0.88) .Thirdly, sexual IPV was assessed by sexual coercion subscale of the Chinese version of short form CTS2. Specifically, the self-reported frequency of intimate partner’s sexual coercion from the other spouse in the past year was recorded. Examples of sexual IPV include: physically forced to have sex; did not want to have sex or forced to have sex without a condom. The sexual coercion subscale consists of four items with good degree of internal consistency reliability among the Chinese participants (Cronbach’s α = 0.93) .P-values are 2-tailed with statistical significance set at 0.05.First of all, socio-demographic characteristics of the sample were described by the number and the percentage of each category for categorical variables. Secondly, we calculated prevalence estimates, frequency and overlap in different forms of IPV among married migrant workers in the past 12 months. Thirdly, multivariate binary logistic regression analysis was used to determine the risk factors for IPV of married migrant workers, and crude odds ratios and adjusted odds ratios (OR) and 95% confidence intervals (CIs) for OR were calculated. In logistic regression modeling, overall IPV, psychological IPV, physical IPV, and sexual IPV were considered as the dependent variables respectively, and the demographic characteristics of the married migrant workers including individual level determinants , marital determinants  and migratory determinants (duration of migration and number of migratory cities) were considered as the independent variables. All statistical analyses were performed with the use of SPSS statistics package (version 18.0) and all reported Of the 1,744 participants, 875 (50.1%) were male and 871 (49.9%) were female. The participants’ age ranged from 19 to 61 years old (37.74 ± 9.01 years). 45.9% of migrant workers could be classified as “second-generation” migrants. Their duration of marriage ranged from 1 to 45 years (13.15 ± 9.70 years). Over a half of the married migrant workers only had a junior high school education or below, and the average time in schooling was 9.29 ± 2.62 years. Regarding monthly income, the average monthly income of the participants was 3883 RMB (approximately US$596). Only 10.3% of the participants earned less than 2500 Yuan , nearly half (48.5%) earned 2501–3500 Yuan (RMB), and 41.2% earned more than 3500 Yuan (RMB). The average duration of migration was 12.66 ± 6.89 years, and almost 60.5% of the participants reported having migrated to only one or two cities, while 8.1% reported having been migrated to more than five cities. In terms of marital status, 1633 participants (93.6%) were first married and 111 were remarried (6.4%). The majority of participants were satisfied with their marriage (79.4%) and living with their spouse together every day (78.2%). It is worth mentioning that nearly 32.8% of the participants reported having sexual intercourse before marriage and 7.9% reported having an affair after marriage. The general demographic, migration and marital characteristics of the married migrant workers are summarized in Table Table The different forms of IPV and their overlapping are shown in the Venn diagrams in Fig. In the regression model of overall IPV, as shown in Table In the regression model of psychological IPV, as shown in Table In the regression model of physical IPV, as shown in Table In the regression model of sexual IPV, as shown in Table This study estimated the prevalence, frequency and patterns of different types of IPV in a large sample of typical Chinese married rural-to-urban migrant workers, and identified the risk and protective factors for IPV at three levels: individual, relationship and societal level.The first finding of the study is that as high as 45% of married rural-to-urban migrant workers experienced at least one act of physical, psychological or sexual IPV during the past 12 months. The incidence rate of IPV in this study is within the estimated range of IPV but is much higher than the findings of other Asian studies, including studies from other parts of China –33. For The second important finding of the study is that among these domestic violence victims, over a half of them experienced multiple forms of violence from their intimate partners, especially three overlapping patterns of IPV. These findings are in line with most of previous studies , 35, 36.The third important finding of the study is that some individual, relationship and societal factors are significantly associated with an increased or decreased likelihood of intimate partner violence against married rural-to-urban migrant workers.At the individual level, the high level of education for the subjects was identified as a protective factor of IPV, especially physical IPV. Meanwhile, low level of education is the most consistent factor associated with both the perpetration and experiencing of overall IPV and physical violence across studies –40. For Furthermore, compared to the first-generation rural-to-urban migrant workers, the second-generation rural-to-urban migrant workers are less likely to report current experience of overall IPV, especially psychological violence. This finding is inconsistent with results of previous studies which always identified young age to be a risk factor for intimate partner violence , 41, 42.At the relationship level, low level of marital satisfaction was identified as a significant risk factor of IPV, especially psychological and physical IPV. In this study, respondents who reported dissatisfaction with their marriages were more than five times as likely to experience IPV as respondents who expressed satisfaction. Our findings are in line with previous research that individuals dissatisfied with their marriage are more likely to be involved in psychologically or physically abusive relationships than those individuals satisfied with their marriage , 44. ThiIn particular, premarital sex and extramarital affairs were two of the most consistent markers of IPV. On the one hand, premarital sex was considered a moral issue which was still taboo in traditional Chinese culture and typically unacceptable by the old generation. Hence, premarital sex usually enable an individual to suffer from poor self-image, low self esteem, feelings of embarrassment, humiliation and other risk factors contributing to violence in the family. On the other hand, extramarital affairs also are a strong risk factor of IPV. This is consistent with findings from other studies elsewhere –48. InfiAt the societal level, duration of migration acted as a protective factor for IPV, especially physical IPV and sexual IPV. Specifically, long-term migrant workers are less likely to have experience of physical IPV and sexual IPV than short-term ones. It is possibly explained that migration from rural to urban areas is the process of urbanization which create great opportunities for migrant workers to get good education and improve their living standards. Furthermore, their traditional social norms supportive of violence may be transferred through urbanization processes. On the contrary, the increasing number of migratory cities appears to be a risk factor for being a victim of physical IPV. In this study, compared to respondents migrating to one or two cities, those migrating above five cities were about twice more likely to report physical IPV. It is clear that frequent moves could increase the likelihood of unstable living situations, and several studies have demonstrated that housing instability was a significant predictor of domestic violence , 50. As We should acknowledge some limitations in our study. First and foremost, our study was based on cross-sectional design, which is not possible to get a valid cause-and-effect relation between intimate partner violence and the associated factors. To clarify the causality, we need longitudinal data or panel data for further research. Secondly, we only examine prevalence of intimate partner violence in past 12 months without including the prevalence of lifetime IPV, which may limit the generalizability of the findings to the target population. Third, information on experiences with IPV is very sensitive and private. In our study, data were self-reported in nature and respondents may be too embarrassed to reveal private details, which may be subject to reporting bias. Future studies should consider triangulating self-reports with clinical records, and health and social services records. Fourth, some relevant potential factors that are important to the IPV research were not included, such as participant’s drug use, alcohol, smoking, poverty, having children, being pregnant and different types of marriage. The investigation of these factors could be key directions for future research. Additionally, the use of the Conflict Tactics Scale to measure the psychological IPV, physical IPV and sexual IPV also limits the findings. Although the CTS scale has been widely used in a large number of studies on IPV, there have been several criticisms regarding this scale . For insThe present study has several strengths. First, the sample size was large enough to allow more reliable results with greater precision and power. In addition, interviewers and supervisors received systematic training and have past experiences of data collection; hence it was found a high response and prevalence rate of the study. Second, to our knowledge, this study is the first estimation of the prevalence, frequency and patterns of different types of IPV in a large sample of typical Chinese married rural-to-urban migrant workers. Thirdly, our study is one of the first studies to identify the risk and protective factors for IPV against migrant workers based on the ecological model . It might offer a framework for understanding the associated factors that influence IPV, and can therefore provide key points for prevention and intervention of IPV among married rural-to-urban migrant workers.In conclusion, this study provides empirical evidence for the prevalence of different types of IPV against married migrant workers. Nearly half of married migrant workers experienced at least one incident of IPV during the past 12 months. Moreover psychological IPV was the most prevalent type of violence married rural-to-urban migrant workers experienced. Alarmingly, the joint occurrence of multiple forms of violence is the most commonly reported features of IPV, especially three overlapping patterns of IPV. Some individual (education and age), relationship  and social (duration of migration and number of migratory cities) factors of the respondents, were negatively or positively associated with IPV in the study area.Given the massive number of married migrants in China, the domestic violence against them should receive urgent attention at all levels of societal organization including policymakers, stakeholders, professionals and other concerned body. Furthermore, despite limited resources, the screening, treatment, and intervention programs targeting IPV and its risk factors should be developed to identify, prevent, and reduce the occurrence and reoccurrence of IPV among the millions of migrant workers in China. Moreover, extensive and longitudinal research is needed to validate the current findings