THE PATTERN AND CORRELATES OF INTIMATE PARTNER VIOLENCE AMONG WOMEN ATTENDING THE GENERAL OUT-PATIENT CLINIC OF AMINU KANO TEACHING HOSPITAL, KANO, KANO STATE, NIGERIA

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THE PATTERN AND CORRELATES OF INTIMATE PARTNER VIOLENCE AMONG WOMEN ATTENDING THE GENERAL OUT-PATIENT CLINIC OF AMINU KANO TEACHING HOSPITAL, KANO, KANO STATE, NIGERIA

                                                        SUMMARY

Intimate partner violence has been increasingly recognized as a public health problem associated with serious medical, family and societal effects. Intimate partner violence occurs across all populations, irrespective of social, economic, religious or cultural groups and the only variation is in the pattern of violence in different populations. Physicians need to be aware of the patterns of abusive behaviour that may present to them so that screening for undisclosed intimate partner violence could form part of their routine medical consultations.

This was a cross-sectional descriptive hospital based study carried out between August and September, 2013. The objectives were to determine the prevalence, pattern and socio-demographic correlates of intimate partner violence among women attending the General Out Patient Clinic (GOPC) of Aminu Kano Teaching Hospital (AKTH), Kano. It was also designed to determine the pattern of health complications associated with intimate partner violence as well as the perception of women attending the GOPC of AKTH on intimate partner violence.

Three hundred and ninety three randomly selected women aged 15-49 years who were in or had ever been in an intimate relationship were studied. Interviewer-administered questionnaires were used to collect data about their socio-demographic characteristics, presenting complaints and clinical examination. Information on intimate partner violence was obtained using the Composite Abuse Scale (CAS).

The prevalence of intimate partner violence within the previous year was 42.0%. Of all the 393 study participants, 46.6% had experienced emotional/psychological violence,

harassment/controlling behaviour was present in 43.3%, physical violence was reported in 29.0%, sexual violence was present in 21.9% and 37.9% of the participants had experienced severe combined abuse. Age, ethnicity, religion and level of education were not associated with intimate partner violence. Alcohol consumption by the partner (p= 0.000), increased use of substances such as sleeping pills by the victims of IPV (p=0.000), depression (p=0.000), miscarriage (p=0.004), and the presence of physical injuries in the participants (p=0.024) were significantly associated with intimate partner violence. One hundred and fifty nine (40.5%) of the participants agreed that a husband is justified for beating or hitting his wife and neglecting the child was the reason given by most of the participants (26.7%) to justify intimate partner violence. General and non-specific complaints, Musculoskeletal complaints, Psychological complaints such as; depressed mood, insomnia, anhedonia and cardiovascular complaints like palpitations were significantly commoner among victims of IPV.

The finding of a high prevalence of intimate partner violence among women of reproductive age in this study shows that it is an important problem and is associated with poor physical and mental health of women who are victims. It is therefore recommended that physicians routinely screen for IPV especially in patients with depressive symptoms, non-specific complaints, miscarriage, low back pain and physical injuries on the face, trunk and upper limbs. Screening will be a safe and cost effective means for identifying women experiencing IPV, leading to appropriate interventions that will decrease further exposure to IPV and its adverse health consequences.

                                             TABLE OF CONTENTS

Certification…………………………………………………………………………            i

Declaration…………………………………………………………………………….         ii

Dedication…………………………………………………….……………………….         iii

Acknowledgement……………………………………………………………………….     iv

Table of Contents…………………………………………………………………………. v

List of Tables………………………………………………………………………….         viii

List of Figures………………………………………………………………………….        ix

List of Abbreviations…………………………………………………………………….     x

Summary………………………………………………………………………………..       1

Chapter One: Introduction

1.1 Introduction…………………………………………………………….………….       3

1.2 Statement of the problem………………………………………….…….……………. 8

1.3 Aim and Objectives………………………………….……………………………..     9

1.4 Justification for the Study…………………………………………………………       10

Chapter Two: Literature Review

2.1 Background, Definition and Classification of IPV..………………………………       12

2.2  Epidemiology of Intimate Partner Violence………………………………………..     19

2.3 The Pattern of Intimate Partner Violence……………………..…………………..       22

2.4 The correlates of Intimate Partner Violence….…………………………….……..       27

2.5 Family and Social Support and Intimate Partner Violence……………………….       30

 

2.6 Effect’s of Intimate Partner Violence on women’s Health………………………..      31

2.7 Management of Intimate Partner Violence …………………………….…….……      34

Chapter Three: Materials and Method 

3.1 Study Area……………………………………………………………….……….… 43

3.2 Study Population………………………………………………..………….…….…    44

3.3 Study Design……………………………………………………………….…….…    44

3.4 Sample Size Determination…………………………………….…………..………     44

3.5 Inclusion and Exclusion criteria ……………………………………………………. 45

3.6 Sampling Method……………………………………………………………..…….    45

3.7 Study Procedure…………………………………………………………………….     46

3.8 Data Analysis……………………………………………………………………….     49

3.9 Ethical considerations……………………………………………………………         49

Chapter Four: Results

4.1 Socio-demographic characteristics of the study participants………………….…        50

4.2 Prevalence of Intimate Partner Violence……………………………………..…….     53

4.3 Pattern of Intimate Partner Violence……………………………………………….     54

4.4 Socio-demographic correlates of Intimate Partner Violence………………..……..     55

4.5 Perception of participants to justify Intimate Partner Violence……………………     59

4.6 Pattern of health complications associated with Intimate Partner Violence……….     60

4.7 Common symptoms presented by the patients……………………………………..     63

4.8 Bivariate analysis of the correlates of Intimate Partner Violence……………….         65

4.9 Multiple logistic regression analysis of correlates of Intimate Partner Violence……. 68

Chapter Five:  Discussion, Conclusion and Recommendations

5.1 Discussion……………………………………………………………………….          70

5.2 Conclusion…………………………………………………………………….……     84

5.3 Relevance of the study……………………………………………………….…….      85

5.4 Recommendations………………………………………………………………….      86

5.5 Strength of the Study…………………………………………………………..…… 88

5.6 Limitations of the study…………………………………………………………….      89

References: ……………………………………………………………………………………… 90

CHAPTER ONE

INTRODUCTION

1.1 INTRODUCTION

Violence as defined by the World Health Organisation working group is “the intentional use of physical force or power, threatened or actual, against oneself or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.”1

Intimate partner violence, initially viewed largely as a human right issue, has now become an important public health problem of international concern. Violence against women by their male partners is common, widespread and far reaching in its impact. Intimate partner violence occurs in

all countries, irrespective of social, economic, religious or cultural group.1

Violence against women as defined by article one of the declaration on the elimination of violence against women passed at the United Nations General Assembly in 1993 is “any act of genderbased violence that results in, physical, sexual or psychological harm or suffering to women including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in

public or private life.”2

Intimate partner violence (IPV) has also been defined as behaviours within an intimate relationship that cause physical, psychological or sexual harm to those in the relationship, including acts of

physical aggression, sexual coercion, psychological abuse and controlling behaviours.3

Intimate partner violence has been defined by the Centre for Disease Control (CDC), as physical and/or sexual violence or threat of such violence; or psychological/emotional abuse and/or coercive tactics when there has been prior physical and/or sexual violence; between persons who are spouses or non marital partners (dating, boyfriend-girlfriend).4

The term “domestic” violence is now being replaced by “intimate partner violence”. 3

Intimate        partners       include:       current       spouses,       current       non-marital        spouses

(boyfriends/girlfriends); former marital partners (divorced spouses, separated spouses); former non-marital spouses (boyfriends). Intimate partners may be cohabiting, but need not be.4

IPV is a very sensitive issue as it is usually regarded as a ‘family problem’ which does not concern outsiders. This is especially so in Africa where the family is held sacred. According to the WHO’s World Report on Violence and Health, one of the most common forms of violence against women is that performed by a husband or male partner which is frequently invisible since it happens behind closed doors. Moreover, legal systems and cultural norms often do not treat it as a crime, but rather as a “private” family matter or normal part of life. Although, women can be violent towards their male partners and violence occurs also between partners of the same sex, the overwhelming burden of partner violence is borne by women at the hands of men. 1

Violence against women takes many forms from the overt to the subtle. Violence is divided into

four categories:5

Physical violence means the intentional use of physical force with the potential for causing death, disability, injury or harm. Physical violence includes but is not limited to: scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, poking, hair pulling, slapping, burning, use of weapon and use of restraints or one’s body, size or strength against another person. Physical violence also includes coercing other people to commit any of the above acts.

Sexual violence involves the use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed. It also includes an attempted or completed sex act involving a person who is unable to understand the nature or condition of the act to decline participation or to communicate unwillingness to engage in the sexual act, abusive sexual context.

Threat of physical or sexual violence means the use of words, gesture or response to communicate the intent to cause death, disability, injury or physical harm. Also the use of words gestures or weapons to communicate the intent to compel a person to engage in sex act.  Psychological or emotional violence means someone has been humiliated or belittled, being scared or intimidated purposefully.

In developed countries, abused women can present or be referred to shelters or homes where they are nurtured and harboured till they can eventually support themselves and their children while fleeing their assailant. There are also effective laws which restrain the perpetrator from establishing contact with the victim or her children.6,7  In the developing world, however, even though domestic violence is widespread, societal norms discourage women from speaking out. The abused women are scared of the abuser, his family and the community. To complicate issues, she is often dependent on her abusive intimate partner for financial and social support.8

Women who are abused by their husbands are encouraged by their family and friends to forbear and remain with him as it is culturally improper for an outsider to house another man’s wife and women who seek refuge outside the home may be judged to have questionable character.9 Regarding laws protecting women in Nigeria from violence it is important to note that Nigeria has a tripartite legal system. This includes the statutory laws (Penal code or Criminal code), the customary laws and the Muslim personal law (Sharia). In matters relating to  family and marriage, statutory laws are generally more binding or effective in the southern part of the country while Muslim laws are consulted in the Northern part of the country.10 Customary laws are consulted in all parts of the country depending on the situation. This contributes to contradictions and inconsistencies.

In the constitution of the Federal Republic of Nigeria, there are no specific laws prohibiting violence against women.10,11 However, Lagos state has a Domestic Violence Law while Ebonyi and Cross River States House of Assembly have passed the Domestic Violence Bill.11 There is a general provision against violence or assault for both men and women in Section 42 of the Nigerian Constitution which states that “Every Nigerian has a right not to be subjected to cruel, inhuman and degrading treatment or punishment.” It further states that “No Nigerian shall be subjected to discrimination on the basis of sex or gender.”11 In Igbo Customary law, a husband has a right to chastise his wife for “failing to perform her duties”, “laziness”, “wastefulness”, and “destructiveness”. In Northern Nigeria, the penal code (Section 55d) permits a husband to ‘correct’ his wife provided no grievous hurt is inflicted in the process.12 Similarly, Sharia law permits the

husband to ‘admonish’ his wife, although the instrument used must not leave a mark on her body.10  In Nigeria, some women justify domestic violence perpetrated by husbands depending on the situation. In the 2003 Nigerian Demographic Health Survey, 64.5% of women and 61.3% of men

were reported to support wife beating in at least one of the six scenarios described in the survey.13,14   Most women who suffer physical or sexual abuse by a partner generally experience multiple acts over time. Likewise, physical and sexual abuse tend to co-exist in many reletionships.15

It has been reported that IPV can result in short- and long-term negative physical and mental health problems.16,17 Women experiencing intimate partner violence suffer a wide range of health complications resulting from physical, sexual, and psychological assaults. This can result in severe physical injuries, reproductive health problems including terminated pregnancies, undesired pregnancies and child loss during infancy.18-19 Other manifestations of intimate partner violence include,  symptoms of depression, anxiety and post traumatic stress disorder and risky health behaviour such as unhealthy feeding habits, substances abuse, alcoholism and suicidal behaviour.20  Victims of intimate partner violence have increased health care needs and increased utilization of healthcare services.20 Depression and post traumatic stress disorder, which have substantial co-

morbidity, are the most prevalent mental health sequelae of intimate partner violence.20 

In order to prevent the onset of intimate partner violence (i.e, primary prevention), educating people about the cycle of violence through the media or during hospital consultation for unrelated ailment can enhance public knowledge on how to communicate and seek help. They can also be educated on the need to build a culture of non violence within their families. In order to reduce existing intimate partner violence (i.e, secondary prevention), primary care physicians should be able to screen, identify and treat victims of intimate partner violence. Direct intervention can help victims of intimate partner violence rebuild their lives.

Intimate partner violence is not simply a matter of family privacy, individual choice or inevitable facet of life. It is a complex problem related to patterns of thought and behaviour that are shaped by a multitude of forces within our families and communities, forces that can also transcend national borders. Violence may take place within a very different societal context, and the degree to which it is sanctioned by a community will naturally influence the kind of strategy needed. Most researchers agree that cultural norms can greatly affect the extent and characteristics of violence, as well as the way that specific acts are interpreted in different societies. Cross cultural research will help reveal how societal norms influence violent behaviour.

Family Physicians, through effective case management co-ordinated and continuing care, can alleviate some of the negative effects of partner violence on women suffering in silence. In addition, through publications of research findings, Family Physicians can create awareness of the burden of the problem and as such promote advocacy for women empowerment.

Previous studies in our environment have examined health care provider’s readiness to screen for intimate partner violence in northern Nigeria.21 and the acceptance of screening for intimate partner violence amongst female clients visiting a health facility in Kano.16 There is paucity of data on the pattern and extent of intimate partner violence in the region. It is important to understand the pattern of intimate partner violence in our environment so that the individual and societal consequences can be forestalled.

It is therefore paramount on primary care physicians to adopt an approach that is proactive, scientific and comprehensive in order to identify those at risk or affected and offer them help.

 

 1.2 STATEMENT OF THE PROBLEM

Intimate partner violence has been increasingly recognized as a public health problem associated with serious medical, family and societal effects.20 Violence against women is the most pervasive yet under recognized human rights violation in the world. It is also a profound health problem that saps women’s energy, compromises their physical and mental health and erodes their self esteem.

In addition to causing injury, violence increases women’s long term risk of a number of other health problems including chronic pain, physical disability, drug and alcohol abuse and depression.1,2 Women with a history of physical or sexual abuse are also at increased risk for unintended pregnancy, sexually transmitted infections and miscarriages.3 Violence against

intimate partners occurs in all countries, all cultures and at every level of the society.1

Because intimate partner violence is a health problem with documented short and long term health consequences, primary care physicians have a responsibility and unique opportunity to identify intimate partner violence in the clinical setting.

The health setting has been identified as one of the best contexts in which intimate partner violence can be identified and studied, mainly because of its accessibility and because women who have experienced this form of violence make greater use of  health services than those who have not

suffered such an experience.1

Primary care practice provides an ideal opportunity for the discussion of the remarkably prevalent yet often hidden problem of intimate partner violence. Despite the willingness of women in our environment to be screened for intimate partner violence, 74% of healthcare providers had not screened for intimate partner violence among women presenting for consultation in a healthcare

setting.22

Therefore, physicians need to be aware of the patterns of abusive behaviour that may present to them so that screening for undisclosed intimate partner violence could form part of their routine medical consultations.

1.3 AIM AND OBJECTIVES

AIM: 

To determine the pattern and socio-demographic correlates of intimate partner violence among women of reproductive age attending the general out-patient clinic(GOPC) of Aminu Kano   Teaching Hospital(AKTH) in order to create awareness among physicians about the magnitude of the problem and encourage routine screening.

 

 

SPECIFIC OBJECTIVES

  1. To determine the prevalence of intimate partner violence among women of reproductive age attending the GOPC of AKTH
  2. To determine the pattern of intimate partner violence among the study participants.
  3. To determine the socio-demographic correlates of intimate partner violence among the study participants.
  4. To determine the perception of the study participants on intimate partner violence.
  5. To determine the pattern of health complications associated with intimate partner violence among the study participants.

1.4 JUSTIFICATION FOR THE STUDY

Intimate partner violence occurs across all populations, irrespective of social, economic, religious

or cultural groups and the only variation is in the pattern of violence in different populations.23 

Family Physicians are not only in an ideal position to identify victims of intimate partner violence and provide the victims and their families the appropriate care that is needed, they also are obliged to do so because of the magnitude of the problem. Primary care physicians can play an important role in secondary prevention. Because of their training to care for the entire family within the context of the larger community, Family Physicians can provide continuity of care, gain patient confidence over time and provide patient advocacy as well as make appropriate referrals.  Each healthcare visit for a patient with intimate partner violence provides the potential for secondary prevention, intervention and provision of referrals to further reduce the adverse health impact of intimate partner violence.

In a study to determine the acceptance of screening among women for intimate partner violence and satisfaction with care, 76 % of the participants found it acceptable to be screened for intimate partner violence in a healthcare setting.21 Being screened for intimate partner violence seemed to improve satisfaction with care, an indicator for good medical practice. 21

Primary care practice presents a confidential, safe, and powerful opportunity to confront intimate partner violence. In many primary care settings, a patient may develop a long term trusting relationship with his physician.

The focus of primary care on health and well being present an ideal opportunity for discussing intimate partner violence as an important health concern in a non judgmental manner.

 

THE PATTERN AND CORRELATES OF INTIMATE PARTNER VIOLENCE AMONG WOMEN ATTENDING THE GENERAL OUT-PATIENT CLINIC OF AMINU KANO TEACHING HOSPITAL, KANO, KANO STATE, NIGERIA

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