Intimate partner violence IPV is widely prevalent in Tanzania. Women expressed less equitable attitudes than men at baseline. Multivariable logistic regression analyses suggested that inequitable attitudes and couple discordance were associated with higher risk of IPV. Our findings point to the need for a better understanding of the role that perceived or actual imbalances in relationship power have in heightening IPV risk. Intimate partner violence IPV is a major public health and human rights concern in Tanzania [ 1 ].
A growing of studies have documented the association between IPV and an array of adverse reproductive and sexual health outcomes, including pregnancy loss and HIV infection among women in Tanzania [ 3 — 7 ]. Of particular concern is evidence on the links between IPV, sexual risk behaviors, and HIV infection among young Tanzanian women and men [ 6 — 9 ]. Another study involving young men aged 16 to 24 years in two neighborhoods of Dar-es-Salaam found that about a third had ever perpetrated IPV and that those who reported more lifetime sexual partners were also more likely to perpetrate IPV [ 7 ].
Given the high prevalence of IPV and its adverse health impacts, a better understanding of the risk of IPV, especially among young women, is needed. Several qualitative studies in Tanzania have documented the links between entrenched gender inequities and IPV [ 8911 ]. In one study, 16—year-old men and women in Dar-es-Salaam described the ideal woman as one who is home-bound, loyal to her partner, and sexually submissive [ 9 ].
Young women who deviated from these prescribed behaviors risked being beaten. Infidelity or perceptions of infidelity were the most commonly cited triggers of violence against female partners across studies [ 89 ]. Furthermore, it was not uncommon for women to be blamed for provoking IPV, preventing women from seeking support or medical care, and making law enforcement difficult [ 12 ].
Survey data lend support to the observation that both men and women in Tanzania condone IPV as a normal part of an intimate relationship [ 713 ]. Maman et al.
A similar proportion of women attending an HIV voluntary counseling and testing center in Dar-es-Salaam felt that physical abuse was justified in at least one of several situations such as infidelity, disobedience, and nonperformance of domestic work [ 14 ]. For example, a cross-sectional survey of men working in three municipalities in Cape Town, South Africa found that men who thought it was acceptable to hit women were more likely to also report recent or past physical violence against a partner [ 16 ].
A recent analysis of DHS data from six African countries Kenya, Liberia, Malawi, Rwanda, Zambia, and Zimbabwe examined the relationship between couple concordance on attitudes towards IPV partner agreement that violence is justified in at least one situation and IPV any physical or sexual violence reported by women [ 17 ]. The authors found that IPV was more commonly reported among couples who agreed that IPV was acceptable in at least some situations as well as those who expressed discordant attitudes towards IPV compared to couples who agreed that IPV was never acceptable.
Notably, statistically ificant associations between concordance on IPV acceptability and reported IPV and between discordance and IPV were observed in five and four out of six countries, respectively. The year-long RESPECT study was a randomized controlled trial deed to evaluate whether conditional cash transfers CCT promoted safe sex and reduced the incidence of sexually transmitted infections STIs see [ 18 ] for additional details regarding the study.
Participants who were interested in enrolling tly with their spouse were encouraged to do so and considered to be a couple if they each reported that they were married to one another or were living together as if married. Couples were linked through a common household identification. Participants were followed for 12 months and interviewed every 4 months to gather data on a range of issues, including sociodemographic background, economic status, sexual and reproductive health knowledge, practices, and history, attitudes about IPV and relationship power, as well as experiences of IPV women and perpetration of IPV men.
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All enrolled individuals were invited to group counseling sessions that focused on relationship and life skills training based on the Stepping Stones curriculum [ 19 ]. The analysis is guided by a social-ecological framework, which posits that IPV risk is shaped by the interplay of a host of individual, community, and societal factors, including individual beliefs and practices within an intimate relationship as well as community and societal norms regarding gender and power [ 20 ].
It is also informed by the proximate determinants framework proposed by Boerma and Weir, which enables the classification of factors into distal and proximate predictors of IPV [ 21 ]. According to the proximate determinants framework, ecological factors such as cultural norms influence a particular health outcome through a set of intermediate or proximate variables.
These proximate determinants, which can include a combination of social and biological factors, directly influence the health outcome of interest. In this analysis, we considered attitudes toward IPV as proximate determinants, and gender norms as a key underlying, distal determinant of IPV.
We outlined our hypotheses about the causal relationships between all variables in a Directed Acyclic Graph DAG; not presented and used the DAG to determine the minimum variables necessary to include in multivariable analyses to remove confounding of the main effects.
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We further hypothesized that the very fact of discordance between couples is more important than the nature of that discordance; that is, we proposed that lack of agreement between a woman and her partner regardless of which partner held the more inequitable attitudes would be associated with a higher risk of IPV than if she agreed with her partner. This finding would be consistent with earlier studies that have found that women themselves often exhibit highly inequitable attitudes about IPV as a way of fitting in with their communities and protecting themselves from violence [ 2425 ].
Study protocols were approved by institutional review boards in Tanzania and the United States. All study participants gave written informed consent to participate in the study. Couples were interviewed separately at a study station that was set up on the outskirts of the village, and care was taken to ensure privacy and confidentiality.
Study interviewers received in-depth training on interviewing techniques, gender and reproductive health, and the study protocols. A study liaison was identified in each village to help participants gain access to further information, counseling services, and study personnel. In addition, study counselors received training on how to offer psychosocial support and were equipped with information on domestic violence-related services.
The RESPECT questionnaire did not ask women about lifetime experience of violence; at all rounds, women were asked about their experience of violence in the four months. For each of these questions, couples were coded as having concordant responses if both partners shared the same binary response.
Other covariables we considered included age measured as a continuous variableeducation status measured as a categorical variable—no schooling, some primary school, primary school completed, some secondary school, secondary school completed, and postsecondary or university educationand socioeconomic position measured by asking participants to rate themselves on a scale from 1 to 7 relative to others in their community.
We also examined differences in reported IPV by study arm.
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Analyses were conducted using data from the subset of heterosexual couples who were enrolled in the study together. All couples were included in the baseline data analysis, and couples on whom data were available for a minimum of two out of the four rounds were included in the longitudinal analyses.
For each round, couples were included in the analysis as long as there were no missing data on the variables of interest. We conducted tests for trend to determine whether changes were statistically ificant. We also ran a multivariable logistic regression model to examine the association of each main exposure variable and IPV, adjusting for socioeconomic status, age, and education.
A random effects model was chosen to evaluate the change in IPV odds for a single woman when she expressed inequitable attitudes versus when she expressed equitable attitudes.
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This model produced an odds ratio of experiencing IPV for an individual woman when she expressed inequitable attitudes relative to when she expressed equitable attitudes. Socioeconomic position, age, education, and round of data collection were included in the models as confounders. Interactions between these confounders and the exposures of interest were also considered. However because they were not statistically ificant, they were not included in the final model.
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We believed that an individual hypothesis within each family would have to be considered in light of the additional tests performed on other hypotheses within the subgroup. Since each family of hypotheses included four exposure variables, we determined that an appropriate ificance level alpha for each hypothesis test would be set at 0. A comparison of individuals who reported being married or living together as married and who did not enroll as a couple and those who did enroll as a couple indicated that there were no statistically ificant demographic differences between the two groups.
A total of 26 couples were lost to follow up: seven after the baseline round and an additional 19 between rounds 2 and 4. Additionally, at each round, between two and four couples were missing data on one or more variables and were excluded from the analysis. Participant characteristics at baseline including demographic background, experiences of IPV, attitudes about violence and opinions about sexual decision making and relationship power are shown in Table 1.
About one in five women Women who reported experiencing IPV and those who did not were of similar age and had similar levels of education and self-reported socioeconomic status. In addition, according to both women and men, husbands had more say over sex and had more power in their relationship than wives. Overall, men espoused more gender-equitable attitudes than women.
Reported IPV in the four months prior to the interview decreased steadily over time from The decrease was statistically ificant and was not associated with demographic characteristics or study arm.
In addition, at 12 months, fewer women and men noted that violence against a wife was acceptable, and a larger proportion of participants reported that sexual decision making was shared by both partners Table 2. Interestingly, for both men and women, responses to questions about the acceptability of IPV showed more dramatic changes from baseline to 12 months than responses to questions about power within relationships, which barely changed.
Table 3 summarizes the of the longitudinal and random effects of multivariable logistic regression analyses. For all four exposures of interest, women were more likely to report IPV when couples expressed discordant attitudes relative to when they shared concordant attitudes, but these effects were relatively small and not statistically ificant Table 3.
In all longitudinal analyses, a statistically ificant portion of the variance of the estimates was due to the random effect of individuals, suggesting that there was a ificant amount of between-subject variation data not shown. Our observation that gender inequitable attitudes were more commonly reported by women than men is consistent with findings from other studies [ 13 ]. It is possible that due to social desirability bias, men were less likely than women to openly agree that violence against women is justified.
Studies elsewhere in the world have noted that women who transgress norms, for example, by choosing their spouse or by seeking economic independence, are more likely to experience IPV [ 2728 ]. Indeed, conformity to social norms and expectations may be a protective mechanism-enabling women to fit in and avoid family and community censure. Qualitative research in Tanzania suggests that pressures on women to conform are considerable.
In Lary et al. Other research by Laisser et al.
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It is encouraging to note that men and women tended to express more gender equitable attitudes by the end of the study. However, to our knowledge, no major interventions on IPV occurred during this time period and it is unlikely that such a substantial reduction in IPV could be explained in this fashion. Engaging men and women—as individuals, couples, and community members—is widely accepted as an important component of IPV prevention efforts worldwide [ 2329 ]. At a minimum, our study demonstrates the feasibility, safety, and potential effectiveness of engaging young Tanzanian men and women as couples in programs that address subjects considered controversial or taboo in their communities.
of the longitudinal regression analyses point to the potential benefits of promoting notions of equity in relationships. Women who reported that they shared sexual decision making and relationship power with their partner were consistently less likely to report IPV. In contrast, IPV was reported more frequently when men and women espoused inequitable attitudes or reported that women had more decision making control in the relationship although few of these associations were statistically ificant.
Further qualitative research may shed light on the dynamics of power, conflict, and violence within relationships in which partners hold similar or differing views.
Thus, we were unable to examine whether IPV risk differed depending on who held more equitable attitudes within a relationship. For example, future research should explore whether risk is higher among women who feel IPV is unjustified and whose partners feel it is justified. research has suggested that discordance within a couple arising from perceived or actual gains in power by women can result in backlash, including IPV by men [ 272930 ]. Overall, much remains to be learned about how women and men perceive and engage with ideas of greater equity in intimate relationships.
Gender norms and values are dynamic, and their relationship with individual behaviors and experiences is complex. Several questions merit study. Do they desire greater equity and how do they define equity in a relationship? Our study has additional limitations.
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First, the decision to measure IPV as a binary variable without ing for frequency or type of IPV, while providing us with more statistical power, may have prevented us from observing crucial differences in the associations between attitudes and IPV risk. Third, the decision to use only partnered couples in these analyses also raises issues of potential selection bias. It is possible that partners who both chose to participate in the RESPECT study differed in important ways from participants whose partners chose not to be in the study, including on attitudes about the acceptability of IPV.