In Rwanda, women who self-reported in household surveys ever experiencing intimate partner violence (IPV) increased from 34 % in 2005 to 56 % in 2010. This coincided with a new constitution and majority-female elected parliament in 2003, and 2008 legislation protecting against gender-based violence. The increase in self-reported IPV may reflect improved social power for women, and/or disruptions to traditional gender roles that increased actual IPV.This is a cross-sectional study of IPV in 4338 couples interviewed in the 2005 and 2010 Rwanda Demographic and Health Surveys (RDHSs). Factors associated with physical or sexual IPV in the last 12 months were modeled using manual backward stepwise logistic regression. Analyses were conducted in Stata v13 adjusting for complex survey design.p < 0.05) were: experiencing emotional IPV (OR = 18.1), beating husband/partner unprovoked (OR = 12.3), witnessing IPV against mother (OR = 1.82), husband/partner consumes alcohol often (OR = 3.13), and polygynous marriage (OR = 1.51), whereas having a husband/partner with secondary education (OR = 0.43) was protective. Factors associated with increased IPV in 2010 (p < 0.05) were husband/partner (OR = 1.30) or woman (OR = 1.36) believes IPV is justified, husband/partner has sex with non-marital partners (OR = 2.52), bottom wealth quintile (OR = 1.25), polygynous marriage (OR = 2.29), having a son (OR = 2.05) or only daughters (OR = 2.58) versus no children, and having a husband/partner employed with in-kind versus cash compensation (OR = 1.58). In 2010, woman being involved with her own health (OR = 0.79) or earnings (OR = 0.57) decision-making was protective against IPV. Several variables were not available in the 2010 RDHS.Risk factors for IPV in 2005 (Abunzi mediators to hear IPV cases in communities, and involvement of men in grassroots efforts to redefine masculinity in Rwanda are suggested. Additional research is needed to understand why self-reported IPV has increased in Rwanda, and to evaluate effectiveness of IPV interventions.Our results may provide evidence of both increased self-reporting of IPV and social power disruption. Rwanda’s Isange One Stop Center project, with medical, legal, and psychosocial services for domestic violence victims, is currently scaling to all 44 district hospitals, and police station gender desks reduce barriers to legal reporting of IPV. Additional support to  Intimate partner violence (IPV) describes physical, sexual, or psychological harm by a current or past partner. Not only does IPV compromise survivors’ basic human rights, physical and sexual assault can result in direct physical harm, sexually transmitted infections, or pregnancy, and all IPV can result in long-term mental and physical health problems , 2. WhilWithin region and country, however, experiences of IPV vary widely, underscoring differences in national histories, institutional policies, cultural identities, resources, and other factors. When comparable measures and methods are used to measure lifetime prevalence of physical and sexual violence across national surveys –7, they Rwanda is a small, densely populated country that has undergone rapid demographic, social, and economic transition in the last 20 years since the Tutsi Genocide that killed around 1 million people. In the period between 2005 and 2010, fertility rates fell from 6.1 to 4.6 children per woman, child mortality was halved from 152 to 76 deaths per 1000 live births, and the percent of women completing secondary school increased from 1.6 to 4.3 % , 9. MeanWomen’s political representation and legal protection is an important step toward gender equity. Several factors may contribute to women’s political representation in Rwanda; foremost, Rwanda’s government has prioritized women’s political inclusion. In 2003, new legislation reserved 24 of 80 parliamentary seats for women-only parliamentarians to be filled by women-only voters . While tViolence in intimate partnerships is a common phenomenon worldwide, and is partially attributed to couples spending lots of time with each other . Time exIn Africa, systematic gender inequality is often reinforced by cultural traditions of men in roles of head of household in charge of family finances and decisions , as wellGender roles in Rwanda are in the midst of rapid transition, and the implications for IPV are not well understood. In a qualitative study in Rwanda after 2003, women described experiencing greater respect by family and community members, new confidence to speak in public forums, more autonomy and opportunities, as well as increased friction with their brothers and husbands, perceptions that men were withdrawing from politics, and feelings that the institution of marriage had been disrupted due to rapid changes in conventional gender roles . A 2010 This analysis is based to the 2005 and 2010 Rwanda Demographic and Health Surveys (DHSs), which are nationally and sub-nationally representative two-stage cluster samples, conducted every 5 years to monitor demographic, socioeconomic, and health indicators . In bothOf the 11,321 and 13,671 women interviewed in 2005 and 2010, respectively, 4066 and 5008 were randomly selected and agreed to complete a special module about domestic violence. Only one woman per household was selected for the domestic violence module to ensure that no one else in the household knew about sensitive questions that could compromise her safety, and to minimize the total number of women asked to describe traumatic events. Female interviewers received special training to conduct secure, confidential interviews in respondents’ homes and administered the domestic violence module in face-to-face interviews; they were supposed to skip the module if a confidential interviewing environment was not possible. According to the DHS datasets, 100 % of women in 2005 and more than 99 % of women in 2010 who were selected for the domestic violence module completed it. Of the 9074 women interviewed across the two surveys, 4338 had husbands/partners who were interviewed in the men’s survey. In this analysis of 4338 couples , we link women’s self-reports of intimate partner violence in the last 12 months with husband/partner’s survey responses based on wife-ID in the men’s questionnaire.In the domestic violence module, women were asked directly about their experiences of physical and sexual violence in the last 12 months and this outcome was modeled as a binary variable. In the 2005 survey only, women reported emotional IPV, physical violence perpetrated against her husband/partner when he was not already physically hurting her, history of her father beating her mother, and frequency of husband/partner’s alcohol usage, all of which are key risk factors for IPV against women , 21–25. Both the 2005 and 2010 DHSs were reviewed and approved by the Macro International Internal Review Board, Rwanda’s National Institute of Statistics, and the National Ethics Committee of Rwanda. We were granted permission by Macro International, Inc. to use these de-identified data for this analysis.p < 0.05) socio-demographic characteristics of women in this study with married/partnered women not in the study (because their partner was not interviewed) and divorced or separated women. Then we defined 25 potential covariates and tested bivariate Chi-square distributions among women who had, and had not, experienced physical or sexual IPV in the last 12 months. Non-collinear (Pearson correlation r < 0.5) variables associated with IPV (at p < 0.1) were retained for multivariable model building. Finally, we used manual backward stepwise logistic regression, first removing variables that were least associated with IPV and retaining those variables that were associated with IPV (p < 0.05). Separate models were fit for 2005, for 2005 using the reduced set of variables available in 2010, and for 2010. The analysis was carried out in Stata version 13 using survey commands to apply sampling probability weights, account for clustering and stratification in the sample design, and perform subpopulation analysis in couples only. We presented final models as odds ratios (ORs) with 95 % confidence intervals.We used multivariable regression to identify belief or behavioral and socio-demographic factors associated with sexual or physical IPV against women in Rwanda in 2005 and 2010. We used percentages and Chi-square tests to compare   (Table p < 0.001), though only nine women (<1 %) reported this behavior. No other beliefs or behaviors were associated with IPV in 2005. A number of socio-demographic factors were associated with IPV in 2005 (p < 0.1) including rural residence, polygynous marriage, having any children, there being no adults other than the couple in the household, having a husband/partner with less than secondary education, and the woman having less than secondary education.In bivariate analysis in 2005, sexual or physical IPV was associated with emotional IPV (84.7 %), witnessing physical violence by father against mother as a child (31.5 %), and having a partner who consumes alcohol often (54.3 %) (p < 0.1) including partner believes a man can beat his wife, woman believes a man can beat his wife, woman is not involved with her own health decision-making, woman is not involved with decision-making about her earnings, husband/partner has sex with non-wife partner(s), and the woman says she cannot refuse sex with her partner or request use of a condom.In 2010, many of the same socio-demographic factors were associated with IPV, however, a number of beliefs and behaviors were newly associated with IPV (p < 0.001) of sexual or physical IPV, and women who reported beating their husband/partner unprovoked had 12 times the odds (p < 0.01) of sexual or physical IPV. Having a partner that consumes alcohol very often , witnessing physical IPV against her mother in childhood , and being in a polygynous marriage  were also associated with increased odds of sexual or physical IPV. Women who had a partner with secondary or higher education had lower odds of IPV . When emotional violence, woman beats husband/partner unprovoked, woman witnessed IPV against mother in childhood, and husband/partner consumes alcohol often were removed from the model to make it comparable to the 2010 analysis, two additional demographic characteristics were associated with IPV: women’s primary education versus no education , and woman has at least one son  or daughters only  versus no children.In the 2005 multivariable analysis, two factors stand out as being strongly associated with IPV Table . Women wp < 0.05), woman believes a man is justified to beat his wife , and partner has sex with non-wife partner(s)  were all associated with greater odds of IPV. Furthermore, woman being involved with decisions about her own health  or about her own earnings  versus her partner alone were protective against IPV. Being a household in the bottom wealth quintile , being in a polygynous marriage , having a son  or only daughters  versus no children, and having a partner employed with in-kind versus cash earnings  were associated with greater odds of IPV.Several beliefs and behaviors that were not associated with IPV in 2005 were significant in the 2010 multivariate analysis. Partner believes a man is justified to beat his wife  self-reported in household surveys doubled between 2005 and 2010 which coincided with a rise in the percent of women who say that IPV is justified from 46.7 % to 57.0 %. In 2010, nearly half of all partnered women experienced physical or sexual IPV in the previous 12 months, and IPV tended to occur in tandem with multiple other forms of violence. Our 2005 finding that women who experienced emotional violence , who witIn our study, IPV was associated with high alcohol usage by husbands/partners, which is consistent with findings from diverse settings including Brazil, Kenya, and India , 27–29. Our 2010 finding that IPV was associated with husbands/partners who earned in-kind rather than cash compensation may provide evidence of social power disruptions within relationships as a source of increased incidence of IPV in Rwanda. In-kind rather than cash compensation may be related to the husband/partner having low education , 22, 33 Certain family dynamics such as polygynous marriage and having children are slow to change in response to women’s changing roles in society, and it is therefore not surprising that these two factors remained significantly associated with IPV across years in our study. The practice of polygyny in Rwanda is illegal, uncommon, and may be falling . In 2005While there is great variability in risk factors for IPV across countries, IPV beliefs and behaviors are commonly associated with IPV incidence , 42. TheGiven the complexity of IPV and the mixed evidence in this analysis, the higher incidence of IPV in 2010 may have resulted from both improved self-reporting and increased incidence of IPV due to social disruption. As such, we recommend multiple avenues to address IPV in Rwanda at a social-level. To the extent that prevalent violence against women already existed due to entrenched social, cultural, or historical norms, or has been inflamed by disrupting those norms, we recommend improved legal systems to protect women against violence, and campaigns to reduce acceptance of IPV and to redefine gender roles.Abunzi community mediation system [Abunzi Secretariat which oversees mediator training and coordination with the Ministry of Justice. Like the gacaca courts, which heard genocide cases, the Abunzi system is a hybrid of traditional and modern methods of conflict resolution, and is perceived by many as more accessible and responsive than legal courts. Each Abunzi committee is comprised of at least 12 members, 30 % of whom are supposed to be women, and serve a local group of villages. While the Abunzi system may present fewer social barriers to victims of IPV than the justice system, many Abunzi committees do not maintain 30 % + women representation, mediations are public, and mediators are often unfamiliar with existing laws and turn to customary laws that may be prejudiced against women [Abunzi system may be a positive forum for certain IPV cases, especially if the victim is comfortable with the process, and the system is able to support couples to effectively communicate through differences that prevent future violence. However, better support and training of Abunzi mediators is needed to appropriately protect victims of domestic violence according to national law.An alternative to the One Stop Center program is the n system  which wast women . The AbuPressure on men to change their behaviors and perception of themselves as men without well-formed alternative models of masculinity will not lead to sustained reductions in violence , 42. Thiumaganda, the monthly national day of service, and facilitates dialogues about IPV in umugoroba w’abashakanye evening meetings of five to ten couples [Perhaps as a result of atypically top-down approaches, Rwandans overall hold highly inequitable attitudes about gender roles; for example, 61 % of Rwandan men agree with the statement “changing diapers, giving kids a bath and feeding kids are the mother’s responsibility” , and DHS couples , furtherThe doubling in self-reported IPV in Rwanda between 2005 and 2010 is deeply concerning, and further investigations of reasons for this increase are urgently needed. This study summarizes trends, correlates, and broad hypotheses for IPV, however, the cross-sectional nature of the DHS does not allow us to draw causal conclusions about predictors or consequences of IPV. Furthermore, measurement of physical and sexual IPV in household surveys is subject to under-reporting due to interviewer traits and difficulty securing privacy in smaller, densely populated homes . We findAbunzi mediators are able to address IPV should be investigated. Campaigns that involve men and women in redefining gender roles could be an important contribution to the gender equality agenda moving forward in Rwanda, and the effects of these campaigns on IPV and IPV perceptions should be systematically evaluated.The 2015 DHS was recently completed but not released at the time of this writing, and results from that survey might provide important insight about trends in IPV. Preliminary results of the 2015 DHS indicate continued rapid economic development in Rwanda, which is expected to correlate with a drop in IPV , 17. We Rwanda has one of the highest self-reported rates of intimate partner violence against women worldwide, and multiple forms of current or past violence are reported by the same women. Doubling in self-reported violence between 2005 and 2010 coincided with major political and social gains. While the Rwandan health and legal sectors have multiple initiatives to support victims, additional campaigns may be needed to shift public perception and perpetration of intimate partner violence. The impact of these programs, and changes in reported violence, need further investigation.


The adverse relationship between income and health is well documented, but less is known of how income trajectories, i.e. downward or upward trends in income, determine health. We therefore link longitudinal income information to cross-sectional data on self-rated health and conduct logistic regression models in order to investigate income trends over time and their relationship with health.The data, with the exception of income information, are derived from the Swedish Level-of-Living Survey 2000. The information on income was drawn from the income register covering the period 1995 to 2000. We used an age-restricted sample of those 30–64 years of age, and generated a series of models accounting for average income position, lagged income position, income decrease and increase, and annual periods in specific income positions. The analysis was conducted for men and women separately.Apart from the overall association between income and health, we found a similar pattern when including average and lagged income in the model. The analysis of length of time in a specific income position showed substantial sex differences in poor health. Income decrease was more strongly associated with men’s poor health, whereas income increase revealed only weak associations with self-rated health.It was shown that income changes and the time dimension of income are important for self-rated health. Self-rated health responds to decreases in absolute income and lowered rank position in the income distribution to a greater extent than to income gains over time. Lagged lower income position and its associations with health suggest that socio-economic disadvantages accumulate over time. Extensive research has been dedicated to demonstrating the adverse health consequences of low income position; however, much less attention has been paid to income dynamics and lagged effects of income. The priResearch on income inequalities in health has mainly focused on the income-specific mechanisms involved in the relationship, such as absolute income mainly drawing on material resources or relative income addressing non-material aspects and social comparisons–5. In reEarlier studies have almost consistently shown that increasing income is more beneficial for health than falling income. The extPrevious literature is not particularly clear about the causal mechanisms involved in the complex of income change and health. However, earlier research has revealed that the discontinuation of specific aspects in people’s life (like the disruption of access to resources) and certain events can trigger health problems and deteriorate well-being. In this respect, falling income evokes a frustrating experience that might initially trigger stress reactions. In the long run, a fall in income is accompanied by material shortages and less purchasing power, the loss of social integration and feelings of deprivation, which might also lead to health problems such as distress, 11.The health implications of income increase appear to be ambiguous. Looking at previous studies, there is no consistent proof that income increase entails health improvements. Obviously, higher income increases the ability to consume, but it must be questioned to what extent this can be converted into better health. Depending on individual priorities, additional income can be invested in healthy food and lifestyle or health care, but also in consumption goods and hazardous activities, which in turn might deteriorate one’s health.A further question concerns the role of contextual conditions, like welfare provisions, which are able to mitigate the consequences of low income, income loss, unemployment, poverty and related economic hardships. Regarding low income position and poverty, it has often been argued that these conditions are less severe in the Swedish context since Sweden has a relatively generous welfare system that provides comprehensive social security, parachuting basically everyone in society.per se contribute to social inequalities in health. The specific aim of this paper then is to explore short and longer-term consequences of individual income position on health in Sweden, and further, to account for income variations over a six-year period by combining longitudinal income information with self-rated health from a cross-sectional survey. In a somewhat explorative approach, different modeling strategies are used in order to identify income developments in terms of both changes and stability over time. The proposed analysis distinguishes between health effects due to income level and income change by adding the respective covariates that distinguish the two dimensions. Of particular interest is the extent to which income changes affect people’s health in their respective income position; whether income changes have similar health consequences for those in low and high income groups. Further, enduring low-income position and its health consequences will be tested.The present study hypothesizes that the individual’s current income situation is crucial for health, and further that income changes The data for this study were derived from the Swedish Level-of-Living Survey (LNU), using the latest available cross-section with data from the year 2000 comprising a total sample of 5,142 individuals. The croWith respect to the quasi cross-sectional data and the categorical nature of the variables of interest, the analysis was conducted using logistic regression. In one of the analytical models, OLS regression was additionally applied. All calculations were performed in Stata 11. An age-restricted sample of persons between 30 and 64 years was used to capture those mainly receiving working income. The income pooled sample size thus covered about 3,377 individuals. All models were adjusted for age of years of the respondents.The health measure used in this study was self-rated health (SRH). The reliability and applicability of this measure has been frequently discussed, 14. TheLike SRH, information on the individual’s educational attainment was derived from the LNU cross-section. The level of education an individual attains can be regarded as reliable indicator of later socio-economic position. Because educational degrees remain relatively stable throughout the life course, the use of education as a covariate may reduce the effects of social selection and reverse causality between income and health in the presented analysis. The education variable reflects highest attainment and was categorized into “primary/no degree”, “secondary” and “post-secondary” levels.Length of time below median incomeTo measure enduring low income, a variable was created that considers the number of years in the income position below the income median. The median was calculated separately for each calendar year. This covariate consists of seven categories, ranging from “never” (0 years) below median up to a maximum of six years with below-median income.The modeling of income change and income stability was based on the pooled income information we obtained for the years 1995 to 2000. The income quintiles were calculated on the basis of the mean income over time and considered the income distribution of the total sample. Because the using sample was age-restricted and stratified by sex, the initially coded income quintiles resulted in unevenly distributed income groups. In addition, a set of income-based covariates was generated to assess income changes over time, to explore whether changes in income position or absolute income were important.(2)Changes in the rank position in the income distributionChanges in income position were analyzed by considering the variations of income position between 1995 and 2000. Relative income position was assessed by creating income percentiles, which gave 100 income subgroups of equal size. The calculation of percentiles was based on the total sample for which income information was available. The income percentiles for the period 1995 to 2000 were then used to trace changes in the rank position in the income distribution over time. First, all changes were tracked by calculating the difference in percentiles of income between the current and the preceding income year . In the next step, a variable was created which kept all substantial changes and non-changes. This variable consisted of four distinct categories and considered all changes with more than ten percentiles from one year to another. The reference category included all those in the sample with a stable income . In the second category, all those without income increase were included (i.e. those who experienced periods with stable income in combination with income decrease). The third category captured those without income decrease (i.e. with stable income in combination with income increase). The fourth category included all others (i.e. those without a particular trend during the considered period). This group, labeled as “inconsistent”, included all subjects who had not only periods of income increase and decrease but also stable income periods.(3)Relative changes in absolute incomeIn order to assess the relative changes in the nominal amount of income, we explored how a relative change with amplitudes of more than ten percent (+/- 10%) in absolute income affected the health outcome. We chose this approach to test the extent to which a substantial income change in relation to the income level would affect the health outcome. In this approach we took into account that an income change – particularly loss of income – has different meaning and consequences for those in higher or lower income positions likely with less severe consequences for those with high income.Similar to the approach in changes in the rank position, four distinct groups with income developments over time were specified. The reference group included all those with stable income. The second category captured those without income increase. The third category accounts for individuals without income decrease, and the fourth, labeled as “inconsistent”, subsumed all others with downward and upward income changes during the observation period.(4)Regression based slopesFinally, income trends over time were assessed through the slopes of linear regression. Regression slopes were calculated for each individual capturing the income developments between 1995 and 2000. The obtained b-coefficient of the slope then was recoded into a five-fold ordinal variable, reflecting the following categories: “strong decrease”, “weak decrease”, “stable income”, “weak increase” and “strong increase”.The slope extrapolates income development and reflects the individual income trends in a very crude way. A strong increase then corresponds to a gain of more than 10,000 SEK, weak increase between 10,000 and 1,000 SEK. Stable income was defined as the range between 1,000 and -1,000 SEK. Weak and strong decrease mirrored the threshold for income increase. Analogue to income increase, income decreases were defined as “strong” when income dropped with more than 10,000 SEK and as “weak” for losses between 1,000 and 10,000 SEK over time.An overview of the distribution of the variables, the prevalence of poor health and levels of absolute disposable mean income during the observation period are shown in Table In Model 1 Table we exploModel 2 Tables and4 shIn Model 3 the relative change in income position was explored. The analysis reveals that a substantial downward change in relative income position increases the risk for poor health – stronger for men than for women. Income loss combined with stable income showed increased ORs for both men  and women  compared to the reference category. The gender differences are even more pronounced for income increase. Men with at least one period of income increase have an 81 percent higher risk of ending up in poor SRH compared to the reference group. The estimates for women in the same category, however, reveal the opposite association, although the results are non-significant . In the mixed category of “inconsistent” income, we detect an increase in odds of poor health for men by 61 percent and a non-significant increase for women by 32 percent.Model 4 shows the changes in income based on absolute income, i.e. the nominal amount of income a person received. Income loss in combination with stable income reveals the same estimate for men as shown in Model 3 . Increased odds ratios for poor health are also found for women . The estimates for income increase are slightly below the reference category, but non-significant. In contrast to Model 3, inconsistent income does not reveal a significant association with poor SRH for men, but a notable though non-significant estimate for women.The results based on the individual income slopes are shown in Model 5. The estimates somewhat contradict the findings from Model 3 and 4. The analysis of the male sample demonstrates a significant gradient between income trends and health, although the single estimates remain non-significant. The estimates shown for women suggest a U-shaped association between income trends and health. Increases in income are significantly associated with better health. In addition, Model 5 shows the linear gradient for the association of income slopes and SRH. When collapsing the five categories into a single estimate, a significant association between the steepness of the income trajectories for men and women is observed.The aim of this study was to explore income changes and their relevance for subsequent self-rated health, by implementing income histories based on register records into a cross-sectional survey. The type of analysis we presented in this study was restricted by a cross-sectional design, with variables accounting for various types of income development over time and length in a specific income position. The cross-sectional nature of the used data and the characteristics of the variables determined the choice of analysis. We attempted to circumvent the static nature of cross-sectional analysis by including income histories that were recoded into categorical variables applicable for logistic regression. Generally, cross-sectional analysis underestimates the flexible nature of income and conceals that the aspect of time within the association between income and health might be potentially important.The first model revealed the lagging effect of prior low income which seems to determine the health outcome. Using an alternative cut-off point for the level of deprivation and cruder time intervals, Benzeval and Judge identifiIn a set of models, we accounted for short-term income change and income mobility within a six-year period and the subsequent outcomes for SRH. The modeling strategy distinguished between changes in absolute income and changes in the relative rank position in the income distribution, which led partially to fairly different results. Both approaches revealed that a substantial loss of income at one or more occasions during the past six income years is associated with an increased risk of poor health (more for men than for women). Inconsistent rank positions in the income distribution yielded increased estimates of poor SRH for men, whereas inconsistent absolute income disclosed a higher prevalence of poor SRH only among women. Counter-intuitive and somewhat paradoxical were the health implications of upward income for men when change in relative rank position was accounted for. The somewhat inconclusive findings resemble a previous study that explored changes in income over time by using an earlier wave of the same data: Lundberg and Fritzell found anIt is widely accepted that low income is risk factor for poor health. Evidence in previous research is mostly based on income inequality measured closest to health outcomes, but it is uncertain whether income affects only influence health instantaneously. The preThe study uses one income variable; however it was scaled in different ways throughout the presented analysis. The contrasting findings between absolute income and rank position indicate that the type of scaling used on the income variable is important with respect to the health outcome. For example, previous studies on the causal implications of income on health have shown that the method of scaling income may lead to different conclusions regarding health. The incThe overall income development in the study population may have influenced the presented results. In particular the findings based on absolute income follow the trends of the overall income development on the population-level. The findings based on relative rank measures, however, are less prone to fluctuations in income on the national level and are more influenced by changes in the income distribution. The compression of the income distribution affects the relative distances between lower and higher income groups and thus the rank positions in the income distribution, 29.Not to be downplayed, the rise and fall of individual income over time is primarily a consequence of preceding changes in the individual’s employment and labor market position. In the presented analysis, confounding from employment status may have occurred and affected the findings because an appropriate control variable was not available in the data material. Previous studies adjusting the income-health relationship for employment showed that magnitudes in poor health become attenuated. HoweverThe data format and structure restricted the possibilities of data analysis in this study. The presented analyses proposed to enhance cross-sectional studies, but are nevertheless not powerful as true longitudinal time-series approaches. A shortcoming in the current study is the availability of the outcome measure at only one time-point during the observation period. For the same reason, an appropriate adjustment for socio-economic positions was impeded and relied on education alone. Thus, the temporal ordering of social position and health status cannot properly be determined. At least some of the findings may therefore be a result of reversed causality with health influencing income.The inconsistent and not always conclusive findings for women in this study may because women’s income depends to some extent on that of their partner’s socio-economic situation, 33. AlsIncome information may be biased due to an overall increase in income. However, as inflation in Sweden was comparably low during the observation period , its influence on the used income variables and results is presumed to be rather low.The lack of longitudinal information on control variables impeded investigation into the specific reasons for changes income. It is very likely that changes in income coincide with events like unemployment, family dissolution etc. which themselves explain variations in SRH.Although we were able to show that the income distribution is relatively stable over time and that income inequality did not change substantially during the considered period, individual income mobility did occur. Following individual income trajectories, we showed that individual income change is an important determinant for health. This holds true independent of level of income. Although we used relatively old data, covering the 1990s in Sweden, we still believe the results are relevant. Income inequality in Sweden has increased in the past decade, and has certainly affected the income-health relationship.The study showed that the dimension of time and thus the lagged effects of income should be considered when studying income inequality in health. In absence of reference data, the analytical design could not control for potential influences stemming from welfare reforms and retrenchments in the wake of the 1990’s recession in Sweden. However, it was shown that loss of income is likely a threat for health while increases income revealed rather inconsistent results.Although this study could not identify a consistent pattern and clear direction of associations between income and self-rated health over time, it was shown that the time dimension matters. In particular income instability – in either upward or downward trends of income – show an adverse association with health.


Intimate Partner Violence (IPV) has serious negative health effects to millions of women around the globe. While disclosing IPV could open doors for support and eventually prevent partner abuse, the factors associated with IPV disclosure during pregnancy are not well known. The aim of this study was to examine factors influencing IPV disclosure to any person of interest or organization supporting women during pregnancy in Moshi Municipality, Tanzania.Data were from a prospective cohort study of 1123 pregnant women followed-up by the project aiming to assess the impact of violence in the reproductive health conducted in Moshi Municipality, Tanzania from March 2014 to May 2015. Inclusion criteria to the current analysis were all 339 pregnant women who reported to have experienced physical, sexual and/or emotional violence during the index pregnancy. Data analysis used SPSS Version 20. Odds ratio with 95 % Confidence Interval (CI) for factors associated with IPV disclosure was estimated using multivariate logistic regression models while controlling for age, education and parity. A p-value of less than 0.05 was considered for a statistically significant difference.n = 79). Disclosure of IPV was less likely among unemployed  and women whose index pregnancy was unplanned . Women who regularly participated in women’s or community groups, religious groups or political associations at least once a month had 2 times higher odds of IPV disclosure compared to those who did not attend regularly . Most of the abused women during pregnancy who disclosed their experience of IPV (69 %) disclosed to a member of the family of birth followed by friends (14 %) and a member of family of the partner (11 %).IPV disclosure was found to be 23.3 %  disclosed their experience to someone. Identification of the women experiencing IPV during pregnancy should be done as a starting point for supporting victim of IPV. Women empowerment in economical and reproductive health will reduce their vulnerability and facilitate disclosure of IPV for support. Key individuals who informally support victims of IPV should be targeted in interventions.The online version of this article (doi:10.1186/s12889-016-3345-x) contains supplementary material, which is available to authorized users. Intimate partner violence (IPV) is a serious public health problem globally. IPV is the most common type of violence against women perpetuated by men and estimated to be around 30 % globally . IPV preIPV disclosure may result into positive impacts to the victims if the process of disclosure is taken care well. The reported positive impacts of IPV disclosure include stop of further violence, safety of pregnant women and their pregnancy and assisting in the creation of new interventions towards violence , 9. AlsoDespite the high prevalence of IPV to the general population and during pregnancy, disclosure of IPV experience has remained low globally. Studies that tried to explore IPV disclosure have estimated to happen among 4 to 8 % globally , 8.8 % iThis study was carried out within a larger study titled “The Impact of Violence on Reproductive Health in Tanzania and Vietnam (PAVE)”. The study was a prospective cohort and recruited a total of 1123 pregnant women when they were attending antenatal care in two health care facilities in Moshi District –Tanzania from March 2014 to May 2015. Women who fulfilled the inclusion criteria were enrolled in the study, interviewed at baseline and followed up at 34 weeks gestation for the second interview. Only women with singleton pregnancy, at gestational age below 24 weeks based on ultrasound scan and willing to be followed up for the entire period of the study were enrolled in the study.Swahili language.After consenting participation, first interview was conducted using questionnaire to capture baseline socio-demographic and reproductive health characteristics of the participants , reproductive history  and health risk behavior of alcohol consumption during pregnancy. Detailed social characteristics were inquired and included place of growth (this community or another community), living close to the family of birth and/or the family of the partner (yes/no), frequency of talking to a member of family of birth and/or of the partner  and whether they counted support from family of birth and/or of the partner in case of problems (yes/no). Socialization was also inquired as to whether they participated in women’s or community groups, religious groups or political associations at least once a month (yes/no).Data were analyzed using Statistical Package for social Sciences . Descriptive statistics including frequency and proportion for baseline characteristics were done. On bivariate analysis, socio-demographic and reproductive health characteristics among those who did or did not disclose were compared using odds ratio (ORs) with 95 % confidence interval (CIs). Multivariate logistic regression analysis was done by including all factors which were significant in the bivariate logistic regression analysis to determine the most significant factors for IPV disclosure and also control for confounders. A factor was considered a confounder when a change to crude OR after adjustment was 10 % or more. P-value of less than 0.05 was considered for a statistical significant difference.The mean age of participants was 26 years (Standard deviation SD = 5.8 years). Their age ranged from 18 to 44 years. The overall characteristics of respondents are displayed in Table As shown in Table Over one third (35.4 %) of women would never depend on support from a member of family of the partner as compared to nearly a quarter 82 (23.2 %) who did the same to a member of the family of birth. Most of the participants in the study 282 (83.2 %) were not attending any support group or organizations.Out of 339 pregnant women who experienced any form of IPV, 79 (23.3 %) reported to have disclosed IPV to someone. As Table Table Results of adjusted analysis in Table Disclosure pattern is as displayed in Fig. This study aimed at examining factors influencing disclosure of IPV experienced by women during pregnancy in Moshi Municipality, Tanzania. To the best of our knowledge, this is the first study in low income countries to determine factors influencing disclosure of IPV abuse during pregnancy in a longitudinal study and at a primary health care setting.The key findings of this study indicate that, less than a quarter (23 %) of all women who were exposed to physical, sexual and/or emotional abuse during pregnancy disclosed their experience and the rest kept suffering in silence. IPV disclosure was less likely among women who were unemployed and with unplanned pregnancy. Participation in women’s or community groups, religious groups or political associations facilitated IPV disclosure. Abused women during pregnancy preferred to disclose IPV to members of family of origin followed by friends and to the family of in-laws.This study found that IPV disclosure is very low. Tanzania Demographic Health Survey (TDHS) 2010 , 10. InfLow level of IPV disclosure could be due to African kingship system, cultural and religious background where family issues are not expected to be exposed outside the marriage/relationships. Women are expected to be submissive to their husbands and disclosing information related to violence outside marriage/relationship is seen as immoral . On the This study revealed that women who were unemployed were less likely to disclose their experience of IPV compared to women who were employed. Pregnant woman who depend on their partner for economic support fail to disclose because the partner may, as a consequence, refuse to support them. In many instances, unemployment is determined by education level and in such cases, education remains as a pro factor to employment. Although education was not significantly associated with IPV disclosure in our study, its link to employment and IPV disclosure cannot be overlooked. Studies have shown that educated women feels more safe, confident and protected when compared to those who are less educated . In addiAccording to previous studies, other factors which influence IPV disclosure are nature/type of the IPV, severity of IPV, having children, personal factors and normalizing violence experiences as an expression of love , 21, 22.This study further revealed that participants who attended women’s organizations were more likely to disclose compare to those who did not attend. The reasons here could be because those who attend organizations are more likely to be exposed to others who might have experienced IPV. They may be encouraged by others to share their life challenges and therefore contribute to the likelihood of IPV disclosure. On the other hand, most of women associations are geared towards economic empowerment and therefore decreasing women vulnerability from economic dependency to their partners , 24.Victims of abuse preferred to disclose their IPV status to a member of the family of origin compared to a member of the family of partner. The majority of women who experienced IPV in this study relied on the informal networks as their first point of contact rather than formal services. Similar pattern of IPV disclosure was reported previously . It coulNearly three quarter of the participants had disclosed IPV to the family of origin. Majority of them preferred their parents, followed by their brothers or sister and uncle or aunt. These findings are similar to the study done in Nigeria where larger proportions of participants (68 %) were willing to disclose their IPV status to the family . The plaFamily of the in-laws could play a very significant role to end IPV because of the feeling that it is easy for the parents to face their son. But the situation was different from this study as only 11 % disclosed to the family of in-laws. In African settings, a woman is seen by the in-laws as someone respected. This may hinder victims from facing the in-law to disclose IPV .. One reason for less likelihood of disclosing to institutions would be that they are more formal and women are not sure of what formal action/measures will be taken to stop further violence once they disclose IPV. Primary focus of abused women is bringing back peace in the relationship and the least they would want is family breakdown. This may be the case if men decide to react when appropriate actions are taken to them as perpetrators [Less than one in ten participants had disclosed to police, counselor, NGO/women’s organization or local leaders while in Nigeria, 26 % of women exposed to IPV disclosed to formal institutions . Formal etrators . TherefoHealth-care providers are in a unique position to create a safe and confidential environment for facilitating disclosure of violence, while offering appropriate support and referral to other resources and services . One docThe study relied on secondary data which made it difficult to clarify missing information with participants. Violence being among the sensitive topics, interviewed participants may have with-held information or provided socially desirable answers to avoid being deviant to their culture or religious beliefs.The disclosure of IPV is complex. The findings presented in this study have shown that very low proportions of women who experienced IPV during pregnancy disclosed their experience. Factors for IPV disclosure includes occupation, planned pregnancy and attending group organization or association. We have also observed that majority of women prefer to disclose to their family of origin. Since disclosure is important for setting up interventions to support victims of IPV, findings of this study need to be used to provide important background for interventions that aim at encouraging IPV disclosure and support of victims of IPV. Patterns of disclosure show that members of family of origin and of the partner are preferred by women who share their IPV experience. Therefore, parents and other family member need to be equipped with knowledge on IPV and proper ways to assist IPV victims after disclosure. Family based violence counseling strategies are imperative. Because discloser to the formal institution is very low, these institutions should be equipped to play their role in address IPV in collaboration with informal networks. For pregnant women to be supported well and in a comprehensive way, identifying women who need support should be done and antenatal care could be the best place to start. Further research is needed to explore how informal institutions are effective in addressing the problem of IPV and in helping victims of IPV.CI, confidence interval; DANIDA, Danish international development agency; HIV, human immunodeficiency virus; IPV, intimate partner violence; NGO, non-governmental organization; OR, odds ratio; SD, standard deviation; SPSS, statistical package for social sciences; TDHS, Tanzania demographic health survey; WHO, World Health Organisation


Intimate partner violence (IPV) is common worldwide and occurs across social, economic, religious and cultural groups. This makes it an important public health issue for health care providers. In South Africa, the problem of violence against women is complex and it has social and public health consequences. The paucity of data on IPV is related to underreporting and a lack of screening of this form of violence in health care settings.The aim of this study was to determine the prevalence of IPV and explore the risk factors associated with this type of violence against women who visited a public hospital in Botswana.A descriptive, cross-sectional survey was conducted among randomly sampled adult women aged 21 years and older, during their hospital visits in 2007. Data were obtained by means of structured interviews, after obtaining written and signed, informed consent from each participant.2 = 17.318; p = 0.001) and IPV, as well as cigarette smoking  and IPV.A total of 320 women participated in this study. Almost half (49.7%) reported having had an experience of IPV in one form or another at some point in their lifetime, while 68 (21.2%) reported a recent incident of abuse by their partners in the past year. Experiences of IPV were predominantly reported by women aged 21 – 30 years . Most of the allegedly abused participants were single  and unemployed . Significant associations were found between alcohol use by participants’ male intimate partners , especially among young adult women, but the prevalence of reported IPV is low (13.2%). It is essential that women are screened regularly in the country's public and private health care settings for IPV. IPV is sometimes referred to as domestic violence. The word ‘violence’ is also used interchangeably with ‘abuse’.4 This makes it an important public health issue for health care providers. Most of the time the abuse from IPV is hidden from the public's view and society remains uninformed of the nature and extent of such violence and abuse. Consequently, this form of violence and the extent of the problem cannot be directly observed.In South Africa, the problem of violence against women is complex and has social and public health consequences.5Of concern is the paucity of data on IPV due to ‘underreporting’ and ‘lack of screening’, which contributes to the complexity and the magnitude of this form of violence, especially against women. Furthermore, obtaining reliable data on IPV is a complicated and intricate task, because of the private and intimate context in which this form of violence and abuse often takes place and also because of methodological challenges imposed by the nature of such studies.6Research on violence against women is considered an important objective of any programme designed to eradicate this problem. At the fourth World Conference on Women held in Beijing in 1995, one of the strategic objectives established was to study the causes and consequences of violence against women and the efficacy of preventive measures, thus encouraging governments and organisations to promote research in this area.7 The objective of this study was to develop methodologies to measure violence against women and its health repercussions in different cultures.A World Health Organization's (WHO's) population-based survey on women's health and domestic violence against women in 2005 established that 10% – 69% of women had been assaulted by their male intimate partners at some stage in their lives, and that 15% – 30% had been assaulted in the previous year.4 In Africa, men are seen as the head of the marriage or relationship, which indirectly promotes either verbal or physical abuse towards their female partners.8 The latter has also been observed in Mochudi, a village in Botswana, which shares common socio-cultural features with other southern African countries.9Furthermore, the results of the WHO survey showed that the national lifetime prevalence of partner abuse among South African women was estimated at 13% and occurrence in the previous year at 11%. The Eastern Cape was found to have the highest lifetime prevalence of 27% and previous-year prevalence of 11%.10 and the recommendations prescribed in the ethical and safety guidelines for research on domestic violence.11 Written and signed informed consent was obtained from each participant prior to data collection. Special arrangements were made for participants to be interviewed after their consultations. Participants were informed of their voluntary participation and that they could decline to participate or withdraw from the study at any time, without any negative consequences. Confidentiality and anonymity of participants were maintained throughout the study by non-disclosure of information obtained and analysis of data as ‘group’ data. Participants who had psychological distress during the interviews were referred to the hospital social worker for counselling and follow-up care, as pre-arranged by the researchers.Ethical clearance for the study was granted by the Medunsa Research Ethics Committee of the University of Limpopo (MCREC/PH/114/2007), South Africa. The study was conducted following the standard ethical guidelines on conducting gender-based violence studies as stipulated by the WHO,12 The health setting has been identified as one of the best contexts in which IPV can be identified and studied, mainly because of its accessibility and because women who have experienced this form of violence or abuse make greater use of health services than those who have not suffered such an experience.14This study was conducted to determine the prevalence of IPV and explore the risk factors associated with this type of violence against women who visited a public hospital in Botswana. A descriptive, cross-sectional survey was conducted among adult female participants aged 21 years and older (the lower age limit was chosen because of consent rules in Botswana) who sought medical care for themselves or their children in a public hospital in Botswana. Participants were recruited after their medical history was taken, in order to exclude those with serious physical illnesses . Moreover, participants were interviewed after their consultation, as their medical conditions could then be considered as stable. A hospital setting was used for this study in order to reduce the risk of further abuse of participants, especially if accompanied by their abusive intimate partners.Two trained, female research assistants fluent in Setswana (participants’ home language) and English assisted with data collection. The statistics program SPSS version 14.0 was used to analyse data and a chi-square test and univariate logistic regression analysis were used to determine the relationships between socio-demographic characteristics and behavioural risk factors associated with IPV. Odds ratios were obtained for each risk factor and logistic regression analysis was done to determine the relationship between the risk factors and IPV.From a sample of 352 that was recruited, a total of 320 adult women who attended the outpatient department at a public hospital in Botswana consented to and participated in this study (a 90.9% response rate). Participants were enrolled consecutively over a three-month period on outpatient days that were quieter – hence some days were omitted. Some participants were recruited and agreed to participate in the study but because the interviews were conducted after their consultations, they did not come back to the researchers as they were in a hurry to return home.Results indicated the participants’ marital statuses at the time of the study as follows: 173 (54%) were single, 75 (23%) were married, 14 (4%) were divorced and equal proportions indicated that 29 (9%) were widowed and cohabiting with their intimate partners .The majority (91.9%) indicated that they had formal education, of which 25% had post-secondary level education. Only 8.1% indicated that they did not have any formal education .According to the results, 140 (44%) participants were unemployed and had no source of income, 117 (37%) were formally employed either by the government or in private establishments, 27 (8%) were self-employed and 11% were engaged in casual jobs. Of those employed, 78 (43%) indicated that they earned below BWP1000 per month . This was categorised into: (1) a lifetime, or (2) within-one-year experience of IPV. As depicted in Participants were asked if they were financially dependent on their male partners. Responses indicated that 208 (65%) denied financial dependence, compared to 112 (35%) who admitted to such dependence, as they otherwise had no source of income, being unemployed.Slightly more than half of the participants  stated that their intimate partners consumed alcohol, of which 54 (16.9%) were habitual alcohol drinkers . About tp-value < 0.005). Chi-square analysis showed a significant association between participants’ marital status and lifetime experience of abuse  and experience of abuse in the previous year .Participants were asked about known risk factors associated with IPV. Participants who reported experiences of IPV in their lifetime  were asked to indicate the person(s) they had reported the experiences of abuse to. Slightly more than half of the participants (51%) had reported their IPV experiences to close relatives and 40 (25.1%) had reported to the police. Eight respondents (5.03%) stated that they had reported IPV experiences to the nearest hospital and an equal number of participants reported it to other people, mainly social workers  and friends . The remaining participants  indicated that they did not report their IPV experiences for various reasons (not explored in this paper).7 A WHO report on violence and health indicates that young women and those below the poverty line are disproportionately affected by IPV. 11 Previous reports on IPV have shown that the young ages of male perpetrators and their victims could also be a risk factor to violence and abuse because of various factors such as immaturity, poverty and unemployment.The results of this study showed that IPV is common in young women and those who are economically dependent on their male partners. These findings concur with those from other national surveys done globally, which show that IPV is more common among women than men.15 In a similar study conducted in Uganda in 2003, the authors estimated the lifetime prevalence of partner abuse among women to be 54%, while the past-year prevalence was 14%.16The results of this study estimate the lifetime and past-year prevalence of IPV to be 49.7% and 21.2%, respectively. This indicates a high prevalence of IPV among the study population, that is, one in every two and one in every five adult female patients who visited the out-patient department of the institution had experienced lifetime and past-year IPV, respectively. These findings are similar to those from a study conducted in China in 2005, which showed the lifetime and past-year prevalence estimations to be 43% and 26%, respectively.17 Findings from a similar study conducted among female patients in a public hospital in Durban  showed an estimated lifetime prevalence of IPV of 38%.18 Data from health care-based IPV prevalence studies in the United Kingdom in 2004 estimated lifetime and past-year prevalence to be 12% – 46% and 6% – 28% respectively,19 while in the United States of America in 2002, it was 30% – 39% and 6% – 23%, respectively.20 Although IPV is regarded as a global concern, the challenge of its underreporting affects the prevalence estimates and magnitude of this form of abuse.19In South Africa, the results of a WHO population-based survey carried out in 1998 estimated the national lifetime prevalence of IPV among women to be 13% and the past-year prevalence of IPV to be 11%. Furthermore, provincial figures established that the Eastern Cape province had the highest lifetime prevalence of 27% and a past-year prevalence of 11%.16A London-based study in 2002 on domestic violence revealed that the lifetime prevalence of partner violence in health care settings was 41% and the past-year prevalence was 17%.20In 1999, a national study on violence against women conducted in Botswana by the Women's Affairs Department found that violence against women was an immense problem, with three out of every five women having been a victim of such violence.9 In a similar study in Uganda, the authors estimated the lifetime prevalence of partner abuse among women to be 54%, while the past-year prevalence was 14%.p-values included the participants’ questioning of male partners about their extra-marital relationship(s) (p < 0.0001), financial dependence on the male partner (p = 0.002), and refusing to engage in a sexual relationship (p < 0.0001). All were found to increasingly expose participants to IPV.Several risk factors have been ascribed to IPV, including socio-demographic, cultural and behavioural factors. In this study, as reported by the participants, infidelity and actions against the wishes of the male partners were the most common risk factors for IPV, with odds ratios of 23.26 (95% CI: 9.31–58.09) and 63.81 (95% CI: 7.10–573.42), respectively. Other factors with statistically significant c2 = 40.967; p < 0.001) it was not reported by most of the participants as contributing to their experience of IPV. The most common behavioural risk factors associated with IPV found in studies carried out in China, USA, UK, South Africa, Uganda and Malawi are (1) extramarital affairs, (2) use of alcohol and other drugs, (3) doing things against the wishes of the male partner and (4) arguments about monetary issues .21 Results from other studies revealed that alcohol did not initiate IPV, but worsened its outcomes in terms of severity.22Regarding alcohol and other substances used by male partners, although there was a significant association with IPV  a relatively young age, (2) poverty or unemployment, (3) being divorced or separated and (4) a low level of education.14Several studies have revealed an association between socio-demographic characteristics of both the victims of IPV and the offenders and significant relationships.c2 = 7.991; p = 0.035) for a lifetime experience of abuse, where the chances of abuse decreased with increasing age of participants. Such findings (that IPV occurs more frequently in younger people) was also supported by findings from a study conducted in London in 2002, UK, which confirmed that women younger than 45 years (with the highest risk occurring between the ages of 16 and24 years) have a higher risk of experiencing IPV than those older than 45 years.20 This has been ascribed to immaturity and lack of patience among partners in a relationship.1 Results of this study did not reveal any statistically significant association between age and a past year's experience of abuse , which is similar to results of a similar study carried out in China.15 The reason for this difference is not clear.The results of this study further showed a strong relationship between the ages of participants and the occurrence of abuse. This association was only significant  between marital status and lifetime experience of abuse, with the highest occurrence among divorced participants (93%), followed by cohabiting partners (75%), singles (49%) and married partners(40%) and the lowest occurrence among widowed participants (34%). This trend was also found with a past-year experience of abuse. A similar trend and order of occurrence, was found in the National Violence Against Women Survey carried out in the USA in 2000.2 Several other studies conducted in Botswana, South Africa, USA, China and Malawi also reported similar associations, with the highest occurrence among unmarried and cohabiting couples.22This study found a strong association  between the educational level of participants and the occurrence of abuse: both educated and uneducated women experienced abuse equally. This was supported by the findings of a Ugandan study, which established that the educational level of women only reduced the frequency of IPV but did not prevent it.16Studies conducted in 2005 in South Africa and Malawi have found that a lower educational status exposes women to IPV.7 This study found that about 44% of all participants were unemployed and therefore did not earn any income, 35% depended economically on their male partners, while others depended on parents and relatives. A significant relationship  was found between the ‘economic status’ of abused participants and the experience of abuse and the risk decreased as the amount of income that was earned increased. This is in agreement with studies carried out in Africa, Asia and America, which found that women with low socio-economic status are more prone to abuse.22Unemployment, poverty and economic dependence of women expose them to IPV.21 A similar trend was found by researchers in a South Africa national survey on partner violence.18 A high level of education, however, does not rule out violence: it sometimes predisposes women to abuse, especially if the male partner is less educated.14A systematic review of relevant studies conducted in the USA, UK and Malawi found that the low educational levels of women predispose them to abuse by their intimate partners.22 The results of this study also indicated a very strong association between the frequency of use of alcohol and other drugs (both with p < 0.001) by the male partner and the occurrence of IPV in their relationships. There are significant differences between studies in terms of the methods used to measure the presence or absence of alcohol and in the definition of alcohol consumption as a risk factor for the development of violent behaviour. A Chinese study revealed that the use of cigarettes and other drugs increased the chances of a man to abuse his female partner.15 This is consistent with the significant association between the use of other drugs (mainly cigarettes) and occurrence of abuse found in this study.The consumption of alcohol, a major cause of many social vices, has been found to be related to IPV. A number of studies reveal that alcohol only contributes to violence rather than causing it, and that those women who live with heavy drinkers are at far greater risk of physical partner violence, which tends to be more serious, than that found in those not consuming alcohol.21 The results of this study are not consistent with these findings, since no statistically significant association was found between participants’ experiences of abuse and economic dependence or independence on their male partners . The majority of the women who participated in this study stated that they were not economically dependent on their male partners but, despite such confirmation of financial independence, about half of them still experienced abuse and the overall prevalence of abuse was high. Findings from a study conducted in Botswana reported that almost half of the households in Botswana are headed by women who sustain their families, including their male partners or husbands.9 Our results indicated that the majority of the participants were unemployed and earned no income. It did not include consideration of others upon whom the women could depend for financial support.As indicated earlier, studies conducted in the USA, China, Malawi and South Africa found that economic independence of women protected them from various forms of abuse by their male partners.13 For this reason, participants who were accompanied by their partners were not included in the study and thus valuable data could have been overlooked.This study was limited to one public health institution and, although a high response rate was achieved, the views of other women from other institutions, or in the community, regarding their experiences of IPV, could not be explored. Furthermore, because this study was self-reported and retrospective, the risk of ‘recall’ bias from participants cannot be overruled. In this study participants were recruited in a health care setting, which increases the chance of a ‘selection’ bias, as it is known that women who experienced violence and abuse make greater use of health services, resulting in a possible overestimation of the prevalence of IPV in the general population. On the other hand, because of the methodological limitations imposed by the nature of this study, the researchers had to protect participants from further harm and abuse by their partners, as recommended in the ethical and safety guidelines for research on domestic violence.IPV is a common public health problem globally. The prevalence of alleged IPV in Botswana is relatively high (49.7%), especially among young adult women, but the prevalence of reported IPV is low (13.2%). It is essential that women are regularly screened in public and private health care settings for undisclosed IPV. In order to quantify the magnitude of such violence, and to implement interventions that can lead to improved outcomes for women who have experienced IPV, it is crucial that clinical guidelines be made available to enable health care professionals to conduct effective screening for IPV. It is our view that the risk of benefit versus harm could be determined once the magnitude of IPV has been established through IPV screening.


The objective of this study was to investigate factors contributing to intimate partner violence in pregnancy among antenatal attendees at the health facilities in West Pokot Sub-County. The study was done in West Pokot Sub-County.Using cross sectional study design, a total of 238 antenatal attendees were systematically sampled for the study. Four focused group discussions and 20 key informant interviews were conducted for qualitative data collection. Qualitative data was consolidated into various themes while bivariate and logistic regression analysis was done to determine factors associated with experience of IPV in the index of pregnancy with P ≤ 0.05 being considered significant.The study found prevalence of overall, physical, psychological and sexual IPV in pregnancy to be 66.9%, 29.9%, 55.8% and 39.2% respectively. After adjusting for confounders, Overall IPV in pregnancy was significantly associated with Alcohol intake by partner  and partner's level of education , while psychological and sexual IPV was significantly associated with age of partner  and age of pregnant women  respectively. The care offered to antenatal attendees experiencing IPV was not in line with WHO guidelines and standard on handling gender based violence cases.The study finding indicates that IPV in pregnancy among antenatal attendees in West Pokot is very high. This unearths the gaps on gender based violence interventions in the maternal and child health programs. Violence against women perpetuated by intimate partners is a worldwide and an important public health concern as well as human rights issue. More than 1.3 million people worldwide die each year as a result of violence in all its forms, accounting for 2.5% of global mortality . In KenyStudy area: The study was conducted in health facilities in West Pokot Sub-County in West Pokot County, Kenya. It lies within longitude 34°47' and 35°35' East and latitude 1 and 2 North.Research design: This was both quantitative and qualitative descriptive cross-sectional study to determine the prevalence of intimate partner violence during the pregnancy among antenatal attendees in 11 sampled health facilities.Sampling procedure: Stratified two stage random sampling was used in this study. The health facilities in the Sub-County were first stratified according to MOH service delivery levels . This resulted into three strata; Level II, III and IV from which 11 health facilities were proportionately and randomly sampled from a total of 20 health facilities in the Sub-County. The respondents were distributed proportionately to each health facility depending on the average number antenatal attendees in health facilities in the year 2012 as per District health information system .This was followed by systematic random sampling of 238 participant at interval of three mothers at each health facility to identify the respondents where the interval was the overage monthly antennal attendance divided by required sample size (622/238 = 2.613≈3). The starting point was randomly generated number at each facility included in the study. This was done using the established clinic queues to systematically sample antenatal attendees for interview until the sample size was achieved for each health facility. Data was collected within one month from 1st to 26thSeptember 2014 to avoid any bias that might have resulted from antenatal revisits in the following month.Data analysis: Data was entered; cleaned, analyzed and stored using SPSS. Descriptive analysis of variables and graphical presentation was done using proportions and frequency to describe the social demographic characteristics of women and intimate partner's. Prevalence of women reporting the various forms of IPV in the current pregnancy was sought. Odd ratio was used to show the strength of associations. Bivariate analysis was done to compare independent factors of women who experience violence in the index of pregnancy with women who did not. Multiple logistic regression analysis predicting overall, physical, psychological and sexual IPV was used to explore the adjusted association of covariates that had a p < 0.1 in the bivariate analyses with a P ≤ 0.05 being considered significant. Responses from the FGDs and KIIs were analyzed by content analysis, summarized under various themes, inferences made from each theme and conclusions drawn was then triangulated with the data from the questionnaire.Sociodemographic characteristics of respondents: The study approached 238 antenatal attendees and achieved a response rate of 224 (94.1%). Among the 224 women respondents, 44 (19.6% were aged between 35 and 39), 20 (8.9%) were aged between 45-49. More respondents reported to have had more than one pregnancy 117 (52.2%) while 311 (13.6%), 90 (40.2%) and 103(45%) were in their first, second and third trimesters respectively. Most respondents reported to be married 184 (82.1%) with 116 (51.8%) having been in marriage for four year and less and only 65 (29%) had been married for ten years and above. Most of women had formal education 182 (81.3%) with the highest level of complete primary school 114 (50.9%). The majority of the respondents 168 (75%) were unemployed.Prevalence of intimate partner violence: The prevalence of overall, physical, psychological and sexual IPV was in the current pregnancy was 150 (66.9%), 67 (29.9%), 125 (55.8%), 88 (39.2%) respectively. Figure 1 is a three-way contingency table analysis of different forms of IPV experienced singly or combination. These results were also supported by the outcome of the FGDs. Across all the FGDs participants mentioned psychological, physical, sexual, and economical violence. Psychological was ranked first, Economical second; where the man controls the expenditure of the woman, sexual third and physical fourth .Predisposing risk factors of IPV in pregnancy: The bivariate analysis showed association between various factors and overall IPV among the pregnant women, however only alcohol intake by partner was significantly associated with overall IPV (p = 0.000). Risk factors associated with physical violence: Level of education of pregnant women, polygamy marriage and alcohol intake by both partner and pregnant women were significantly associated with physical IPV in bivariate analysis (p ≤ 0.05). Risk factors associated with psychological violence: Age of partner, Length of relationship and Partner's alcohol intake were significantly associated with psychological IPV, (P < 0.05) in the bivariate analysis while Multiple logistic regression analysis indicated two factors to be associated with psychological IPV. Pregnant women with partner less than 25 years of age were two time more likely to experience psychological IPV than women whose partner were more than 25 years of age (p = 0.007) while pregnant women with partner who takes alcohol were slightly more likely to experience psychological IPV than those whose partner don't take alcohol (p = 0.000) (= 0.000) .Risk factors associated with sexual violence: Partner's level of education and partner alcohol intake were significantly associated with sexual IPV (P < 0.05) while age of respondent was not significantly associated with sexual IPV (P = 0.065) in bivariate analysis. However multiple logistic regression analysis indicated only alcohol intake by partner to be significantly associated with sexual IPV, (P = 0.015). Pregnant women with partner's who take alcohol were 2.486 more likely to experience sexual IPV than pregnant women whose partner were not taking alcohol  a higher prevalence than that of many conditions normally screened for during pregnancy.Risk factors of IPV in pregnancy among antenatal attendees;Quality of care offered to pregnant women experiencing intimate partner violence.The authors declare no competing interest.


Intimate partner violence (IPV) during pregnancy is prevalent across the world, but more so in low- and middle-income countries. It is associated with various adverse outcomes for mothers and infants. This study sought to determine the prevalence and predictors of IPV among pregnant women attending one midwife and obstetrics unit (MOU) in the Western Cape, South Africa.A convenience sample of 150 pregnant women was recruited to participate in the study. Data were collected using several self-report measures concerning the history of childhood trauma, exposure to community violence, depression and alcohol use. Multivariable logistic models were developed, the first model was based on whether any IPV occurred, the remaining models investigated for physical-, sexual- and emotional abuse.Lifetime and 12-month prevalence rates for any IPV were 44%. The 12-month IPV rates were 32% for emotional and controlling behaviours, 29% physical and 20% sexual abuse. The adjusted model predicting physical IPV found women who were at risk for depression were more likely to experience physical IPV , and the model predicting sexual IPV found that women who reported experiencing community violence were more likely to report 12-month sexual IPV .This is the first study, which illustrates high prevalence rates of IPV among pregnant woman at Mitchells Plain MOU. A significant association was found between 12-month IPV and unintended pregnancy. Further prospective studies in different centres are needed to address generalisability and the effect of IPV on maternal and child outcomes. Violence can have detrimental effects for those who encounter it, often resulting in bodily harm; mental, physical and emotional suffering; loss of productivity; and fatality, representing an increased burden for social and public health sectors  focuses on violence against women in the general population . Alcohol use has been associated with countless personal harms including violence and aggression; elevated rates of IPV; general familial friction as well as poor parenting styles, as it affects both cognitive and physical functioning, often reducing the ability of self-control and increasing the likeliness of violent altercations  in the Western Cape, South Africa, and the associations between alcohol use, depression, childhood abuse and exposure to community violence. This study was conducted at Mitchell's Plain MOU, a primary level maternity facility offering pregnant women antenatal care throughout the pregnancy, as well as HIV testing and counselling. The facility also has a labour ward for deliveries as well as post-natal care. Understanding the frequency of IPV within this community is essential to identify possible need for psychosocial interventions. The present study attempts to address this gap by answering the following two-pronged research question: What is the prevalence of IPV among women attending one antenatal clinic in the Western Cape, South Africa and what are the risk factors associated with IPV among this population.Data were collected at an MOU in the Western Cape, South Africa. This community forms part of one of the largest townships in the Western Cape, South Africa. Townships are commonly used to describe urban or peri-urban communities that are largely economically and geographically underdeveloped.A convenience sample of 150 pregnant women attending antenatal care appointments at the MOU was asked to participate in this study. Participants had to be 18 years or older, pregnant (any term during pregnancy), a registered patient at the MOU, as well as being willing and able to participate in an interview in either English or Afrikaans.Recruitment of participants occurred over a 2-month period (November–December 2015). Potential participants were approached while they waited for the clinic. Appointments for interviews were scheduled for those who interest in participation on days and times that were most convenient for the participants. Sampling took place 5 days of the week for ~5 h/day.et al., G*Power version 3.1.9 software  for a local grocery store as compensation for their time. Participants who required further intervention after the interview, where assessed and given referrals to social workers, counsellors or mental health nurses, as deemed necessary by the researcher (a registered trauma counsellor).Data were collected using the following measures:Information was collected regarding participant's race, age, level of education, current employment status and marital status, whether the pregnancy was planned or unplanned, the number of previous pregnancies and pregnancy gestation.lifetime and 12 months). It includes subscales for the assessment of emotional abuse and controlling behaviour as well as physical and sexual abuse. Questions such as ‘Have you ever been hit, slapped, kicked or otherwise physically hurt by your current or previous intimate partner?’ are included. While it has not yet been validated for the use in South Africa, local studies have shown good reliability rates  (23.0) was used to analyse the data. Frequency distributions and descriptive statistics were calculated for categorical and continuous variables. The unadjusted associations between IPV as the dependent variable, and participant demographic characteristics, history of childhood abuse, self-report alcohol abuse and perception of community violence as independent variables, were analysed. In addition, multivariate logistic models were developed to control for demographics and socio-economic variables , alcohol abuse, community violence and childhood trauma. The first was based on whether any IPV occurred (lifetime and 12 months), while the remaining three models investigated IPV for physical abuse, sexual abuse and emotional abuse for both lifetime and 12 months experience. The results of the regression models are reported as odds ratios (ORs) with 95% confidence intervals (CIs).n = 93, 62%) and between the ages of 18 and 30 years old . Just over half of the respondents completed high school . Respondents reported that many of them indicated that their current pregnancy was unplanned . Notably of the 115 participants who indicated that their pregnancies were unplanned only 32 (65.3%) specified being in an intimate relationship. More than half of the participants,  reported that they were in their second trimester of pregnancy (weeks 13–28). Respondents reported high levels of childhood trauma  and witnessing community violence . It was found that 38.7 and 25.3% met criteria for depression and alcohol, respectively.The socio-demographic details of participants are detailed in n = 70, 46.7%), followed by emotional abuse and controlling behaviours  and sexual violence (n = 24.7%). Most types of IPV victimisation were reported to occur during the second trimester of pregnancy  (see p > 0.05).Both the 12-month and lifetime prevalence rates for IPV were calculated to be 44.7%. Physical violence was the most common form of abuse experienced in the women's lifetime (.2%) see . It was The unadjusted and adjusted associations between participant characteristics and the experience of emotional and controlling behaviours in the past 12 months are reported in The unadjusted and adjusted effects of participant characteristics on the experience of any 12-month IPV are displayed in The unadjusted and adjusted associations between participant characteristics and the experience of sexual IPV in the past 12 months (by an intimate partner) are reported in n = 94, 62%), while possible cases of depression and alcohol dependence problems were detected in 38 and 25%, respectively.Several important findings were made. First, the prevalence of IPV among pregnant woman attending an MOU in the Western Cape, South Africa was high. Second, the study identified four main variables as risk factors for IPV in this sample of pregnant women. Significant associations were found to exist between IPV and depressive symptoms; IPV and unintended pregnancies; as well as IPV and exposure to community violence. Furthermore, 82% of all respondents reported experiencing high levels of childhood trauma; 62% had witnessed community violence  were more likely to experience IPV than women who were older than 30. Burgos-Soto et al.  have arget al., et al., et al., et al., et al., et al. (Experiencing depressive symptoms during pregnancy was also found to predict elevated IPV in this sample. The results showed that women with symptoms of depression were four times more likely to experience physical IPV than those who were asymptomatic. Increased symptoms of depression were also found to be significantly associated with any form of IPV in the previous 12 months. Depression may also be an outcome/consequence of IPV rather than a predictor; however as this study was cross-sectional, no directional relationship could be determined. These findings are consistent with studies that have found mental health problems to be highly correlated with experiences of IPV (Rao , et al.  found thet al., et al., et al. (The association between IPV and depression appears to highlight the impact that violence has on the mental health functioning of the individuals exposed to it. However, while no directional link between depressive symptoms and IPV can be inferred from this data, some research has shown that individuals with mental health problems, such as major depressive disorder, are at risk for becoming victims of abuse or ill-treatment (Elbogen & Johnson, , et al.  posit thet al., et al., et al., et al., et al.,Unintended pregnancy was found to be another predictor of IPV in this sample. Women who reported experiencing emotional and controlling behaviours in the previous 12 months were three times more likely to have an unintended pregnancy than women who reported experiencing no abuse. Remarkably, more than 70% of the study's respondents indicated that their current pregnancy was unintended. Furthermore, of those who reported any form of IPV in the past 12 months, 88% of the women in this sample indicated that their current pregnancy was unintended. Studies investigating the association between IPV and unintended pregnancy are limited. However, it does appear to be a relatively widely recognised risk factor (Pallitto et al., th on the list of the 50 most violent communities in the world (Leggit, The fourth predictor of IPV identified in this study was exposure to community violence. Data from this study showed that women who reported witnessing community violence were four times more likely to report 12-month sexual IPV, than women who reported no exposure to community violence. Very little research has been conducted to investigate the relationship between IPV and exposure to community violence. However, recent data have shown that the Western Cape has significantly high levels of violence within its communities (Prinsloo  Leggit, . It is pet al., et al., et al., et al., Where South African policy is concerned, there has been very little recognition of IPV as a major health concern, nor has the development of strategies to effectively deal with IPV been attended to. Currently, the National Mental Health Policy Framework for South Africa (Freeman et al., et al., The study had several limitations. First, the study's sample size is small and drawn from one site, making any generalisation to even this setting as well as other parts of South Africa or elsewhere impossible. The substantial prevalence rate found is supported by other studies in the Cape Town area (Abrahams Recommendations for future research might include longitudinal designs investigating the experience of IPV postnatally and whether there are differences before and after the birth. Longitudinal studies might also provide important data about the long-term impact that IPV has on the mother and child. This would help to inform the development of appropriate intervention strategies and programmes for those affected. The effectiveness of screening and intervention programmes should be investigated. Further research could help examine and identify ways to incorporate screening interventions for IPV among pregnant woman, in primary health care settings. This data this could aid in detecting IPV and linking woman to resources such as non-profit organisations, social services and support groups or legal services.This is the first study of IPV to be conducted with pregnant women receiving antenatal care at the Mitchells Plain MOU. These findings are consistent with findings from other SA studies. The results from this study identified three major risk factors associated with IPV during pregnancy; high levels of unintended pregnancies, witnessing community violence and experiencing depressive symptoms. They also highlight the urgency for the development of appropriate policy and strategies to address IPV, particularly among pregnant women. Due to the high levels of IPV among pregnant woman, healthcare institutions and practitioners need to find new ways to identify, contain and provide adequate intervention and support for the victims.