Intimate partner physical violence and associated factors in reproductive age married women in Aksum Town, Tigray, Ethiopia 2018, and community based study

Objective As reports indicated about 1 in 3 of women worldwide have experienced physical violence but there is no enough reports on the current status of the act in Aksum town so this study intended to identify the prevalence and factors associated with physical violence of reproductive age married women in Aksum town Tigray Ethiopia. Result A total of 398 women were enrolled in the study and making a response rate of 100%. 112 (28.1%) women had physical violence in their lifetime. Educational level of women (AOR = 2.2; 95% CI 1.28, 6.7), Occupation of women’s (AOR = 3.8; 95% CI 2.32, 12.8), age of husband (AOR = 5.2; 95% CI 2.3, 11.5), husbands having other wife (AOR = 7.8; 95% CI 4.2, 18.9) and husbands having alcohol habits (AOR = 3.8; 95% CI 1.74, 14.7) had significant association with physical violence.


Introduction
According to the definition of the world health organization violence is the intentional use of physical force or power against another person that results in injury, death, psychological harm, mall development or deprivation and physical violation is a type of violence where someone is bodily suffered/harmed due to physical force [1][2][3][4].
Physical violence against women is increasingly recognized by the international community as it is a significant violation of human rights, and so many studies done in response to this in different regions, countries, cultures and socioeconomic classes, and the studies indicating women's in developing countries experience higher rate of intimate partner physical violence than women's from developed countries [5].
Physical violence affects women's physical and mental health directly like injury and indirectly like chronic health problems that can develop from prolonged stress. As severe as physical violence exists there will be a greater impact on the women's health and the health impact seem cumulative in a long duration [5,6].
Intimate physical violence can have huge personal, social and economic effects on women's status; it may result in conflict or dissatisfaction in the relationship of the partners, male partner dominance in the family, economic instability and high levels of general violence in society [7].
Data availability on physical violence is high in Africa, according to available data on the prevalence of physical violence, indicating that the highest prevalence was in Africa, in almost countries lifetime prevalence reported over 40% in the range varied from 14% in Comoros and 64% in Democratic republic Congo but in Asian countries it ranges from 13% in Azerbaijan to 40% in Timor-Leste. In Tennessee, 40% of women had intimate partner physical violence in their lifetimes. As current reports even the prevalence of physical violence declines it is still high in Ethiopia, which is 49% [8][9][10][11].
According to the WHO estimation about 1 in 3 of women worldwide have experienced physical violence which was reported as a pandemic problem. Globally, physical violence against women, recognized as a fundamental human rights violation, is widely prevalent across high, middle and low-income countries, but still the health system not adequately addressing the problem of intimate partner physical violence and for this reason it is contributing to comprehensive multi-sectoral problems/ responses [1,3,5,8,10,14].
As reports in Ethiopia around 23% of women have ever experienced intimate partner physical violence since 15 years old, and the most common perpetrator of physical violence among ever-married women were current husband/partner which covers around 68%. Though there are many studies in Ethiopia there is no study in Aksum, and IPV is routine in the outpatient visit in the area, as well as we absorb the problem in our daily activities, that is why we are intended to study focusing on intimate partner physical violence [13,15].

Study area and period
The study was conducted in Aksum town which is located in the Central Zone of Tigray Regional State, at a distance of 1024 km from Addis Ababa. The total population of Aksum town is 60,766, with 30,991 (51.0%) females and 29,775 (49.0%) males. Administratively the town is divided into five Keble [16].

Study designs and population
Population based cross sectional study was conducted to study reproductive aged married/cohabited women living in Aksum selected three Keble's during the study period.

Sampling size and sampling technique and procedure
The sample size was determined using single population proportion with assumptions, prevalence = 20.6% [17], 95% CI, 5% marginal error, correction formula and 10% non-response rate, yielding to final sample size of 398, it also assumed sample size calculation for different associated factors. To select study participants at their permanent place of residence, systematic sampling technique was used.

Data collection tool, procedure and data quality control
Data was collected using a pretested semi structured questionnaire to assess women Socio demographic characteristics, women's husband characteristics and the women's experience of IPV. The questionnaire was originally prepared in the English language, and then translated to the local language. Data were collected in a timeframe of 4 months by trained data collectors and three supervisors were supervised the data collection. Training was given for data collectors and supervisors. Supervisors and researchers were strictly supervised data collection. Data were cleaned before commencement of the analysis. Finally for victims of IPV "need based" support were given in their interested time and place like hospital, church or local organization [18].

Operational definitions Intimate partner physical violence
Self-reported one or more episodes of physical threats in which husband/partner battered his wife either by push, shake, or throw something at; slap; twist arm or punch you with his/her fist or with something that could hurt; kick, drag, or beat up; or threaten or attack with a knife, gun, or any other weapon that can result in physical harm of married women [1,19].

Data analysis
Data were entered to EPI data version 3.02, transported and analyzed using SPSS version 20.0. Both measures of central tendency and dispersion were calculated. Bivariate logistic regression was run to infer an association between dependent and independent variables and independent variables with a p-value 0.25 were inserted to multivariable logistic regression to obtain significant variables associated with the dependent variable. The significance level was declared at a p-value 0.05.

Ethical considerations
This study was reviewed and approved by the Research Committee, Health Science College and Comprehensive Specialized Hospital of Aksum University. Data were collected after full written informed consent was obtained from each study subjects. Consent and assent also obtained from their parents for those whose age was less than 16 years old.

Socio demographic characteristics of participants
A total of 398 women enrolled in the study and yielding a response rate of 100%. Around 175 (44%) of the participants were in the age group ≥ 31 years old and 280 (70.4%) married at the age of 16-20 years old. Around 56.8.2% of the participants were orthodox by their religion. Regarding the occupational status of the participants, 245 (61.6%) were housewife. 198 (49.7%) was 2-4 parity and 95 (23.9%) women were pregnant during the study period (Table 1).

Intimate partner physical violence
Out of the 398 study participants, 112 (28.1%) and 27 (6.8%) married reproductive age women had intimate partner physical violence in their lifetime and in the last 3 months respectively, from the physically violence reproductive age women, 88 (22.1%) had conflict with their husband, 35 (8.8%) and 65 (16.3%) battered by their husband usually and sometimes respectively. A total of 48 (8.7%) and 27 (6.8%) respectively had conflict and battered in the last 3 month (Table 2).

Factors associated with intimate partner physical violence
After controlling the confounding effect educational level of women, occupation of women's, age of women's husband, women's having husbands with other extra wife and women's having husbands with alcohol/smoking habits had significant association with intimate partner physical violence in the multivariate logistic regression model (Table 3).

Discussions
In Ethiopia and other developing countries as well as in the study area, intimate partner physical violence is a major health problem, but in the specified study area there was no enough evidence related to intimate partner physical violence, hence we intended to show the status and its associated factors of it. Based on this, our study result showed that out of the total; 28.1% and 6.8% had reported lifetime and in the last 3 months respectively. Our study finding is also lower than comparable to a study conducted in Shanghai, China (31.9%) [19], Kusheshwor, Sindhuli, Nepal (29.6%) [20]. Another study conducted in Uganda (41%), Nigeria 30.5%, both study findings were higher as compared to our study finding [21,22]. Our Study finding also less than from the study finding in Ethiopia from 2000 to 2014 which ranged from 31 to 76.5% [4]. Our Study finding also less than from the study conducted in Debre Tabor town in 2015, which showed, 56.1% lifetime and 27.9% in the last 12 months [23]. Additionally, another Study conducted in Shimelba refugee camp was 25.5% [12], and Southwest Ethiopia, 64.7% [24], Hawzen, 38.6% which is higher than our study finding [25].
In this study Women's educational status had significantly associated with intimate partner physical violence among those reproductive aged, married women's. Women's who had no formal education was 2 times more likely to experience intimate partner physical violence than college and above educational level women's, and those grade 9-12 were 0.34 times less likely to report intimate partner physical violence. This is consistent with earlier studies finding of WHO, 2010 [6], Shire Endaslassie, Ethiopia [17], Iran [26], Nepal [20] and in contrast to the study finding in Mozambique [27], the possible reason for this difference might be due to study area and/ or study participants Socio-demographic characteristics difference.
Being a housewife in their occupation was 4 times more likely to experience intimate partner physical violence than women's in women's association leader occupation. Since housewife's are most of the time economically dependent on their husband, they are more vulnerable to intimate partner physical violence and this is consistent with studies finding in Nigeria [22], Nepal [20], Pakistan [28], and in contrast with study finding in Southwest Ethiopia, this could be as women's exposure to the larger society, husband/partner might be violent on the working women just to prevent women from working outside the home as a way of controlling them and involvement of women in economic activity might be considered as a challenge in power sharing with man in the home [24].
Women's being daily laborer in their occupation was 4 times more likely to experience intimate partner physical violence than women's in women's association leader occupation. This was in line with study findings in Shanghai, China [19], Nepal [20] and Pakistan [28].
A woman who had husbands in the age group ≤ 30 years old was 5 times more likely to report intimate partner physical violence than those who had  husbands ≥ 41 years old. This result is in contrast with study finding in Hawzen, Ethiopia [25], in our finding as age of husband increasing experience of intimate partner physical violence decreases irrespective of women's age, but in the study in Hawzen as women's age increases the experience of intimate partner physical violence increases irrespective of husbands age, it was also in contrast with the report in WHO [14] and Iran [26].
Women's where their husband had another extra wife were 8 times more likely to report intimate partner physical violence than those Women's where their husband had no extra wife. This is in line with studies result in WHO, 2010 [6], Shimelba [12], Uganda [29] and Northwest Ethiopia [23].

Conclusions
A significant number of married reproductive age women's had experienced intimate partner physical violence.  Being women with have no formal education, house wife, having husband ≤ 31 years old, women's having husband with other additional wife and having an alcoholic/ smoker husband were independent variables significantly associated with intimate partner physical violence.

Limitations
The result depends only on the response of participants, so that there might be chance of recall bias. Since we only focus on the physical violence, this may make under or over reporting. During participants' selection, our study had not included homeless and street married women.
Interviewer and respondent power differential may be happened but we tried to minimize it using location, location, location (interview in private, participants choosing, where she feels comfort) and rapport.