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) around the time of pregnancy is a serious public health concern and is known to have an adverse effect on perinatal mental health. In order to craft appropriate and effective interventions, it is important to understand how the association between IPV and postpartum depression (PPD) may differ as a function of the type and timing of IPV victimization. Here we evaluate the influence of physical, sexual and psychological IPV before, during and after pregnancy on PPD.Cross-sectional survey data was collected between October 2015 and January 2016 in the Chandpur District of Bangladesh from 426 new mothers, aged 15–49 years, who were in the first six months postpartum. Multivariate logistic regression models were used to estimate the association between IPV and PPD, adjusted for socio-demographic, reproductive and psychosocial confounding factors.Approximately 35.2% of women experienced PPD within the first six months following childbirth. Controlling for confounders, the odds of PPD was significantly greater among women who reported exposure to physical , sexual  or psychological  IPV during pregnancy as opposed to those who did not. However, both before and after pregnancy, only physical IPV evidences a direct effect on PPD. Results highlight the mental health consequences of IPV for women of Bangladesh, as well as the influence of timing and type of IPV on PPD outcomes.The findings confirm that exposure to IPV significantly increases the odds of PPD. The association is particularly strong for physical IPV during all periods and psychological IPV during pregnancy. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV who may at risk for PPD and to offer them necessary support. Culturally, pregnancy is often viewed as a time of happiness and expectancy in women’s lives, with the welcoming of the next generation and growing anticipation of the joys a new child will bring to the family. At the same time, pregnancy can also be a stressful and anxiety-provoking life event , and manPPD has been recognized as a significant global public health concern due to its profound health consequences for both mothers and their families , 11. PPDIPV includes acts of physical, sexual and psychological coercion along with controlling behaviors against women by a current or former intimate partner , 31. OneAlthough our understanding regarding the links between IPV and PPD is progressing, notable gaps remain. Until recently the majority of research has focussed primarily on physical IPV , 48, andWhilst the literature on IPV in Southeast Asia is growing, it still remains limited and there are few scholarships examining the association between IPV and PPD for women of Bangladesh. To help build this important knowledge base, we assess how the association between IPV and PPD changes as a function of the type and timing of IPV in a population-based sample of new mothers in Bangladesh. The aim of this study is to examine whether:1) recent exposure (occurred after childbirth) to physical, psychological and sexual IPV is associated with PPD in the first six months after childbirth; and 2) prior exposure (occurred before and during pregnancy) to physical, psychological and sexual IPV is also associated with PPD. Understanding the association between PPD outcomes and exposure to different forms of IPV during different periods has clinical implications regarding early detection and targeted preventative measures around the time of pregnancy to support at-risk women.A cross-sectional survey was conducted from October 2015 to January 2016 in two sub-districts of the Chandpur district of Bangladesh. New mothers who visited vaccination centers to receive their baby’s vaccinations were the target population. Married women between 15–49 years of age currently living with their husbands for the last two years, and who had at least one child aged six months or younger were eligible for the study. These criteria were used to determine the women’s experience of IPV from their current husband. A multistage random sampling method was adopted to identify vaccination centers from which to draw 426 estimated subjects. Interviewers approached 453 postpartum mothers to reach the desired sample size, yielding a response rate of 94%.The data collection procedure has been described in detail previously in , 51. FacParticipation was entirely voluntary and confidential and did not affect receiving health care in any way. Women who reported an experience of IPV were offered primary counselling services and referrals to local social and psychological services. Women who scored ≥10 on the EPDS were referred to the nearby district hospital for adequate follow-up . The intEthical approval was received for scientific and ethical integrity from the National research ethics committee of Bangladesh Medical Research Council (BMRC/NREC/2013-2016/305) and Griffith University Human Research Ethics Committee (CCJ/41/14/HREC) before conducting the study. The study was also conducted following the WHO guidelines on ethical issues for violence research . InterviThe main outcome of the present study was postpartum depression assessed by using the Bangla version of the Edinburgh Postpartum Depression Scale (EPDS) . The EPDEach participant was asked if she had experienced any of these symptoms during pregnancy or before, referred to herein as previous depressive symptoms (categorized as: no = 0 and yes = 1).Women’s experience of IPV before, during and after pregnancy was the main research interest, and for the purpose of the study ‘intimate partner’ refers to the respondent’s current spouse. The study collected information on IPV experienced by women before, during and after pregnancy using the domestic violence module from the WHO’s Demographic Health Survey Questionnaire. The domestic violence module used in the WHO study was validated for use in Bangladesh and some other countries . A positA woman was coded as having experienced sexual violence by an intimate partner if she reported having been physically forced to have sexual intercourse; having intercourse out of fear, or being forced to perform other sexual acts that she found degrading or humiliating. Psychological IPV was measured by at least one affirmative response to questions asking whether or not the respondent’s husband had insulted her or made her feel bad about herself; humiliated her in front of others; threatened to hurt her or someone close to her; isolated her from friends and family; denied her access to money or other basic resources; or threatened to divorce her. The Cronbach’s alphas for physical, sexual and psychological IPV scale in this study were 0.78, 0.47 and 0.75, respectively.Each participant was asked if she had experienced any of these indicators of IPV during the first six months after birth of her last baby, during her pregnancy, and during the 12 months prior to pregnancy, referred to herein as ‘IPV after pregnancy’, ‘IPV during pregnancy’ and ‘IPV before pregnancy’, respectively. Physical, sexual and psychological IPV before, during and after pregnancy were coded as no (= 0) and yes (= 1).Several socio-demographic variables that have been theoretically and empirically associated with IPV and PPD , 57–62 wObstetric and reproductive characteristics such as pregnancy intention , parity , number of children under five years of age , complications during childbirth , mode of birth , a husband’s preference for a son  and timing of breastfeeding initiation  were taken into consideration. Regarding psycho-socio-cultural characteristics, to ascertain the relationship with their mother-in-law, women were asked to evaluate their relationship with their mother-in-law providing a score from 1 to 9, where higher score indicates a more positive relationship  = 1, good (7–9 points) = 2).We control for social support given its protective impacts on mental health in general and PPD in particular , 50, 63.Stress can increase the odds of PPD , 67, so High self-esteem can also protect against PPD . To contWomen with more controlling husbands are at risk for both IPV and PPD, an influence we control with a scale comprised of the following items: (a) husband tries to keep her from seeing friends; (b) tries to restrict contact with her family of birth; (c) insists on knowing where she is at all times; (d) does not trust her with any money; (e) gets angry if she speaks to another man; (f) is often suspicious that she is unfaithful; and (g) expects her to ask permission before seeking health care for herself. The responses to these variables are dichotomous (0 = no and 1 = yes). Based on the total scores, women with scores in the bottom third percentile were classified as having husbands who were less controlling (= 0), those with scores in the middle third percentile as having moderately controlling husbands (= 1), and those in the top third as having husbands who were highly controlling (= 2). The controlling behaviors scale was validated for use in Bangladesh and some other countries . The CroWomen who experience a higher degree of autonomy are less likely to report IPV or PPD . We contSPSS version 22.0 for Windows  was used for coding and analyzing the data. We calculated descriptive statistics for mother’s postpartum depressive symptoms, and exposure to IPV as well as all of our control variables. Our analysis proceeded in two stages. First, we conducted a series of cross-tabulations to assess the bivariate relationships between PPD and the relevant covariates and controls and report chi-squares as our measure of significance. A two-tail p-value of <.05 was set to refer the level of statistical significance for all analyses. We then proceeded to a series of multivariate models that allow us to assess the strength of any association between IPV and PPD, controlling for a range of other known influences. These models employed multivariate logistic regression to estimate adjusted odds ratios (AOR) and 95% confidence intervals to compare the strength of the associations between each of the covariates and PPD. To assess the influence of IPV after childbirths on the odds of PPD, we ran four adjusted multivariate logistic regression models—one for each type of IPV after childbirth to assess the separate effects of different forms of IPV on PPD, and one full model for all types of IPV together with the control variables to examine the effects of each type of IPV, controlling for the other. Each model also included the control variables described above. A second set of adjusted multivariate logistic regression models examined the influence of IPV before and during pregnancy on PPD outcomes. Here we ran one model for all types of IPV victimization before pregnancy and another for all types of IPV victimization during pregnancy to examine whether past IPV victimization is associated with experiencing PPD. The multicollinearity of the variables was tested by auditing the variance inflation factors (VIFs), but there was no evidence that this was a problem (VIF’s<2.5).Approximately, a quarter of women (25.8%) had low decision-making autonomy and one-third of the women (29.6%) reported relationship difficulties with their mother-in-law. About, one in three (27.7%) women’s husband had high controlling behaviors and 26.8% of women reported a prior history of depressive symptoms. Approximately 57% of women had high perceived stress, 58.5% of women had low self-esteem and nearly one-third of the women (30%) had low social support.The prevalence of physical IPV during the 12 months before the pregnancy was 52.8%, while the comparative figure for during pregnancy and after childbirth was 35.2% and 32.2% respectively. The prevalence of psychological IPV before pregnancy was highest (67.4%) compared with that during pregnancy (65%) and after childbirth (60.8%). The rate of sexual IPV after childbirth was lower (15.5%) than that of before (21.1%) and during (18.5%) the pregnancy.Out of 426 participants, 150 had total EPDS scores of 10 or above, indicating the prevalence of PPD is 35.2%. We begin by describing the bivariate relationships between the forms and timing of IPV and PPD outcomes among new mothers. As expected, physical, sexual, and psychological IPV both during pregnancy and after childbirth were significantly associated with PPD among the women in this sample. When we examine IPV experiences prior to pregnancy, physical and psychological IPV increase the odds of PPD, but that is not the case for sexual IPV. Overall, 73.7% of women who experienced physical IPV, 56.1% of those experiencing sexual IPV and 52.9% of women experiencing psychological IPV after childbirth also reported PPD. Similarly, during pregnancy, approximately two-thirds of women who experienced physical IPV (66.7%) and sexual IPV (63.3%) and nearly half of the women (52.7%) who experienced psychological IPV also reported PPD. Prior to pregnancy, the corresponding figures were 60.4%, 41.1% and 49.4%, respectively who reported PPD. Moreover, approximately 57.4%, 79.2% and 71.8% of women who experienced all types of IPV before, during and after pregnancy respectively also reported PPD. Bivariate results see  also reiResults reported in As is evidenced in Similar to the influence of IPV victimization after childbirth, results reported in During pregnancy, the picture looks notably different. At this stage, physical, sexual and psychological IPV victimization were all found to be independent risk factors for experiencing PPD after adjusting for other control variables  highlighted that more research utilizing a longitudinal approach is warranted to examine how IPV victimization not only before and during pregnancy but also after childbirth may affect women’s mental health. Though our study is not longitudinal, it includes retrospective and time ordered measures of abuse, thus offering some insight into the longitudinal links between IPV and PPD. To our knowledge, this is the first study from South Asia, particularly from Bangladesh that specifically examined the association of IPV with postpartum depressive symptoms as a function of the type and timing of IPV occurrence. The strength of the study is the large sample size and the introduction of a large number of different socio-demographic, obstetric and reproductive, and psycho-socio-cultural factors. In addition, it is one of the few studies that included various types of IPV experienced at different time periods to explore the likelihood of experiencing PPD. Most importantly, by using internationally recognized scales and questionnaire for this study, the findings are internationally comparable. It is also important to acknowledge that the potential recall bias of the particular cohort of women in this study is greatly reduced because the mothers were surveyed within six months of the birth. Nevertheless, our findings should be interpreted while acknowledging several limitations to the study. Specifically, due to cross-sectional nature of this study, it is not possible to determine the exact temporal relationship between exposure to IPV and PPD. Neither, did we focus on the frequency of IPV over time. In addition, although we collected information on violence and depression before and during pregnancy and in the postpartum period, because the data are cross-sectional it is possible that women’s current depression and violence experiences influence their recollection of prior violence and depressive symptoms. However, regardless of the limitations, we do see changes in these experiences across the three periods, which would indicate that most women are able to disentangle their current state from previous ones and respond accordingly. It is also relevant that the data were collected from one district only, therefore, the findings may not be considered to be representative of the general population. Although a substantial number of predictors were adjusted in this study, some of the important variables were not controlled for, such as the health of the baby and difficult infant temperament. Finally, due to budget and time constraints, we were only able to collect data on exposure to IPV before, during and after pregnancy at a single period, instead of interviewing women at multiple periods. However, this study serves as a foundation for recommending future research on this important issue to explore how IPV victimization before, during and after pregnancy affects the health and well-being of the women of Bangladesh.The high prevalence rate of IPV and its association with postpartum depression reflect the importance of acknowledging both of them as a significant public health concern in Bangladesh. The strong association between IPV victimization around the time of pregnancy and the likelihood a mother will exhibit PPD symptoms reinforces the need to conduct routine screening during pregnancy to identify women with a history of IPV or those currently experiencing IPV who may at risk of developing PPD. This particular cohort of women likely evidence a variety of additional risk factors that further heighten their risks of PPD and could clearly benefit from a range of help and support offerings. In developing countries like Bangladesh, it is important that well-organised referral pathways and support mechanisms and organizations be put in place before a screening program commences . We propS1 File(SAV)Click here for additional data file.


Violence related injury is a serious public health issue all over the world. This study aims to assess the association between several socio-economic factors and intimate partner violence (IPV) in Nepal.A cross-sectional study was conducted among 236 women working in carpet and garment factories in Kathmandu, Nepal. Interviews were conducted to collect quantitative data on three forms of IPV, namely physical violence, psychological violence and sexual violence, as well as on a number of potentially associated factors.p = 0.025 for physical IPV; OR = 6.94, p = 0.008 for sexual IPV; OR = 3.42, p = 0.043 for psychological IPV], alcohol consumption of the husband , education of the husband above primary level , and economic dependency of the woman on the husband .Twenty-two percent of women experienced sexual IPV, 28% physical IPV and 35% psychological IPV at least once in the last 12 months. The variables independently associated with at least one form of IPV were: age of the woman >29 years [OR = 4.23, This study identified various factors associated with IPV and showed that economic dependence of wives on their husband was among the most important ones. Thus, for the prevention of IPV against women, long term strategies aiming at livelihood and economic empowerment as well as independence of women would be suggested. Intimate Partner Violence (IPV) against women is a serious public health concern and a human rights issue worldwide –3. IPV rIn Nepal, IPV against women is encouraged due to the male dominance social system which discriminates against women and is also connected to cultural factors that limit women’s choices to leave a violent marriage . Women hThe risk for IPV in Nepal also seems dependent on various socio-economic factors. Most of the women from under-privileged castes and ethnic groups are at higher risk for IPV than women from higher castes . In addiIn the Nepalese context, economic dependency of women on their husband is generally high as compared to the western part of the world , which mTherefore, this study aimed at estimating the prevalence of physical, sexual and psychological IPV and at studying demographic, educational, social and economic factors associated with IPV among married women in the reproductive age between 15 and 49 years working in factories in Kathmandu.This cross-sectional study used a standardized, closed ended questionnaire administered orally by interviewers to married women of reproductive age (15–49 years) working in factories in Kathmandu, Nepal. Four carpet and garment factories were included in the study, because the carpet and garment industry is traditionally employing mostly women. The factories were selected on basis of convenience. The study population comprised of only married women currently living with their husband and the sample size calculation was done with OpenEpi software . The samThe total number of respondents included in the study was 236, as it was the required sample size of the study. Data collection was done using purposive sampling technique, meaning that sampling was done until the number of data reached the required sample size i.e. 236. Four factories were included to reach the required sample size. None of the eligible women refused to participate in the study nor did not complete the interview resulting in a response rate of 100%.The structured closed ended questionnaire was constructed by taking the reference from standard survey tools used by the Government of Nepal for the NDHS 2011 for collecting information about IPV at national level . The queThe first part of the questionnaire included general characteristics of women such as their age and their age at first marriage (>20 years/20 years or above according to NDHS ). The woThree forms of IPV were studied, namely physical violence, psychological violence and sexual violence. Physical violence included those acts causing physical harm such as hitting, beating, kicking, slapping, dragging or any form of physical injury. Psychological violence included those acts causing psychological harm such as insulting, threatening, humiliating or controlling on unnecessary activities and sexual violence, including forced sex. The time period for experiencing violence was during the last 12 months. The presence of any form of violence among those three types of violence was considered as the presence of IPV. The response was categorized binary as Yes and No.Psychological violence was assessed by the question: ‘Did your husband ever insult you or make you feel bad about yourself?’ Physical violence was assessed by a single question: ‘Have you ever been hit, slapped, kicked or done anything else to physically hurt by your husband at times?’ Sexual violence was assessed by a question: ‘Has your husband ever forced you to have sex when you did not wish to do so?’ The responses for all forms of IPV were in Yes/No form and for the severity assessment, the response options were ‘often’, ‘sometimes’, and ‘not at all’. The participants were also asked about their knowledge about IPV against women with the question: ‘Do you know what intimate partner violence is?’p < 0.05 for the Pearson value of the Chi-Square test was taken as indicating significance. Only factors significant in the Chi-Square tests (data not shown) were used in the bivariate logistic regression models presented in Tables Data was entered and analyzed in SPSS 22 for Windows. Chi-square tests were conducted to assess any association between the three forms of IPV and relevant socio-demographic factors. A significance level of Table Psychological violence was the form of violence most often reported and 35% reported that they had experienced psychological IPV by their husbands. Women, who reported that they were hit, slapped, kicked or physically harmed by their husband , included 28% of the respondents and 22% had suffered from sexual IPV.Table Table Several other variables only showed an association with sexual IPV, but only when not adjusted for the other variables in the table: women having more than 2 children, those having a love marriage, those with a lower level of education, those with a lower level of education of their husband, those who were economically dependent on their husband, those who had lack of knowledge about IPV and those who had decision making capacity were more likely to have experienced sexual IPV. However, all these associations became insignificant after adjusting for the other variables in Table Table Several other variables only showed an association with sexual IPV, when not adjusted for the other variables in the table: Women having more than 2 children, those who had a lower level of education and those who had a lack of knowledge about IPV were more likely to having experienced psychological IPV. However, all of these associations became insignificant after adjusting for the other variables in Table The first aim of our study was to study the prevalence of three different forms of IPV among female factory workers aged 15–49 years in Kathmandu Nepal. It was found that of 22% of women reported having experienced sexual IPV, 28% reported physical IPV and 35% reported psychological IPV at least once in their last 12 months. The NDHS 2011, a national level survey, reported slightly lower figures with 14% of women aged 15–49 years reporting sexual abuse by their husband at least once in their lifetime, 23% of them reporting physical abuse, one thirds of them reporting physical, sexual or psychological abuse once in their lifetime [As our second aim, this study focused on a number of relevant factors potentially affecting IPV which included age of women, age of women at their first marriage, number of children (parity), marriage type, education of women, education of husbands, economic dependence of women on their husbands, decision making capacity of women, knowledge about IPV on women and alcohol use of the husband. All these factors except for age of women at first marriage were significantly associated with the different types of IPV, but for most of the factors the association disappeared when adjusting for the other factors. The variables that were independently associated with at least one form of IPV were: higher age of the woman, alcohol consumption of the husband, low education of the husband and economic dependency of the woman on the husband. Out of these four variables, two of them showed a consistent association with all three forms of IPV even when adjusted for all other factors: higher age of women and alcohol use of the husband. Women whose age was 29 years and over had 3–7 times higher odds of having experienced psychological, physical or sexual IPV than younger women. The IPV risk for older women may increase due to more marital quarrelling that may be followed by violence , or oldeAlso, alcohol consumption of the husband was a strong independent risk factor for all forms of IPV. Alcohol consumption among men in Nepal is very high in comparison with the alcohol use of women . Our resEconomic dependence on the husband was found to be a risk factor for all forms of IPV in this study and after adjustment remained significant for physical and psychological IPV. Previous studies about the association between IPV and economic dependence of women on their husband also showed that the risk of violence against women was higher for women who were economically dependent on their husband . In NepaSeveral other factors showed some association with IPV, but only in the unadjusted models. E.g. women with an arranged marriage were less likely to report IPV. In Nepal, marriages that were arranged by their family are more frequent than love marriages and this type of marriage is also more secured by the families that arranged the marriage .Knowledge of women about IPV was found to be the protective factor for all forms of IPV in the study, but only without adjusting for other variables. A previous study about IPV conducted in Nepal concluded that women’s decision making autonomy was a strong predictor of IPV on women . HoweverWe also found that age at first marriage was not associated with any form of IPV and therefore the variable was not included in the logistic models. This is in line with another study, which describes causes of IPV showing that age at marriage was not associated with IPV .Our study has limitations and it is crucial to note that the data collection was cross-sectional and no conclusions regarding causal relationships can be drawn. The study population is also limited to factory workers in Kathmandu and the results may be different in rural areas or in other professional sectors. However, the response rate was extremely high which limits a potential selection bias towards only excluding women who may be absent from work due to IPV. Our study also relied on self-reported data and due to the fact that IPV and the associated factors are a sensitive issue, we cannot rule out potential under-reporting of IPV.In summary, we conclude that the prevalence of IPV is high in this group of women and that the odds of IPV was higher in women of higher age, for those with alcohol consumption of the husband, with low education of the husband and with economic dependency on the husband. Future research should identify underlying reasons for the high level of IPV.The findings from this study are important in order to make Nepalese women aware of the problem and to enable advocacy about IPV. A holistic approach is essential to gain family and community trust as well as support for women at the micro, meso and macro levels for the prevention and control of IPV issues in Nepal . The res


This paper investigates gender differences in persistence of intimate partner violence (IPV), for those remaining or leaving an abusive relationship. We followed a sample of males and females to examine whether leaving an abusive partner may alter the continuity of victimization.Data were taken from the 21 and 30-year follow-ups of the Mater Hospital and University of Queensland Study of Pregnancy (MUSP) in Australia. A cohort of 1265 respondents, including 874 females and 391 males, completed a 21-item version of the Composite Abuse Scale.We found proportionally similar rates of IPV victimization for males and females at both the 21 and 30 year follow-ups. Females who reported they had an abusive partner at the 21 year follow-up were more likely to subsequently change their partner than did males. Harassment and then emotional abuse appeared to have a stronger association for females leaving a partner. For males, a reported history of IPV was not significantly associated with leaving the partner. There was no significant association between leaving (or not) a previous abusive relationship and later victimization, either for male or female respondents.Changing a partner does not interrupt the continuity of victimization either for male or female respondents, and previous IPV victimization remained a determining factor of re-abuse, despite re-partnering. Intimate partner violence (IPV) may occur repeatedly in the context of some intimate relationships . There iPrior research following those who have previously experienced IPV has been limited and inconclusive. Only a small number of scholars have suggested that changing a partner may reduce IPV perpetration , 8 and vlife course perspective suggests that particular periods of the life course may be associated with higher rates of IPV. Characteristics of early adulthood  contribute to a greater risk of IPV in this period. Afterwards, developmental changes  may protect individuals from subsequent victimization/ perpetration- regardless of leaving or staying with a partner victimization and staying in an abusive relationship, are related to the following factors: marital status, lower socio-economic status, presence of children, history of child abuse, and poor mental health , 39–43.what is your present marital status? Categories comprised single/never married, living together, married or separated. Education levels included high school or less, diploma and college and university. Having a child was dichotomized into yes and no. Participants were asked about their family income which was defined as gross income before tax. Then using the Australian National Poverty Line as a guide [low income and the rest into higher income. For measuring history of sexual child abuse 21-year respondents were asked whether they had experienced being pressured or forced to have sexual contact before they were 16 years. Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) which is a widely-used self-report scale [during the last 12 months have your sexual partners been: only the opposite sex, only the same sex and both sexes. We then categorised respondents into two categories of heterosexual and homo/bisexual.All participants were about 21 and 30 years of age at each follow up, so we did not adjust for the age differences in the cohort. Marital status was measured by the question  a guide , we catert scale . It contrt scale , 47. Sexp-value< 0.05 for significance. In Table In Table Among 1265 21-year-old participants who were in a relationship, 6.1% were married and 93.9% were living together. 11.1% of respondents had children.p = 0.07) is experienced more often by females. By contrast, 21-year-old males more frequent report being physically abused. At 30, there are no gender differences in any form IPV.Table Table Table A further detailed analysis (data not shown) suggests that although the association between having children and females’ leaving their partners is negative Table , when moTable p = 0.08). For females we note that 55.7% of those experiencing IPV changed partners, while 42.9% of those not experiencing IPV changed partners (p <  0.001) by the 30 year follow up. Females who reported IPV at 21 years and remained with their partners, were no more likely to be abused at 30 years compared to females who had changed partners . A further interaction terms between the experience of IPV at 21 (non-abused/abused) as primary variable and change of partner (stay/change) as moderator was conducted to predict the experience of IPV at 30 (non-abused/abused) separately for females and males (data not shown in a table). Consistent with the findings in Fig. 95 = 0.44–1.35). In contrast, the primary effect of experiencing IPV at 21 remains a robust significant predictor for experiencing IPV at 30 years. For males, no statistically significant difference in experiencing IPV at 30 years is observed between males who left their abusive or non-abusive partners . These findings were independent of a range of potential confounding factors.Figure p <  0.00 by the 3The current study has compared males and females in the continuity of IPV victimization at 21 and 30 years of age. A cohort of 1260 cases was followed to determine whether early IPV victimization was associated with leaving the prior partner and subsequent IPV. In addition, we followed both males and females to examine how a change of abusive partners may alter the continuity of victimization.p <  0.0001). Despite this decline in the IPV rate across time, there was a robust significant association between early victimization and re-victimization for both males and females. We also found that a substantial proportion of females (55.7%) and males (51.0%) who report experiencing IPV at 21 years left their partners (p > 0.05). Victimized males at 21 years were no more likely to change partners, than those not experiencing IPV at 21 years. These findings were not affected by any of the sociodemographic factors that were considered. Harassment and then emotional abuse appeared to have a higher association with leaving partner in females. Relationship change did not appear to prevent males and females from the continued experience of victimization. We found experiencing IPV at 21 remains a robust significant predictor for experiencing IPV at 30 years, regardless of whether there is a change of partner.The results of this study suggest that rates of IPV victimization declined from 21 to the 30 year follow up . Features of this life course stage include instability  and tendency to postpone adults’ responsibilities , which may contribute to a higher rate of IPV victimization at this period [The observed decline in IPV victimization from 21 to 30 years may reflect the longer period in which 21-year respondents were asked about their experiences, compared to that of 30 years (last year). Nevertheless, this finding is consistent with a s period , 12, 13.s period .A relationship between early and further victimization supports previous research which suggests that earlier victimization may be taken to mean violence is considered a normal aspect of intimate relationships. Prior experiences of family violence may lead to cumulative disadvantages  which negatively affect the nature of future relationships , 48–51.Slightly higher rates of leaving the abusive partner in females seems to be consistent with other research indicating that females have disproportionately higher rates of relationship termination than males . ConsideWe also found no support for the effectiveness of leaving an abusive partner. This finding is in line some previous studies which find no significant difference between those who stayed or changed partners , 15. HowA body of research has shown that earlier victimization may lead to long-lasting consequences for survivors like fear, posttraumatic stress, anxiety and disempowerment . SurvivoThis study has several strengths: IPV was assessed by a validated measure at 21 and 30 years. We also used the longitudinal data from a large prospective cohort of both males and females and adjusted for a range of confounding factors. We have found that leaving an abusive relationship makes no significant difference to experiencing further IPV and early IPV victimization remains the strongest predictor of re-abuse, despite changing partner. The current work has extended existing knowledge about IPV victimization experienced in relationships with different partners. Our findings raise the question of whether there are characteristics of those affected by IPV and socio-cultural factors, not measured in this study, that need to be identified and addressed if IPV and its consequences are to be reduced.gender specific IPV interventions. For example, we found similar rates of IPV for 30-year-old males and females and no association between the experience of IPV and males’ leaving their partner. These findings leads to a recommendation that gender-specific prevention efforts should put greater emphasis on males’ IPV victimization and their decision to stay in an abusive relationship.The findings of this study have significant implications for IPV reduction programs: first, gender differences in predictors of IPV and in its association with leaving a partner raise the need for early IPV prevention. If it is possible to prevent first victimization experiences, then the subsequent victimization may be avoided [The finding that early IPV victimization remained a determining factor of revictimization highlights the need for  avoided . More imIPV interventions which protect and assist those affected by IPV, should address complex needs of survivors. For example, in the current study, depression was a significant predictor of both changing partner and IPV victimization. Clinical intervention efforts are required to target pre-existing as well as subsequent mental health problems of victims to minimize the risk of further abuse. Having a low income was also a significant barrier against abused females to leave an abusive partner. IPV interventions should therefore consider the policy of women’s financial empowerment .This study has a number of limitations: The data were collected using a self-report measure from one partner, which may associated with self-serving bias or over-reporting negative behaviours of partners. In addition, at 21 years respondents reported their life-time IPV in either their current or previous relationships, while at the 30 year follow up, they described their most recent relationships during last 12 months . Males’


Background: Although various types of intimate partner violence (IPV) tend to co-occur, risk factors of each type of IPV may differ. At the same time, most of the existing literature on risk factors of IPV among minorities has used a cross-sectional design and has focused on physical rather than sexual IPV. We conducted the current study to compare Black and Hispanic women for psychological predictors of change in sexual IPV over time. Methods: Using data from the Fragile Families and Child Wellbeing Study (FFCWS), this study followed 561 Black and 475 Hispanic women with their male partners for four years. Independent variables included male partners’ depression, anxiety, problem alcohol use, and male-to-female physical and psychological IPV perpetration. The dependent variable was sexual IPV reported by female partners, measured at baseline, two years, and four years later. Covariates included age, income, marital status and education level. We used a multi-group latent growth curve model (LGCM) to explain intercept, linear, and quadratic slopes, which represent the baseline, and linear and curvilinear trajectories of male-to-female sexual IPV, where groups were defined based on ethnicity. Results: Psychological IPV was associated with sexual IPV at baseline among both ethnic groups. The male partner’s depression was a risk factor for an increase in sexual IPV over time among Black but not Hispanic women. Anxiety, problem alcohol use and physical IPV did not have an effect on the baseline or change in sexual IPV over time. Psychological IPV was not associated with an increase in sexual IPV over time in either ethnic group. Conclusions: There is a need for screening of sexual IPV in the presence of psychological IPV among minority women. There is also a need for screening and treatment of male partners’ depression as a strategy to reduce sexual IPV among Black women.Background: Although various types of intimate partner violence (IPV) tend to co-occur, risk factors of each type of IPV may differ. At the same time, most of the existing literature on risk factors of IPV among minorities has used a cross-sectional design and has focused on physical rather than sexual IPV. We conducted the current study to compare Black and Hispanic women for psychological predictors of change in sexual IPV over time. Methods: Using data from the Fragile Families and Child Wellbeing Study (FFCWS), this study followed 561 Black and 475 Hispanic women with their male partners for four years. Independent variables included male partners’ depression, anxiety, problem alcohol use, and male-to-female physical and psychological IPV perpetration. The dependent variable was sexual IPV reported by female partners, measured at baseline, two years, and four years later. Covariates included age, income, marital status and education level. We used a multi-group latent growth curve model (LGCM) to explain intercept, linear, and quadratic slopes, which represent the baseline, and linear and curvilinear trajectories of male-to-female sexual IPV, where groups were defined based on ethnicity. Results: Psychological IPV was associated with sexual IPV at baseline among both ethnic groups. The male partner’s depression was a risk factor for an increase in sexual IPV over time among Black but not Hispanic women. Anxiety, problem alcohol use and physical IPV did not have an effect on the baseline or change in sexual IPV over time. Psychological IPV was not associated with an increase in sexual IPV over time in either ethnic group. Conclusions: There is a need for screening of sexual IPV in the presence of psychological IPV among minority women. There is also a need for screening and treatment of male partners’ depression as a strategy to reduce sexual IPV among Black women. Although both genders commit intimate partner violence (IPV) against their partners, male-to-female IPV is more common than female-to-male IPV . There aSexual IPV includes a wide range of experiences, from coercion to unwanted sexual activity by a partner to more severe forms, such as rape. Up to 21% of women experience sexual IPV . Women wBased on the literature, sexual, psychological, and physical IPV tend to co-occur ,12,13. TExposure to sexual coercion, threats of violence, and physical violence often co-occur in women . VictimsWhile research on the topic is limited, we have reason to believe that anxiety acts as a possible risk factor for perpetration of IPV ,29,30. VAlcohol misuse also increases the risk of IPV perpetration among men ,32,33,34Using a dyadic approach that includes both partners as informants , the curThis study used interview data from Waves 2 through 4 of the Fragile Families and Child Wellbeing Study (FFCWS), an ongoing longitudinal, population-based cohort, which began in 1998 ,41,42. TThe study was approved by Institutional Review Board Committees at Princeton University and Columbia University. Verbal and written informed consent was obtained from participants at each interview, and all participants were compensated for their involvement in the study.The FFCWS used a random sampling method from families in 20 U.S. cities with populations of 200,000 or more. A detailed description of sampling strategy and interview protocol in the FFCWS is available elsewhere . The FFCWe limited the current analysis to couples in which the female partner was either Black/African American or Latino/Hispanic. As a result, 1036 of 4898 total participating couples from different ethnic groups who completed the baseline of the study were entered into the current analysis.Data used here were limited to the parental core interviews, interviews with the mother and father reporting on child health and development, and their own romantic relationships with the other parent and marriage attitudes. The term “parental core interview” is used to distinguish interviews with parents from interviews with a primary caregiver, which may include caregivers other than parents . ParticiMale-to-female sexual IPV. Sexual IPV was assessed by asking female partners “How often does the father (of your baby) force you to have sex/do sexual things?” Response items included never (0), sometimes (1), or often (2). This item was adapted from the Spouse Observation Checklist  and studMale-to-female physical IPV. Physical IPV was assessed by asking female partners two questions on a 3-point scale , regarding how often fathers carried out behaviors toward the female partner  and were adapted from the Conflict Tactics Scale (CTS-2) for adults ,56. The Major Depressive Disorder (MDD). The Composite International Diagnostic Interview-Short Form (CIDI-SF) was used to measure MDD . The CIDGeneralized Anxiety Disorder (GAD). The CIDI-SF was used to screen for symptoms consistent with a diagnosis of GAD . The diaProblem Alcohol Use. Heavy/problem alcohol use was defined as five or more drinks during a single day over the past month (coded “1”). This measure approximates heavy drinking according to the definition by the National Institute on Alcohol and Alcoholism, i.e., five or more drinks in a single day for men . Based on this model, MDD in male partner (at baseline) was associated with a larger linear slope for trajectory of sexual IPV during four years of follow up . Psychological IPV at time 2 was also associated with higher sexual IPV at time 2. Male partners’ age, education level, income, ethnicity, GAD, problem alcohol use and physical IPV were not significantly associated with baseline, linear, or quadratic slopes of sexual IPV over time . Male partners’ age, education level, income, ethnicity, MDD, GAD, problem alcohol use and physical IPV were not significantly associated with sexual IPV at wave 2 or linear or quadratic slopes of sexual IPV over time (Model 2 corresponds to Hispanic women and their partner /spouse. The model showed a good fit to the data [ver time .This study showed similarities and differences in psychological predictors of sexual IPV against Black and Hispanic women. A similar association between psychological and sexual IPV was found for both Black and Hispanic women. Male partners’ depression was associated with a worse trajectory of sexual IPV over the follow-up period among Black, but not Hispanic women.We found ethnic variation in the effects of depression in male partner, meaning the effect was present in Blacks but not Hispanics. Ethnic variations in the associations between psychosocial risk factors and behavioral health outcomes are shown across domains ,62,63,64Our finding on the effect of male partner depression on sexual IPV is supported by literature that shows psychopathology increases the risk of IPV perpetration ,21. AngeOur study did not show that male partner’ problem drinking behavior had any effect on sexual IPV victimization of Black or Hispanic female partners. In a study in Russia, the odds of IPV perpetration were three times greater among men who misused alcohol than those who did not . CommuniFurthermore, alcohol use disorder was reported as the strongest associated factor of IPV perpetration in a study conducted by Smith, Homish, Leonard, and Cornelius . CompareOur study did not find that male partners’ presentation of GAD had any effect on sexual IPV against Black or Hispanic women. Again, most studies which have built our current understanding of the association between anxiety and IPV perpetration are limited to other types of IPV. In a study by Miga et al. , attachmOur study has four policy and clinical implications. First, as this was a community sample, rather than a clinical sample, and as minority populations have greater stigma and lower access to health care, there is a need for screening and treatment programs in the community. The first implication of our results is a need for community-based intervention to prevent of IPV in ethnically diverse communities.Second, we found that psychological and sexual IPV co-occur, regardless of ethnicity. This finding suggests a need for combined programs which can help protect women of minority status against experiences of IPV through preventative and treatment programs. Research findings on risk factors and protective factors contributing to co-occurring physical and sexual IPC may collectively contribute to reducing ethnic disparities in the burden on IPV among women.Third, based on our findings, there is a need to screen male perpetrators for mental health issues, and other types of IPV, particularly psychological IPV. This is an important distinction from prior approaches to identifying and addressing IPV, which have primarily focused on the screening of victims.  Our findAs stated, our research findings provide evidence for the importance of mental health screening of male perpetrators, in addition to female victims. A fourth implication of our study is, as psychological and sexual IPV victimization tend to co-occur among minority individuals, we propose combined programs that simultaneously address various types of IPV. Interventions aimed at the prevention of IPV may benefit from combined programs that target various forms of IPV, including sexual violence. We believe that prevention strategies may benefit from studies that focus on both of these outcomes.The current study had four significant limitations. Firstly, female victims may underreport sexual IPV, which is particularly significant for low SES and minority populations who may suffer from greater stigma in reporting. Low SES and minority status may reduce IPV disclosure ,89,90. SAdditional research is needed to understand why, how, and when women of diverse ethnic minority groups are exposed to a combination of psychological and sexual IPV. A suggested first step would be testing psychological IPV as a possible mediator for the effect of risk factors on sexual IPV. In addition, there is a need to test the efficacy of interventions meant to improve the mental health of male partners as a strategy to prevent male-to-female IPV. Future research should add clinical interviews and more contextual data along with standard measures .Black and Hispanic women showed common and unique psychological determinants of sexual IPV. Psychological IPV was similarly associated with sexual IPV among both ethnic groups. Male partners’ depression was a risk factor for sexual IPV among Black but not Hispanic women. Combined programs that jointly screen for sexual and non-sexual IPV are needed among minority women, regardless of their ethnicity. There is also a need for attention to male partners’ psychopathology in the presence of sexual IPV reported by Black women.