|Year : 2019 | Volume
| Issue : 13 | Page : 1-9
Intimate partner violence among women attending a general practice clinic in Nigeria
Ehichoya D Oseyemwen, Ndudi K Oseyemwen, Bawo O James, Osahon Enabulele, Joseph Ajokpaniovo, Afolabi J Adewole, Leonard A Atsikidi, Oluwabunmi E Egharevba
Department of Family Medicine, University of Benin Teaching Hospital, Benin-City, Nigeria
|Date of Web Publication||19-Feb-2019|
Ehichoya D Oseyemwen
Department of Family Medicine, University of Benin Teaching Hospital, PMB 1111, Benin-City
Source of Support: None, Conflict of Interest: None
Background: There has been an increasing concern about the magnitude of violence against women, especially pregnant women in Nigeria. The long-term health impact of violence on the victims as well as the difficulty in directly associating violence with the health outcome of the victims is understudied in Nigeria. This study aimed to determine associations between physical health outcomes and intimate partner violence (IPV) in adult females attending a general practice clinic. Methodology: This was a cross-sectional descriptive study of 360 participants recruited using systematic sampling methods. A modified Abuse Assessment Screen tool was used to screen for IPV and the data were analyzed using version 21 of the Statistical Package for the Social Sciences (SPSS). Results: The prevalence of IPV in this study was 80%. Sexual abuse had the highest prevalence (56.4%), followed by physical and psychological abuse which had the prevalence of 46.7% and 31.9%, respectively. The common risk factors for IPV observed in this study included younger age of respondents, having a large family size, being employed, and partner's educational status. The common comorbidities found among the respondents experiencing IPV included hypertension, pelvic inflammatory disease, peptic acid disorders, osteoarthritis, and depressive illnesses. Alcohol use by partners was the most common perceived reason given by the respondents for their partners' perpetration of IPV. Conclusion: IPV as a part of violence against women remains very high and underreported in our society. The study showed a strong association between IPV and hypertension; this should be of interest to health-care practitioners and researchers.
Keywords: General practice clinic, intimate partner violence, Nigeria, women
|How to cite this article:|
Oseyemwen ED, Oseyemwen NK, James BO, Enabulele O, Ajokpaniovo J, Adewole AJ, Atsikidi LA, Egharevba OE. Intimate partner violence among women attending a general practice clinic in Nigeria. N Niger J Clin Res 2019;8:1-9
|How to cite this URL:|
Oseyemwen ED, Oseyemwen NK, James BO, Enabulele O, Ajokpaniovo J, Adewole AJ, Atsikidi LA, Egharevba OE. Intimate partner violence among women attending a general practice clinic in Nigeria. N Niger J Clin Res [serial online] 2019 [cited 2019 Sep 21];8:1-9. Available from: http://www.mdcan-uath.org/text.asp?2019/8/13/1/252579
| Introduction|| |
Intimate partner violence (IPV) describes actual or threatened psychological, physical, or sexual harm by a current or former partner or spouse. In countries around the world, 10%–69% of women report physical assault by an intimate partner at some time in their life. Most women who are victims of physical aggression experience multiple episodes of aggression over time., There are three main types of IPV: psychological/emotional, physical, and sexual. Relationships may gradually become abusive in nature, initially as verbal and emotional, but often become physical over time.
Violence against women is not a new phenomenon, nor are its consequences to women's physical, mental, and reproductive health. What is new is the growing recognition that the acts of violence against women are not isolated events, but rather form a pattern of behavior that violates the rights of women and girls, limits their participation in society, and damages their health and well-being in the long run. It has been documented that when studied systematically, violence against women is a global public health problem that affects approximately one-third of women globally.
The World Health Organization (WHO) includes IPV as a part of a larger problem referred to as “gender-based violence.” This also encompasses rapes, female genital mutilation, sexual harassment in the workplace, selective maltreatment of the girl child, and human trafficking.
Research findings show that victims of IPV suffer significant negative health consequences because of the physical, sexual, and emotional abuse they have experienced. This has substantially improved the understanding of the underlying physiological association between violence, victimization, and adverse health outcomes. Given the high prevalence of IPV, particularly among patients seeking care in primary care settings, and the associated medical and societal costs of IPV, it is critical to address this public health problem, since IPV affects all members of the family and the larger community.,
Some local studies on IPV have focused on the general population and on pregnant women, with little attention paid specifically to patients presenting to the health-care provider for other reasons other than physical or sexual assault.,,
Only a small percentage of IPV episodes are reported generally, such that many epidemiologic data are often estimates only., Some studies have reported about 20% of sexual assaults, 25% of physical assaults, and 50% of stalking episodes per annum.
The aim of the study was to determine the burden of IPV and the associated health outcomes in adult women visiting the general practice clinic (GPC) of the University Teaching Hospital in Southern Nigeria.
| Methodology|| |
The study was carried out in the GPC of the UBTH, Benin City. The hospital has a 750 in-patient bed capacity.
The GPC has 10 consulting rooms and a separate room used for management of emergency cases. It runs from 8 am to 6 pm on weekdays and 9 am to 5 pm on weekends and public holidays. An average of 250 adult patients are seen per day during the weekdays, while an average of 50 adult patients are seen per day during weekends and public holidays.
Women between 18 and 65 years of age who accessed the GPC of the UBTH for their health-care concerns during the period of the study were included in the study. The participants were sourced from this population by systematically selecting clients who fulfilled the inclusion criteria.
Sample size determination
Sample size was determined using the formula:
(n = Z2 pq / d2).
n = the desired sample size
z = the standard normal deviate, set at 1.96 which correspond to 95% confidence level
p = the prevalence of IPV (37%) (the WHO prevalence value for African region).
q = 1-p
d = degree of accuracy desired (set at 0.05)
= 0.8955/0.0025 = 358.2 (rounded off to 360)
Thus, minimum sample size required was 360.
Systematic sampling method was used to enroll participants into the study. An initial audit carried out in the record unit showed that an average of 250 clients were seen daily at the GPC and 40% of these were women who fell between the ages of 18 and 65 years. The two research assistants at the point of registration were engaged to systematically select six respondents of the first 60 clients who were registered before 12 noon each weekday. From these 60 females, every 10th client was selected to get the six respondents for each day during the period of data collection until the sample size was reached. A signature marker was placed on the top right corner of the respondents' consultation card to prevent its being selected repeatedly.
Women between 18 and 65 years of age who were ascertained to be in an intimate relationship and gave consent to participate in the study were included in the study.
Before recruitment into the study, the research was fully explained to the participants, inclusion criteria were confirmed, and informed consent was obtained.
A separate consulting room was available for interviewing the clients to ensure privacy and for taking their weights and heights. The clients' actual reasons for consultation were subsequently promptly addressed.
The respondents were interviewed using a semistructured questionnaire based on the electronic, second version of the International Classification of Primary Care (ICPC-2-E) questionnaire as developed by the World Organization of Family Doctors. The questionnaire had previously been used in an African study. The ICPC-2-E assesses health problems related to (a) general signs and symptoms, (b) blood, (d) digestive system, (f) eyes, (h) ears, (k) circulatory system, (l) musculoskeletal system, (p) mental illness, (n) neurology, (r) respiratory system, (s) skin, (t) endocrine, metabolic and nutritional functions, (u) urinary system, (w) pregnancy, child bearing, family planning, (x) female genital, and (y) male genital system. (The last was not used in this study, since the target population were adult females.)
During the study, the questionnaires, along with an already standardized modified partner violence screening tool; The Abuse Assessment Screen, was used to seek information on the respondents' socio-demographic data as well as other information regarding self-reported health problems (presenting complaints) and doctor-evaluated health problems (clinical diagnosis).
Women were classified as having experienced IPV when they gave any positive response to the abuse assessment questions or when they gave any negative response to the “SAFE” questions.
Appropriate clearance was obtained from the Ethical Review Committee of the University of Benin Teaching Hospital. The aim of the study was clearly explained to the various participants on the premise that information gathered in the course of the study was solely for research purposes and would be kept strictly confidential. They were also made to be aware that they could opt out at any point during the interview.
The IBM Statistical Package for the Social Sciences SPSS, version 21.0. (IBM Corp, Armonk, NY, USA) was used for data storage and analyses. Frequencies of sociodemographic characteristics, the prevalence of IPV, presenting complaints, and the common comorbidity patterns found in IPV victims as well as other variables of interest were determined, using the research tools for interviewing the participants. Descriptive statistics such as frequency tables, bar charts, and pie charts were used to summarize the data. Tests of associations were then conducted using Chi-square tests to determine associations between the following categorical variables: relationship status, pregnancy, household size of IPV victims, age, educational level of clients and their partners, as well as the occupation status of the respondents and those of their partners. The level of statistical significance was set at 5% (P < 0.05).
| Results|| |
Sociodemographic characteristics of respondents
The mean age of the participants was 40.5 ± 13.46 years. Most (57.2%) of the participants were married, in monogamous settings (86.4%). Nearly a third, i.e., 121 (33.6%) and 113 (32.5%) had secondary and tertiary level of education, respectively. Christianity was the predominant religion in 334 (92.7%) of the participants.
Two hundred and fifty-six (71.1%) of the respondents were employed and most of these (65.6%) worked as service and sales workers. Three hundred (83.3%) of the respondents' partners were employed while the remaining 60 (17.3%) were unemployed.
The size of each household ranged between 2 and 17 individuals, with an average size of 5. However, 193 (53.6%) of the respondents had household sizes which were <5. A small proportion of respondents, i.e., 41 (11.4%), were pregnant [Table 1] and [Table 2].
Prevalence and pattern of intimate partner violence
Two hundred and eighty-eight (80%) respondents had experienced one form of IPV or another during the preceding year. Sexual violence was predominant in 56.4%, followed by physical and psychological violence in 46.7% and 31.9% of participants, respectively. Thirty-five (85.4%) of the 41 pregnant women also reported IPV.
One hundred and two (35.4%) of the respondents suffered a combination of physical and sexual IPV, while 57 (19.8%) suffered psychological and sexual IPV in combination; whereas, 3 (1.1%) of them suffered both psychological and physical IPV in combination. Furthermore, 18 (6.3%) of the respondents suffered the three forms of IPV in combination. Physical abuse alone was suffered by 45 (15.6%) of the victims while psychological and sexual alone were suffered by 37 (12.9%) and 26 (9%) of the respondents, respectively. However, 72 (25%) of the respondents did not suffer any form IPV.
Sixty six (39.3%) of the 168 respondents who suffered from physical violence, reported being hit, 32 (19%) reported being slapped, 30 (17.9%) reported being pushed, and 27 (16.1%) reported being kicked; whereas, 2 (1.2%) and 11 (6.5%) reported that things were thrown at them and other means in which abused were carried out on them. Furthermore, 90 (78.3%) of the 115 psychologically abused respondents mainly reported being shouted down by their partners. Actual forceful penetration was reported by 168 (82.7%) of the 203 respondents who were sexually abused, while 30 (14.8%) and 5 (2.5%) of them reported attempted forceful penetration and being caressed in an undesirable manner, respectively [Table 3].
Common comorbidities found in respondents reporting intimate partner violence
The most common comorbidity found in IPV respondents was pelvic inflammatory disease, constituting 11.5% of the listed morbidities. This was followed by hypertension, peptic acid disorders, and upper respiratory tract infections which constituted 11.1%, 8.7%, and 7.6%, respectively [Table 4].
|Table 4: Common comorbidities found in intimate partner violence respondents|
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Common risk factors for intimate partner violence
Respondents who were younger were nearly five times more likely to report IPV (P < 0.001). IPV was significantly more likely to be reported in those whose partners had <12 years of formal education (P < 0.001) and were employed (P < 0.01). No significant differences were seen when IPV was compared with marital status (P = 0.25), educational status (P = 0.14), or pregnancy status (P = 0.25) [Table 5].
|Table 5: Relationship between intimate partner violence and related factors|
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Hypertension was significantly associated with IPV (P = 0.01). There were no statistically significant associations between reporting IPV and the other comorbidities [Table 6].
|Table 6: Relationship between intimate partner violence and victims' comorbidities|
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| Discussion|| |
The prevalence of IPV in this study was 80%. This was quite high, but slightly lower than the findings of Silva et al. and Owoaje and OlaOlorun who studied women in Southwestern Nigeria. They reported higher prevalence values of 89.2% and 87%, respectively. The study carried out by Silva et al. was a similar hospital-based study among a population which was predominantly Christians, whereas that of Owoaje et al. was a community-based study among women from other communities who were either Hausas or Fulani and predominantly Muslims. Differences in these prevalence values could be as a result of the different assessment instruments used in identifying IPV in the various studies. Furthermore, these high prevalence values may be explained by the fact that many African Cultures are inherently patriarchal, and often a woman's position in most African countries is to be subservient to men.
Although community-based studies are a better representation of the true situation in a general population, this study being systematic random selection of the respondents from the GPC, where a fairly diverse number and types of women were present, added credence to the results obtained from this clinic-based study. Hence, the results may be generalized in that population.
An IPV prevalence range of 11.5%–79% has been reported previously in different parts of Nigeria., Balogun et al. reported a life time IPV prevalence of 64% and 70% for rural and urban regions, respectively, though their study population was among university students (a relatively younger population). Umeora et al. reported 13.6% in Abakiliki, while Ameh et al. reported 28% in Zaria. However, Fawole et al. reported a record low prevalence of 2.3% in Abeokuta. The lower prevalence in some studies can be attributed to methodological differences across the various studies. For instance, Fawole et al.'s study which reported the lowest rate (2.3%) excluded women who if included could have contributed to a higher and more accurate prevalence. The authors mentioned that “Women who expressed fear that granting the interviews may result in further violence were excluded from the interviews.” Although the number of women excluded for this reason was not mentioned, it clearly shows that the excluded women resulted in underreporting and lower estimates. In addition, the study used an instrument with fewer than usual semistructured questions. The author's nonreporting of response rate was another limitation of the paper.
This study also demonstrated that over half (56.4%) of the respondents had experienced sexual violence. This is much higher than some previously reported prevalence for sexual violence in Nigeria and other parts of the world. Umana et al. reported a sexual assault prevalence of 6.6% in Ibadan, Awusi et al. reported a prevalence of 11% in Oleh, Delta State and Silva et al. reported 10% in Southwestern Nigeria; whereas Ajah et al. reported 6.4% and 4.3%, respectively, for rural and urban populations in Southeast Nigeria. According to the WHO multicountry study on women's health and life experiences, a wide range of prevalence of IPV was reported for different regions. For example, IPV prevalence of 4%, 46%, and 56% were reported in Japan, Provincial Bangladesh, and Ethiopia, respectively. This wide range could be explained by the variation in the definition of sexual violence within an intimate relationship. For example, a woman may not be willing to go all the way with her partner, but may just consent in order to avoid rejection. In other instances, a woman consenting to a relationship is assumed to mean agreeing to fulfill her male partner's sexual desires at all times, irrespective of her own emotional feelings.
The 46.7% prevalence for physical violence in our study is higher than the 18% and 31% reported by Silva et al. and Awusi et al. in Southwestern and Delta regions of Nigeria, respectively. Umana et al. also reported a lower prevalence of 7.9% in Ibadan, Nigeria; the 2008 NDHS report from Anambra state also reported a lower prevalence. The higher prevalence of physical violence in this index study may be explained by the cultural perception in most of our traditions which permits beating as a way to discipline erring members of the society. Furthermore, sexual violence, which had a high prevalence in this study, often occurred in combination with some form of physical violence. This may also be a reason for the high prevalence of physical violence in this study.
Most of the respondents who were physically assaulted in our study reported either having been hit, slapped, pushed, or kicked. This is similar to the findings from previous studies in Southeastern Nigeria and Rwanda, respectively.
Slightly less than a third of the women in this study had experienced psychological violence. This is similar to the findings reported by Silva et al. in Southwestern Nigeria. The most common form of psychological violence in this study was shouting at the victims and this finding is similar with the previous findings in Enugu and Abeokuta., This study showed that 58 (34.1%) of the respondents who had been physically assaulted also had one form of injury or another from the assault. These findings were similar to the WHO multi-country study by Garcia-Moreno et al., in which the prevalence of either or both physical and sexual ranged between 15% and 71%, but differed from the findings by Fawole et al. in Abeokuta which had verbal abuse as their highest prevalence (66.2%). It also differed from the study done in Abuja by Efetie and Salami, in which psychological abuse was found to be as high as 66.4% with physical and sexual violence reported to be 23.4% and 10.2% respectively. Violence cannot occur in isolation as one form would likely lead to another. For instance, a victim who is sexually abused most likely would have suffered from some sort of physical molestations and would certainly suffer some psychological consequences. This also buttresses the fact that victims do suffer injuries from physical assaults.
The age of the respondents, their family size, their educational level, and their employment status, as well as the educational levels of their partners were observed to have significantly influenced IPV in this study (P<0.005). The study showed that the victims who were <38 years of age were four times more likely to experience IPV compared to those older than 39 years of age. This is similar to what was reported by Onoh et al. in Southeast Nigeria, in which the women's age, family setting, educational level, and partners' social habits were found to significantly influenced IPV. Other studies have also reported the relationship between women's age and their experiences of abuse: younger age, was found to be associated with abuse (Kaye et al. and Fawole et al., whereas Ntaganira et al.) The reason for younger age influencing the occurrence of IPV may be explained by the fact that the younger females have less experience in handling relationship issues than older females. They are also more likely to be involved in the abuse of alcohol, drugs, and other substances. Furthermore, they are more vulnerable to being poisoned by their male counterparts.
Of the total respondents who suffered physical violence, 39.3% reported that they were hit by their perpetrators, 16.1% were kicked, and 17.9% were pushed. Another 19% and 1.2% of the respondents reported being slapped and things thrown at them. Majority (78.3%) of those who experienced psychological violence reported that they were shouted down; only 5.2% and 3.5% of the respondents reported being snubbed and jilted, respectively. Furthermore, majority (82.7%) of the sexual violence victims reported actual forceful penetration, 14.8% attempted forceful penetration, and 2.5% inappropriate caressing.
Different studies have reported similar or varied findings to the above. Onoh et al. reported similar findings from the study done in Abakaliki, in which verbal abuse was the most common type of abuse (60.1%). Envuladu et al. in Jos North LGA of plateau state also reported common forceful intercourse among pregnant IPV victims. This revealed that the prevalence of sexual abuse and other forms of IPV which are not being reported remain very high in our society.
Another finding in this study was that higher educational levels of the respondents' partners significantly influenced the occurrence of IPV (P =0.002). This was a variant to the findings of a study that was conducted in a tertiary health facility in Abeokuta, Nigeria, by Fawole et al., where low education of partners was significantly (P< 0.05) associated with IPV. Many studies have also reported strong positive associations between a woman's low level of education and experiencing IPV; Fawole et al. (OR: 12.54), Hoque and Kader (OR 7.59) and Umeora et al. (P = 0.001, OR not stated). However, in some studies, the relationship did not reach statistical significance (P = 0.31 in Ezechi et al., P = 0.145 in Kaye et al., P = 0.05 in Efetie and Salami, and P value was not stated in Olagbuji et al. and Ntaganira et al.). The finding in this study may suggest that the more educated the man is the more empowered he would become and the tendency to want to take more control of the relationship. This, in no time would result in conflicts and eventually in IPV.
This study showed that employment in the woman significantly influenced their becoming IPV victims and the employed women were over three times likely to suffer IPV than the unemployed women (OR: 3.21, 95% confidence interval [CI]: 1.49–7.66, P = 0.001). This is at variance with Hoque and Kader's study, in which it was noted that unemployment was a risk factor for experiencing abuse (OR: 3.57 and 95% CI: 1.83–6.98). This study also differed from the reports in the studies conducted by Ezechi et al. (P = 0.000) and Umeora et al. (P = 0.0037), in which unemployment and having less household decision-making power were reported to significantly influence being a victim of IPV (P = 0.009) in Kaye et al. However, Kaye et al. found no significant differences in the occurrence of IPV between women who were unemployed and those who were employed in either skilled or informal sector (P = 0.701). The relationship between employment and IPV as found in this study can be explained by the fact that when some women become too engrossed in pursuance of their careers, managing their homes alongside could become very challenging and this can result in domestic conflicts and IPV.
Findings from this study showed that among the common comorbidities found in IPV respondents, hypertension was the only comorbidity that was significantly associated with the experience of IPV by the respondents (P = 0.03). This association can be explained by the fact that IPV had been reported to be a prevalent stressor for women, and it may influence the risk of hypertension and other cardiovascular diseases. Mason et al. studied the relationship of IPV and the incidence of hypertension in women where they reported that the risk of hypertension was increased in women who had recent exposure to emotional abuse. However, the generalizability of the study is a possible concern, as it was carried out on nurses in higher education demography. It is possible that a history of IPV in adulthood may be related to hypertension in a more diverse group or in a lower socioeconomic group. Further longitudinal studies may be required to explore the possible association between IPV and the risk of developing hypertension.
Slightly over a third of the respondents who suffered from IPV had associated their partners' alcohol usage as the reason for the perpetrations of IPV. Other previous studies had associated alcohol use by partners of IPV victims with the perpetration of IPV. Umana et al. reported a positive correlation between alcohol consumption and IPV in the study of the prevalence and correlates of IPV among University female students in Ibadan, Nigeria. They further reported in the same study that partners of IPV victims with a history of alcohol use were over two times likely to suffer from IPV than those whose partners did not use alcohol. Fawole et al., in Abeokuta, Nigeria, also reported a statistically significant association between the women's partners' use of alcohol and IPV. They also demonstrated a 2.9-fold higher risk of IPV in partners with alcohol intake over those without alcohol intake.
The effect of alcohol can be explained by the fact that its consumption causes disinhibition and the disinhibition associated with alcohol may result in diminished ability to avoid violence, neglecting a partner may create tensions in intimate relationships and this may ultimately results in exhibition of violence. Male partners tend to lose the control over their emotions when they are disinhibited after the use of alcohol and/or psychoactive substances and so are more likely to perpetrate violence even toward their intimate partners.
Limitation of the study
Other sociocultural factors which may have influenced the association between IPV and adverse health outcomes were not assessed. For example, some IPV victims may try to manage the negative consequences of the abuse through the use of alcohol, tobacco, other illicit drugs, or even prescription medication. Respondents may have underreported certain domains of the IPV due to its sensitive nature as well as the gender of the interviewer.
| Conclusion|| |
The prevalence of IPV in this study was 80%, which is one of the highest reported rates in the region. However, the association found between hypertension and IPV in this study supports the suggestions for routine IPV assessment in our health-care settings as well as the need for further longitudinal studies to explore this.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]