Risk factors for domestic physical violence: national cross-sectional household surveys in eight southern African countries

Background The baseline to assess impact of a mass education-entertainment programme offered an opportunity to identify risk factors for domestic physical violence. Methods In 2002, cross-sectional household surveys in a stratified urban/rural last-stage random sample of enumeration areas, based on latest national census in Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia and Zimbabwe. Working door to door, interviewers contacted all adults aged 16–60 years present on the day of the visit, without sub-sampling. 20,639 adults were interviewed. The questionnaire in 29 languages measured domestic physical violence by the question "In the last year, have you and your partner had violent arguments where your partner beat, kicked or slapped you?" There was no measure of severity or frequency of physical violence. Results 14% of men (weighted based on 1,294/8,113) and 18% of women (weighted based on 2,032/11,063) reported being a victim of partner physical violence in the last year. There was no convincing association with age, income, education, household size and remunerated occupation. Having multiple partners was strongly associated with partner physical violence. Other associations included the income gap within households, negative attitudes about sexuality (for example, men have the right to sex with their girlfriends if they buy them gifts) and negative attitudes about sexual violence (for example, forcing your partner to have sex is not rape). Particularly among men, experience of partner physical violence was associated with potentially dangerous attitudes to HIV infection. Conclusion Having multiple partners was the most consistent risk factor for domestic physical violence across all countries. This could be relevant to domestic violence prevention strategies.

lem [1,2]. Domestic violence is not a single behaviour but a mix of assaulting and coercive physical, sexual, and psychological behaviours designed to manipulate and dominate the partner to achieve compliance and dependence. Women are more likely to experience physical injuries or psychological consequences [3,4].
Domestic violence is well documented in several African countries. In eastern Nigeria, a clinic-based survey of 300 women reported 40% had experienced violence in the previous year [5]. In one district of Uganda, 30% of 5,109 women attending a clinic had received threats or physical abuse. The majority of respondents viewed wife beating as justifiable in some circumstances [6]. In Durban, South Africa, more than one third of women from a low-income community had experienced domestic violence at some stage [7]. A South African study reported domestic violence associated with violence in childhood, education and multiple partners [8,9]. In southern Africa domestic violence is particularly important because of the multiple links between violence and HIV infection [10]. Links between domestic violence and HIV have been reported in Botswana [11], Ghana [12], Malawi [13], South Africa [14], Tanzania [15], Uganda [16,17], Democratic Republic of Congo [18] and Zambia [19]. This is a baseline assessment of attitudes and practices, from which we intend to measure the impact of mass media campaigns, launched since the baseline by Soul City. The survey content was thus geared to measure the impact of education-entertainment messages [20], rather than as a specific research hypothesis. One section of the questionnaire dealt with domestic violence -attitudes and subjective norms, collective efficacy, discussion of the issue and experience of physical domestic violence in the last year -and the results are reported here as a cross-sectional survey.

Design
In Botswana, Lesotho, Swaziland, Malawi, Mozambique, Namibia, Zambia and Zimbabwe we stratified the most recent available census into rural, urban (not within the capital region), and urban capital sites. In each country, we drew a last stage random selection of enumeration areas, with probability proportional to the national population (Table 1).

Ethical considerations
An accredited international ethical review board evaluated the proposal, noting concerns that disclosure might place the respondent at risk and that the questions about sexuality probed confidential issues. Interviewers informed each respondent of their right to refuse to participate, and of their right to refuse to answer any question. Before starting the questionnaire, the interviewers requested verbal consent to proceed. They did not record names or other identifying feature, and took precautions that the interview was out of hearing of others.

Outcome measures
We defined domestic physical violence by responses to the question: "In the last year, have you and your partner had violent arguments where your partner beat, kicked or slapped you?" To facilitate disclosure, interviewers asked this with the respondent alone. If this was not possible, they noted presence of a listener. Interviewers read questions without additional explanations, and recorded answers verbatim. Wherever possible, female researchers interviewed women and male researchers interviewed men. With the exception of one question about pregnancy, interviewers administered the same instrument to men and women.
We limited domestic violence to reports of physical abuse, and we had no measure of severity of the violence. We included items on attitudes to and subjective norms of domestic violence, collective efficacy to reduce domestic violence (Can your community do anything about violence against women?) and discussion of domestic violence (In the last year, how often did you talk with anyone about domestic violence? To whom did you speak most often about domestic violence?). In designing the evaluation of the impact of mass media, we anticipated that some effect might be measured in these intermediate outcomes before changing the actual occurrence of domestic physical violence.
The relevance of partner physical violence to HIV/AIDS risk came from answers to the questions "Do you think you are at risk of getting HIV?" and "If you found you were HIV positive, how would you change your sex life", considering "always use a condom" and "abstain from sex" as positive values. Negative values included "no change", "spread it intentionally", "same partner" and "sleep with virgin to cure".

Analysis
Data technicians manually digitised questionnaire data twice and eliminated keystroke errors by verifying discordant entries with the original questionnaires. We weighted final estimates in line with the national populations and the eight-country estimates weighted national indicators by the population of each country (Table 1). In a univariate analysis, we stratified each association between partner physical violence and potential risk factors by each of the others in turn (List 1, see Appendix), initially ignoring multiple influences [21,22]. We adjusted for the multiple comparisons by requiring 99% confidence.
For risk factors not explained by any stratifying variable and those with multiple influences, a step down logistic regression model tested the effect of country, age, sex, education, income, food security, household size, occupation, and the factors in List 1 (see Appendix). The several items on attitudes to sexuality and violence showed colinearity, with no single variable attaining statistical significance in the preliminary logistic regression model. We included the variable from each group that showed the strongest association with the outcome in the model.

Personal and household factors Sex
The gender gap in reported domestic physical was negligible in Botswana, Lesotho, Namibia, Swaziland and Zimbabwe. Elsewhere, female respondents reported being the subjects of partner physical violence more frequently than . This effect disappears entirely when stratifying by country; the levels of education combined with quite different rates of violent altercation seem to confound the measurement. In Zambia, the only country where education was associated with violent altercations, the average person who had not completed primary school was less likely to report a violent argument with a partner: argument with a partner: OR 0.82 95%CI 0.69-0.98 (600/ 1,979) among those who had not completed primary education compared with 266/768 who had done so reported a violent altercation with a partner).

Household size
We could find no obvious trend of violent altercation with increasing household size; missing data 6.6% (1,360/ 20,639). The average person living in a household with more than five members was less likely to report a violent altercation than one living in a household of 1-5 people (OR 0.88 99%CI 0.63-0.98; 1,295/7,887 in higher occupancy households compared with 2,049/11,383 in lower occupancy households reported a violent altercation).

Relevance of partner physical violence to HIV risk
People who reported partner physical violence (male or female) were significantly more likely to believe they were at risk of getting

Discussion
High rates of domestic physical violence in all eight countries were conspicuously independent of education, household size, household income and remunerated employment. After taking into account age, sex, country and other factors, domestic physical violence was strongly associated with income gradients (being unemployed in  the context of some household income) and home language in one country, and with multiple partners in the last year in all countries. Victims of partner physical violence were more likely to feel at risk of HIV infection and more likely to anticipate antisocial behaviour if they found they were HIV positive. This is a cross-sectional household survey based on faceto-face interviews. This design limits conclusions about causality of, for example, multiple partners leading to physical violence or being the consequence of physical violence. It is likely that some respondents held back from expressing their true belief or experience. Even with the best field practices -including independent translation and back-translation of questionnaires, standardised training of local interviewers, in-country piloting and consultation with local community representatives, doubledata entry and verification -measurement error is possible. The sample makes the results relevant to the eight countries, but not necessarily to other countries.
A major limitation is that we only considered domestic physical violence. This almost certainly underestimates the level of domestic violence. Other forms (verbal, sexual, economic and psychological) were beyond the scope of the study. In all countries we asked the same questions of men and women. We were able to examine several intermediate outcomes related to domestic violence -including attitudes, subjective norms, collective efficacy and discussion/socialisation -but most of these could be addressed only superficially through one or two items in the questionnaire.
We had no measure of severity or frequency of physical domestic violence, making it difficult to interpret the proportion of men and women who reported partner violence in the last year. Large studies in the UK and USA have reported similar proportions of partner violence for males and females, but found male on female violence to be more severe than female on male violence [23,24]. It is quite possible that the same is true for southern Africa.  The men we interviewed were at home during working hours and, in this respect at least, they may not be typical of all men in the eight countries. We also did not ask who initiated the altercation, so it is also possible these reports reflect women defending themselves from male-initiated violence. Even so, the finding is compatible with a degree of female agency in domestic physical violence and supports our conclusions from South Africa that initiatives against sexual violence should look beyond gender stereotypes of victims and villains [25].
There was no recognisable pattern of poverty and domestic violence between countries (Mozambique, the poorest country, reported the lowest rates while Zambia reported the highest). We also did not find significant associations between victims and their individual education or employment, and we could only address the income gradient between partners through a proxy variable. It is possible that in-household inequality in education and income could be more relevant to domestic violence than we were able to measure in this study [26]. There was no interpretable association between the Gini coefficient (measuring inequality in the country) and male or female reports of violence (Tables 3 and 4). The Gini coefficient used for Botswana and Lesotho was 0.63, Malawi 0.50, Mozambique 0.40, Namibia 0.74, Swaziland 0.61, Zambia 0.42 and Zimbabwe 0.61 [27].
The occurrence of domestic physical violence in some parts of Zambia raises the question of something being done differently there, despite efforts to reproduce exactly the same survey in all countries. Whatever the reason for the higher rates of domestic physical violence detected in Zambia, it seems unlikely the same error lies behind the inability to demonstrate an association between violent altercations and education, overcrowding, income and age -consistent across all the countries.

Conclusion
If there is good news from this study, it is that multiple partners, attitudes and subjective norms are more in the control of most individuals than are poverty, overcrowding and education -without detracting from the need for massive investment in these sectors.
An unanswered question is how to modify attitudes or multiple partners. There is also no guarantee that changing attitudes will, on its own, impact on behaviour. The study confirms the importance of moving beyond gender stereotypes of victims and villains. Men also report suffering partner physical violence, although our inability to measure severity could mask an important gender difference. The solutions to domestic violence lie with both men and women, and both have agency in this regard. There was also a prominent sense of collective efficacy, the majority expressing they could do something about domestic violence.
Although many thought their community could deal with violence against women, few victims and still fewer of the non-victims said they had discussed violence against women with anyone. Stimulating discussions about violence against women offers one direction for initiatives against partner physical violence. Wider discussion could influence social norms, in addition to targeting individual attitudes and supportive public policy.

Sexual violence
If a woman gets raped its her own fault.
Forcing sex with someone you know is not rape.
Forcing your partner to have sex is rape.

Subjective norms about sexual violence
Do most people in your community feel forcing your partner to have sex is rape?
Do most people in your community feel women have a right to refuse sex with their partners?
Is violence against women considered a serious problem in this community?

Collective efficacy about sexual violence
Can your community do anything about violence against women?

Attitudes to domestic violence
Women have the right to refuse to have sex with partner Violence between a man and a woman is a private matter Women sometimes deserve to be beaten.

Subjective norms about domestic violence
Do most people in your community feel women sometimes deserve to be beaten?

Discussion about domestic violence
In the last year, how often did you talk with anyone about domestic violence? [never, seldom or often] To whom did you speak most often?

Practices relating to domestic violence
What community activity about violence against women have you participated in?
In the last year, have you and your partner had violent arguments where someone was physically hurt?

Transactional sex
Men have the right to have sex with their girlfriends if they buy them gifts.
Its okay for an older man to have sex with teenagers A person has to have sex with their boyfriend or girlfriend to show that they love them.
Do most of your friends feel men have the right to sex with their girlfriends if they buy them gifts?
Publish with Bio Med Central and every scientist can read your work free of charge