Controlling Behavior and Lifetime Physical,Sexual,and Emotional Violence in sub-Saharan Africa

Abstract

Intimate partner violence (IPV), commonly accompanied by controlling behavior, is a serious public health concern in sub-Saharan Africa. Data from women (n = 37,115) aged 15 to 49 years who completed the Demographic Health Survey’s (DHS) domestic violence module in eight countries in sub-Saharan Africa (Cameroon, Democratic Republic of the Congo [DRC], Côte d’Ivoire, Namibia, Rwanda, Sierra Leone, Togo, and Zambia) between 2011 and 2015 were obtained. DHS questions assessed lifetime physical, emotional, and sexual violence (ever vs. never). Controlling behavior was measured by a revised Conflict Tactics Scale. Multivariate logistic regression examined the association between controlling behavior and IPV adjusting for all covariates, including age, education, marital status, wealth, urban/rural setting, and occupation. An interaction term was included to evaluate the consistency of effect estimates across countries. In all, 45.60% of women reported experiencing one or more forms of IPV (physical, sexual, or emotional violence) in their lifetime, ranging from 31.16% in Côte d’Ivoire to 57.37% in Cameroon. Women who reported controlling behavior by a spouse/partner were more likely to have experienced lifetime physical (adjusted odds ratio [AOR] = 3.57, 95% confidence interval [CI] = [3.31, 3.85], sexual (AOR = 3.98, CI = [3.47, 4.57]) or emotional (AOR = 3.52, CI = [3.22, 3.85]) violence than women who did not report controlling behavior. Women who reported controlling behavior were also more likely to have experienced one (AOR = 2.57, CI = [2.36, 2.81]) or two/three types (AOR = 5.34, CI = [4.80, 5.94]) of violence. AORs did not significantly differ across countries. Further research is needed to evaluate whether policies, programs, and education aimed at preventing or modifying controlling behavior may reduce IPV.

Keywords

cultural contexts domestic violence intergenerational transmission of trauma sexual assault intimate partner violence

Introduction

Intimate partner violence (IPV), defined as any behavior within a current or former intimate relationship resulting in physical, sexual, or psychological harm, is associated with a range of adverse health outcomes and serious financial consequences (Duvvury, Grown, & Redner, 2004; Krug, Mercy, Dahlberg, & Zwi, 2002; Olayanju, Naguib, Nguyen, Bali, & Vung, 2013; World Health Organization [WHO], 2010). IPV is a pervasive global public health problem, and nearly one in three women will experience IPV during her lifetime (WHO, 2010). Among all WHO global disease burden (GBD) regions, the highest prevalence of lifetime IPV is found in central sub-Saharan Africa with a prevalence of 65.6%, and all regions in sub-Saharan Africa have lifetime prevalence estimates of IPV that are greater than the global average of 26.4% (García-Moreno et al., 2013). Many factors contribute to high rates of IPV, including underlying principles of gender inequality and social norms which may manifest as controlling behavior (Atkinson, Greenstein, & Lang, 2005; Jewkes, 2002; Taliep, Lazarus, & Naidoo, 2021).

Controlling behavior is characterized by use of jealousy, threats, and accusations to limit a partner’s social contact and financial independence (Kishor & Johnson, 2004). Controlling behavior is common and significantly increases risk of physical, sexual, and emotional IPV (Aizpurua, Copp, Ricarte, & Vázquez, 2021; Antai, 2011; Fidan & Bui, 2016; Ler, Sivakami, & Monárrez-Espino, 2020). Behavioral control and related determinants of IPV have conceptual underpinnings in feminist theory and patriarchal perspectives within the context of sociocultural and economic factors (Cools & Kotsadam, 2017; Olayanju et al., 2013). Changing gender roles that threaten traditional concepts of masculinity within developing regions may result in efforts to maintain or express power over women.

Change in traditional societal gender roles, such as those related to education and employment, in developing regions may pose a threat to the concept of masculinity and increase risk of violence (Kaukinen, 2004; MacMillan & Gartner, 1999; Nock, 2001; Taliep et al., 2021). Long-standing male-dominated family structures and social orders condone and perpetuate such violence. Unequal gender-based power dynamics are reflected in attitudes and beliefs of both men and women, with widespread beliefs among both genders that wife-beating is justified throughout sub-Saharan Africa (Hindin, 2014; Kishor & Johnson, 2004). The normalization of abuse through witnessing parental violence (Jewkes, 2002) may lead to the intergenerational transfer of ideals that uphold disproportionate allocation of power condoning the systemic use of violence and control (McCleary-Sills et al., 2016). Considering initiatives to advance women’s social and economic status and accompanying high rates of IPV in sub-Saharan Africa, an effort to understand and address the role of controlling behavior, justification of IPV, and intergenerational experiences of violence may be essential in reducing morbidity and mortality.

Studies focused specifically on the role of controlling behavior in IPV have primarily been conducted in North America, Asia, the Middle East, and United Kingdom (e.g. Gage & Hutchinson, 2006; Graham-Kevan & Archer, 2003; Krantz & Nguyen, 2009; Zaatut & Haj-Yahia, 2016). Research conducted in sub-Saharan Africa has typically focused on single countries (Antai, 2011; Dalal, Wang, & Svanström, 2014; Fidan & Bui, 2016; Graham-Kevan, Zacarias, & Soares, 2012; Tenkorang, Sedziafa, & Owusu, 2017; Wandera, Kwagala, Ndugga, & Kabagenyi, 2015). For instance, prior analysis of Nigeria Demographic Health Survey (DHS) data showed that women who reported controlling behavior by an intimate partner were 3 times more likely to experience physical IPV than women whose partners were not controlling (Antai, 2011). Another analysis using DHS data in Zimbabwe reported that women had a greater likelihood of experiencing physical, sexual, or emotional IPV when exposed to controlling behavior by an intimate partner (Fidan & Bui, 2016). In Uganda, an analysis of DHS data found that women with partners who were jealous, limited their contact with female friends and family, or got drunk often had greater odds of experiencing sexual IPV (Wandera et al., 2015). Research in rural Malawi established a unique measure of power within relationships integrating relationship control, economic independence, decision making, and social norms and found that women in relationships with dominant males were more likely to experience sexual IPV (Conroy, 2014).

While studies confined within one country or region identify site-specific sociocultural factors influencing IPV, such an approach results in a limited and fragmented scope of research weakening generalizability (Kidman, 2017). Given the magnitude and ubiquity of IPV across sub-Saharan Africa, incorporating a broader geographical region allows for the development of interventions with greater external validity for widespread application. Furthermore, prior research has failed to incorporate examination of women’s justification of beating, intergenerational effects of violence, and partner attributes which are known to affect the other partner’s health as per the Actor–Partner Interaction Model (Kenny, Kashy, & Cook, 2006).

All forms of IPV, physical, sexual, and emotional, have injurious effects, resulting in negative health consequences (Sugg, 2015). Studies of controlling behavior and IPV in sub-Saharan African countries have often included only one or two types of IPV (Antai, 2011; Conroy, 2014; Graham-Kevan et al., 2012; Wandera et al., 2015), frequently excluding the evaluation of sexual and emotional violence. It is important to acknowledge and distinguish between types of violence as associations and effect sizes may vary (Jewkes, 2002; Measure DHS/ICF International, 2013). Furthermore, surmounting evidence indicates that exposure to multiple types of violence, commonly called cumulative exposure to violence, has a unique and highly detrimental long-term impact on health and well-being (Sundermann, Chu, & DePrince, 2013). Thus, we evaluated both type of IPV and cumulative exposure to IPV in this work.

In our study, we used data from the DHS to assess the relationship between controlling behavior and physical, sexual, and emotional IPV among women aged 15 to 49 years in eight sub-Saharan African countries. This is the first known study to evaluate the role of controlling behavior in IPV within multiple countries in sub-Saharan Africa, assessing controlling behavior, women’s justification of beating, and intergenerational transmission of violence in relation to three types of IPV (individually and cumulatively) adjusting for partner characteristics. The purpose of this study was to (a) assess the prevalence of lifetime physical, sexual, and emotional IPV and controlling behaviors and (b) examine the role of controlling behavior by an intimate partner in experiencing each type of IPV and cumulative exposure to IPV in sub-Saharan Africa. We hypothesized that women who were exposed to a partner’s controlling behavior would be at increased risk of experiencing both single and multiple types of IPV in their lifetime. The examination of behavioral control is imperative for further elucidating the etiology of IPV in sub-Saharan Africa and developing initiatives that can effectively prevent and reduce its public health burden.

Method

Sample and Procedures

The sample for this study was drawn from Demographic Health Surveys (DHSs) conducted in eight sub-Saharan African countries. These data were collected between 2011 and 2015 in Cameroon (2011), DRC (2013), Côte d’Ivoire (2011), Namibia (2013), Rwanda (2014), Sierra Leone (2013), Togo (2013), and Zambia (2013). DHSs are cross-sectional, nationally representative surveys administered by the United States Agency for International Development (USAID) in collaboration with country-specific agencies. These surveys gather data on population health through a two-stage stratified cluster sampling design. Sampling is based on lists of enumeration areas developed from population census data and other sources in respective countries. A full explanation of sampling methodology is described elsewhere, including details on country-specific implementation (Corsi, Neuman, Finlay, & Subramanian, 2012).

Due to the sensitive nature of the individual interview questions, which cover topics such as family planning and breastfeeding, DHS protocol specifies that this section is applied to women of reproductive age (15-49 years in sub-Saharan Africa). All women aged 15 to 49 years were eligible for an individual interview. One woman per household was randomly selected for participation in the DHS domestic violence module. This module consists of questions about domestic violence based on a modified and validated version of the Conflict Tactics Scale (CTS) (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Only one woman per household is interviewed to maximize reporting of actual violence and to minimize risk of security breaches in accordance with WHO’s ethical and safety recommendations. This procedure emphasizes the importance of confidentiality and anonymity by ensuring that field workers are adequately trained and supported to obtain informed consent as well as maintain the privacy of respondents so that other household members are unaware that information about violence was disclosed (Kishor & Johnson, 2004; WHO, 2001). Surveys were conducted through face-to-face interviews, and personal digital assistants were used to record responses during the interviews. Only data from the domestic violence module were used in this study, limiting the sample to women within eight countries in sub-Saharan Africa (n = 37, 179). Cases with missing data for any of the key variables under examination in this study were excluded, leaving a sample size of 37,115 women.

Measures

Outcome variables

Outcomes of interest were physical, sexual, or emotional violence and cumulative exposure to IPV performed by a husband or an intimate male partner (Krug et al., 2002). Types of domestic violence were measured by a modified version of the CTS through questions about 15 discrete acts of violence, a method adopted to maximize cross-cultural comparison by avoiding semantic differences in definitions of violence (Kishor & Johnson, 2004). Physical IPV was measured by asking whether a current or former husband or partner ever (a) pushed, shook, or threw something; (b) slapped, punched with fist, or did something harmful; (c) kicked or dragged; (d) tried to strangle or burn; (e) threatened with knife, gun, or other weapon; or (f) twisted her arm or pulled her hair. Sexual violence was measured by two questions asking whether a current or former husband or partner ever (a) physically forced sex when not wanted or (b) forced other sexual acts when not wanted. Emotional violence was measured through responses to whether a current or former husband or partner ever (a) humiliated her, (b) threatened her with harm, or (c) insulted her or made her feel bad. IPV was assessed as a composite dichotomous variable, such that a woman was considered to have experienced each type of IPV by her partner if one or more affirmative responses (“yes”) were given. Reliability of the items was measured by Cronbach’s alpha (α = .76 for physical violence, α = .72 for sexual violence, α = .75 for emotional violence) prior to the analyses.

Cumulative exposure to violence was assessed by the number of types of violence experienced. Two outcome variables were created to assess cumulative exposure to violence. The first was a binary variable in which women were categorized as never having experienced any type of violence or having experienced one or more types of violence. The second was a categorical variable in which women were categorized as having experienced zero, one, or two/three types of violence.

Independent variables

The first independent variable examined in this study was controlling behavior by a woman’s current or former husband or partner. This was measured through six questions posed to the woman about her current or former partner’s behavior. Women were asked whether a current or former partner had ever engaged in the following behaviors: (a) jealousy if she talked with other men, (b) accusations of unfaithfulness, (c) denied her permission to meet her female friends, (d) limited her contact with family, (e) insisted on knowing where she was, or (f) did not trust her with money. One or more affirmative responses to any of the six questions indicated that the respondent had experienced controlling behavior by an intimate partner during her lifetime. Cronbach’s alpha for controlling behavior was .72.

Second, we assessed justification of wife-beating. Similar to controlling behavior, this measure of women’s attitude toward wife-beating was a composite dichotomous variable consisting of responses to five “yes” or “no” questions. Women were asked whether wife-beating was justified in the following situations: (a) if she went out without telling him, (b) if she neglected the children, (c) if she argued with him, (d) if she refused sex with him, and (e) if she burned the food. Women who gave one or more affirmative responses were considered as justifying wife-beating, and those who responded “no” to all questions were not considered as justifying wife-beating. Cronbach’s alpha for justification of beating was.85. Third, we examined the intergenerational effect of violence, whether the woman had witnessed her father beating her mother. This variable was measured by a single question asking a woman whether she had ever seen her mother beaten by her father with binary “yes” or “no” response options.

Covariates

Sociodemographic characteristics were assessed using standard questions and were included as covariates. They were women’s age, wealth, marital status, residence, sexually transmitted infection (STI) history, women’s education, women’s occupation, partner’s education, partner’s occupation, and country of residence. Age was assessed categorically in increments of 5 years from age 15 to 49. The wealth index is a composite measure of household cumulative living standard used to classify wealth on a continuous scale as poorest, poor, middle, wealthier, and wealthiest. Data on selected assets owned and dwelling characteristics such as materials used for housing construction and type of water and sanitation access were components of the wealth index (Rutstein & Johnson, 2004). Marital status included not married, married, living with partner, widowed, divorced, and no longer living together/separated. Residence was determined as rural or urban. History of STIs was measured as having an STI in the past 12 months. The respondent’s and her partner’s education were categorized as primary, some secondary, or secondary. Occupation for both the respondent and her current or former partner or husband was categorized as not working, professional/technical, clerical/sales/manual, or agriculture/self-employed. Country of residence was determined by the country in which the DHS was administered.

Data Analysis

Weighting was applied to account for the multilevel stratified cluster sample design of this study. The first stage of this analysis involved assessing the data through frequencies and generating estimates of prevalence and other descriptive indicators. In the second stage, multivariate logistic regression was conducted to analyze the relationship between controlling behavior and the experience of IPV (any type of IPV, physical IPV, sexual IPV, emotional IPV, and cumulative IPV) adjusting for potentially influential covariates. Separate models were run for each outcome. An interaction term was used to assess whether the effect of controlling behavior on outcomes differed by country. Results are presented in the form of odds ratios with two-sided 95% confidence intervals (CIs). Values of p ≤ .05 denoted statistical significance. Data were analyzed using STATA software version 14.0 (STATA Corporation, College Station, TX, USA).

Ethical Considerations

This study was conducted using secondary data in which participant identifiers were removed. Survey procedures received ethical approval from country-specific institutional review boards (IRBs) and the Ethics Committee of ICF. Review by the host country IRB ensured compliance with country-specific laws and norms. Review by the ICF IRB ensured compliance with the U.S. Department of Health and Human Services regulations for the protection of human subjects (45 CFR 46).

Results

Sample Characteristics

In all, 37,115 women had complete data for this analysis obtained from household surveys and the domestic violence module from 2011-2015 DHSs in Cameroon, DRC, Côte d’Ivoire, Namibia, Rwanda, Sierra Leone, Togo, and Zambia. Respondents were aged 15 to 49 years, with a mean age of 31.55 years (SD = 8.27). Most respondents were married (72.69%), lived in a rural residence (63.33%), had a primary level of education (73.03%), and/or were agricultural workers or self-employed (42.53%). The majority of respondents did not have an STI (95.19%). According to the interviewed respondents, most partners had a primary level of education (53.59%) and/or were employed as agricultural workers or self-employed (58.18%). Sociodemographic and partner characteristics are shown in Table 1.

Table 1.

Sociodemographic and Partner Characteristics of Women Completing the Domestic Violence Module of Demographic and Health Surveys Conducted in Cameroon, Democratic Republic of the Congo, Côte d’Ivoire, Namibia, Rwanda, Sierra Leone, Togo, and Zambia Between 2011 and 2015.

	Frequency	Percent
Age (years)
15-19	1,991	5.36
20-24	6,205	16.69
25-29	8,295	22.31
30-34	7,391	19.88
35-39	5,914	15.91
40-44	4,079	10.97
45-49	3,304	8.89
Wealth index
Poorest	8,392	22.57
Poor	7,859	21.14
Middle	7,760	20.87
Wealthier	7,226	19.44
Wealthiest	5,942	15.98
Marital status
Married	27,024	72.69
Living with partner	6,115	16.45
Widowed	1,320	3.55
Divorced	1,247	3.35
No longer living together/separated	1,473	3.96
Had STI in past 12 months
No	35,216	95.19
Yes	1,780	4.81
Residence
Rural	23,546	63.33
Urban	13,633	36.67
Education
Primary	27,146	73.03
Some secondary	7,615	20.49
Secondary	2,411	6.49
Occupation
Not working	8,655	23.32
Professional/technical	848	2.28
Clerical/sales/manual	11,827	31.87
Agriculture/self-employed	15,782	42.53
Partner’s education
Primary	19,991	53.59
Some secondary	14,466	39.04
Secondary	2,599	7.01
Partner’s occupation
Not working	634	1.73
Professional/technical	3,021	8.22
Clerical/sales/manual	11,706	31.87
Agriculture/self-employed	21,374	58.18
Total	37,115	100.00

Note. STI = sexually transmitted infection.

IPV: Type, Cumulative Exposure, and Context

Overall, 45.60% of women reported experiencing any form of IPV (physical, sexual, and/or emotional violence) in their lifetime. The lifetime prevalence of physical violence was 35.63%, emotional violence was 28.90%, and sexual violence was 13.38%. Approximately a quarter of women experienced one type of IPV (21.09%), and a similar proportion experienced two or three types of IPV (24.49%). Nearly three quarters of respondents (71.34%) reported experiencing controlling behavior by an intimate partner, 52.55% justified IPV, and 31.48% indicated witnessing their father beat their mother. The prevalence of experiencing any form of IPV ranged from 31.16% in Côte d’Ivoire to 57.37% in Cameroon (Figure 1). The reported lifetime experience of physical IPV ranged from 21.83% in Togo to 45.84% in DRC; emotional IPV from 18.04% in Côte d’Ivoire to 75.02% in Zambia; and sexual IPV from 5.05% in Côte d’Ivoire to 25.46% in DRC. The proportion of respondents experiencing one type of violence ranged from 16.03% in Namibia to 24.27% in Cameroon and those experiencing two or three types from 18.31% in Namibia to 35.92% in DRC. Controlling behavior ranged from 45.65% in Rwanda to 81.83% in Cameroon; justification of beating ranged from 29.19% in Namibia to 74.61% in DRC; and witnessing father beating mother ranged from 13.63% in Côte d’Ivoire to 40.66% in Rwanda. Prevalence of IPV and controlling behaviors by country is shown in Table 2.

Figure 1.

Proportion of women reporting any type of intimate partner violence (emotional, physical, or sexual) by country.

Table 2.

Proportion of Women Reporting Intimate Partner Violence and Indicators of Controlling Behavior by Country.

Country	Any IPV (%)	One Type of IPV (%)	Two or Three Types of IPV (%)	Physical IPV (%)	Sexual IPV (%)	Emotional IPV (%)	Controlling Behavior (%)	Justification of Beating (%)	Father Beat Mother (%)
Cameroon (n = 4,0z04)	57.37	24.27	33.07	44.14	15.07	40.86	81.83	46.63	33.43
DRC (n = 5,687)	56.27	20.36	35.92	45.84	25.46	36.45	80.95	74.61	39.36
Côte d’Ivoire (n = 5,006)	31.16	17.68	13.47	24.84	5.05	18.04	62.97	49.11	13.63
Namibia (n = 1,447)	34.35	16.03	18.31	24.81	7.32	25.35	52.80	29.19	29.69
Rwanda (n = 1,906)	40.19	18.07	22.11	31.37	11.59	26.86	45.65	40.94	40.66
Sierra Leone (n = 4,309)	48.71	23.88	24.78	42.66	6.64	27.93	78.54	63.85	34.86
Togo (n = 5,374)	37.53	19.15	18.35	21.83	8.08	68.55	63.63	32.38	19.75
Zambia (n = 9,413)	47.85	23.22	24.61	38.75	17.20	75.02	74.67	50.22	39.60
Total (n = 37,115)	45.60	21.09	24.49	35.63	13.38	28.90	71.34	52.55	31.48

Note. IPV = intimate partner violence; DRC = Democratic Republic of the Congo.

Controlling Behavior and IPV

Women who reported controlling behavior by their partner were 3.57 times more likely to report having experienced any form of IPV within their lifetime (95% CI = [3.31, 3.85]) compared with women who did not report any controlling behavior. Women who reported controlling behavior were more likely to have experienced physical violence (adjusted odds ratio [AOR] = 3.42; CI = [3.15, 3.72]), emotional violence (AOR = 3.52; CI = [3.22, 3.85]), and sexual violence (AOR = 3.98; CI = [3.47, 4.57]). The likelihood of experiencing one form or two/three forms of IPV was significantly greater in the presence of controlling behavior (AOR = 2.57; CI = [2.36, 2.81] and AOR = 5.34; CI = [4.80, 5.94], respectively).

Justification of beating and having witnessed father beating mother were significantly associated with experiencing IPV as well. Women who responded that violence was justified in response to a certain behavior were 1.38 times more likely to experience any form of violence (CI = [1.29, 1.48]), 1.38 times more likely to experience physical violence (CI = [1.29, 1.47]), 1.24 times more likely to experience emotional violence (CI = [1.14, 1.33]), and 1.40 times more likely to experience sexual violence (CI = [1.28, 1.53]) compared with women who did not think that wife-beating was justified. Women who justified violence were more likely to experience one (AOR = 1.32; CI = [1.22, 1.42]) and two/three types of violence (AOR = 1.46, CI = [1.34, 1.59]). Similarly, women who reported observing violence between parents were more likely to report having experienced any form of violence (AOR = 1.77; CI = [1.66, 1.89]) or physical (AOR = 1.75; CI = [1.64, 1.87]), emotional (AOR = 1.58; CI = [1.47, 1.70]), or sexual (AOR = 1.65; CI = [1.51, 2.81]) IPV. Women who observed violence between their parents were more likely to experience one (AOR = 1.52, CI = [1.41, 1.64]) or two/three types of violence (AOR = 2.05, CI = [1.90, 2.22]). AORs for the association between controlling behavior and IPV are shown in Table 3. AORs did not significantly differ across countries.

Table 3.

AORs and 95% CIs for the Association Between Indicators of Controlling Behavior and Intimate Partner Violence.

	Any Type of IPV AOR (95% CI)	One Type of IPV AOR (95% CI)	Two or Three Types of IPV AOR (95% CI)	Physical IPV AOR (95% CI)	Emotional IPV AOR (95% CI)	Sexual IPV AOR (95% CI)
Control
Controlling behavior
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	3.57 [3.31, 3.85]***	2.57 [2.36, 2.81]***	5.34 [4.80, 5.94]***	3.42 [3.15, 3.72]***	3.52 [3.22, 3.85]***	3.98 [3.47, 4.57]***
Justification of beating
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.38 [1.29, 1.48]***	1.32 [1.22, 1.42]***	1.46 [1.34, 1.59]***	1.38 [1.29, 1.47]***	1.24 [1.14, 1.33]***	1.40 [1.28, 1.53]***
Father beat mother
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.77 [1.66, 1.89]***	1.52 [1.41, 1.64]***	2.05 [1.90, 2.22]***	1.75 [1.64, 1.87]***	1.58 [1.47, 1.70]***	1.65 [1.51, 1.81]***
Demographic and socioeconomic characteristics
Age (years)
15-19	1.00	1.00	1.00	1.00	1.00	1.00
20-24	1.30 [1.13, 1.50]***	1.22 [1.02, 1.45]*	1.39 [1.17, 1.65]***	1.38 [1.19, 1.59]***	1.28 [1.09, 1.50]**	1.00 [0.83, 1.21]
25-29	1.43 [1.25, 1.65]***	1.28 [1.08, 1.52]**	1.60 [1.35, 1.90]***	1.55 [1.34, 1.79]***	1.40 [1.20, 1.64]***	1.06 [0.87, 1.28]
30-34	1.35 [1.17, 1.55]***	1.19 [1.007, 1.41]*	1.53 [1.29, 1.82]***	1.42 [1.23, 1.65]***	1.46 [1.25, 1.70]***	1.00 [0.83, 1.21]
35-39	1.43 [1.23, 1.66]***	1.28 [1.07, 1.53]**	1.60 [1.33, 1.93]***	1.39 [1.18, 1.63]***	1.59 [1.35, 1.87]***	1.03 [0.84, 1.26]
40-44	1.42 [1.22, 1.67]***	1.29 [1.07, 1.57]**	1.56 [1.29, 1.89]***	1.42 [1.21, 1.68]***	1.55 [1.31, 1.83]***	0.98 [0.78, 1.22]
45-49	1.38 [1.18, 1.63]***	1.25 [1.02, 1.54]*	1.54 [1.26, 1.87]***	1.32 [1.11, 1.56]**	1.60 [1.34, 1.92]***	0.94 [0.75, 1.19]
Wealth
Poorest	1.00	1.00	1.00	1.00	1.00	1.00
Poor	0.97 [0.89, 1.06]	0.98 [0.88, 1.09]	0.96 [0.87, 1.07]	0.94 [0.86, 1.03]	0.98 [0.89, 1.08]	1.05 [0.92, 1.19]
Middle	1.07 [0.97, 1.17]	1.06 [0.95, 1.19]	1.07 [0.95, 1.20]	0.99 [0.90, 1.09]	1.02 [0.92, 1.14]	1.23 [1.06, 1.42]**
Wealthier	0.98 [0.87, 1.10]	1.04 [0.91, 1.20]	0.92 [0.80, 1.07]	0.95 [0.84, 1.07]	0.92 [0.81, 1.05]	1.06 [0.90, 1.25]
Wealthiest	0.94 [0.82, 1.09]	1.03 [0.87, 1.22]	0.86 [0.73, 1.03]	0.94 [0.81, 1.09]	0.86 [0.74, 1.00]	0.97 [0.78, 1.19]
Marital status
Married	1.00	1.00	1.00	1.00	1.00	1.00
Living with partner	1.17 [1.07, 1.28]**	1.18 [1.06, 1.32]**	1.16 [1.03, 1.30]*	1.11 [1.01, 1.22]*	1.17 [1.06, 1.31]**	1.08 [0.94, 1.24]
Widowed	0.82 [0.70, 0.96]*	0.75 [0.61, 0.92]**	0.88 [0.73, 1.08]	0.88 [0.74, 1.05]	0.93 [0.79, 1.10]	1.07 [0.85, 1.34]
Divorced	2.05 [1.72, 2.43]***	1.25 [1.02, 1.54]*	2.95 [2.43, 3.57]***	2.11 [1.78, 2.50]***	2.52 [2.15, 2.97]***	1.94 [1.62, 2.32]***
No longer living together/separated	2.05 [1.75, 2.39]***	1.41 [1.16, 1.71]**	2.71 [2.29, 3.22]***	2.06 [1.77, 2.40]***	2.27 [1.88, 2.50]***	1.98 [1.65, 2.37]***
Residence
Rural	1.00	1.00	1.00	1.00	1.00	1.00
Urban	1.10 [0.99, 1.21]	1.00 [0.89, 1.12]	1.21 [1.07, 1.37]**	1.19 [1.07, 1.31]**	1.13 [1.01, 1.27]*	0.99 [0.86, 1.14]
Had STI in past 12 months
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.65 [1.44, 1.90]***	1.47 [1.24, 1.74]***	1.84 [1.56, 2.17]***	1.67 [1.45, 1.93]***	1.46 [1.27, 1.68]***	1.61 [1.35, 1.93]***
Education
Primary	1.00	1.00	1.00	1.00	1.00	1.00
Some secondary	0.97 [0.89, 1.05]	1.07 [0.97, 1.18]	0.88 [0.80, 0.97]*	0.95 [0.89, 1.03]	0.91 [0.83, 0.99]*	0.93 [0.83, 1.04]
Secondary	0.81 [0.69, 0.96]*	0.97 [0.78, 1.20]	0.67 [0.55, 0.82]***	0.74 [0.62, 0.87]***	0.85 [0.69, 1.03]	0.65 [0.51, 0.84]**
Occupation
Not working	1.00	1.00	1.00	1.00	1.00	1.00
Professional/technical	1.24 [0.99, 1.56]	1.11 [0.83, 1.48]	1.41 [1.05, 1.88]*	1.23 [0.97, 1.56]	1.27 [0.96, 1.67]	1.33 [0.93, 1.91]
Clerical/sales/manual	1.32 [1.21, 1.44]***	1.30 [1.18, 1.44]***	1.35 [1.21, 1.50]***	1.18 [1.09, 1.29]***	1.23 [1.12, 1.35]***	1.36 [1.19, 1.55]***
Agriculture/self-employed	1.33 [1.22, 1.45]***	1.35 [1.22, 1.50]***	1.32 [1.18, 1.47]***	1.17 [1.07, 1.28]**	1.25 [1.13, 1.37]***	1.33 [1.17, 1.51]***
Partner’s education
Primary	1.00	1.00	1.00	1.00	1.00	1.00
Some secondary	0.92 [0.86, 0.99]*	0.95 [0.87, 1.03]	0.90 [0.82, 0.98]*	0.95 [0.89, 1.03]	0.89 [0.83, 0.96]**	0.90 [0.82, 1.00]
Secondary	0.69 [0.59, 0.81]***	0.73 [0.60, 0.88]**	0.65 [0.53, 0.79]***	0.72 [0.61, 0.85]***	0.69 [0.58, 0.82]***	0.82 [0.64, 1.04]
Partner’s occupation
Not working	1.00	1.00	1.00	1.00	1.00	1.00
Professional/technical	0.75 [0.57, 0.98]*	0.78 [0.56, 1.08]	0.71 [0.52, 0.98]*	0.67 [0.51, 0.87]**	0.92 [0.70, 1.20]	0.84 [0.57, 1.24]
Clerical/sales/manual	0.80 [0.62, 1.03]	0.80 [0.59, 1.07]	0.80 [0.59, 1.08]	0.76 [0.59, 0.98]*	1.00 [0.77, 1.30]	0.97 [0.68, 1.38]
Agriculture/self-employed	0.82 [0.64, 1.06]	0.80 [0.59, 1.07]	0.84 [0.62, 1.13]	0.82 [0.64, 1.05]	0.97 [0.75, 1.26]	0.96 [0.67, 1.37]

Note. IPV = intimate partner violence; AOR = adjusted odds ratio; CI = confidence interval; STI = sexually transmitted infection.

p < .05. **p < .01. ***p < .001.

Sociodemographic Factors and IPV

Several sociodemographic characteristics were significantly associated with experiencing IPV. Women who were divorced or separated, who were agriculturally active or self-employed, or who had an STI were at increased risk of all outcomes (any form of IPV, physical IPV, emotional IPV, sexual IPV, one type of IPV, and two/three types of IPV). Women who were in older age categories were more likely to report any form of violence, one type of IPV, two/three types of IPV, and physical or emotional IPV, although not sexual IPV, in comparison with the youngest age group (15-19 years old). Living in an urban setting increased the likelihood of experiencing physical IPV (AOR = 1.19, CI = [1.07, 1.31]) and two/three types of IPV (AOR = 1.21, CI = [1.07, 1.37]). Women who reported their current or former partner had a secondary education were less likely to report any form of IPV (AOR = 0.69, CI = [0.59, 0.81]), physical IPV (AOR = 0.72, CI = [0.61, 0.85]), emotional IPV (AOR = 0.69, CI = [0.58, 0.82]), one type of IPV (AOR = 0.73, CI = [0.60, 0.88]), and two/three types of IPV (AOR = 0.65, CI = [0.53, 0.79]) in comparison with women who reported their partner had a primary education. Women indicating that their partner was employed in any type of occupation were less likely to report physical IPV in comparison with women who reported their partner was unemployed (professional/technical AOR = 0.67, CI = [0.51, 0.87]; clerical/sales/manual AOR = 0.76, CI = [0.59, 0.98]; agriculture/self-employed AOR = 0.82, CI = [0.64, 1.05]). Women reporting that their partner was employed in professional/technical occupations were less likely to report any form of IPV (AOR = 0.75, CI = [0.57, 0.98]) or two/three types of IPV (AOR = 0.71, CI = [0.52, 0.98]). Further information on odds ratios is shown in Table 3.

Discussion

In this study we investigated the association between controlling behavior and IPV among women in sub-Saharan Africa. We found relatively high rates of partner’s controlling behavior and IPV overall and within countries.

Controlling behavior, intergenerational transfer of violence, and justification of beating by an intimate partner significantly increased the likelihood of having experienced physical, sexual, and emotional violence, as well as multiples types of violence. This is the first known study to explore controlling behavior in relation to subtypes of and cumulative exposure to IPV among women within multiple countries in sub-Saharan Africa. These findings suggest that partner’s behavioral control may play a critical role in the etiology of IPV and in turn may be an important factor to address in future research and interventions targeting IPV.

Consistent with prior work examining sub-Saharan Africa, we found a high overall prevalence of IPV in the eight included countries compared with regional and global estimates. Prior evidence indicates that women in sub-Saharan Africa may be more likely to experience any form of IPV than anywhere else in the world (García-Moreno et al., 2013). Many determinants of IPV in this region of the world are the same as those found elsewhere, such as individual risk factors of unemployment, substance use, or history of child abuse (Beyer, Wallis, & Hamberger, 2015; Gil-Gonzalez, Vives-Cases, Alvarez-Dardet, & Latour-Perez, 2006). In addition, women within this region are subject to cultural norms founded in long-standing patriarchal traditions in which men are granted higher levels of power and status within hierarchical systems (Morrell, Jewkes, & Lindegger, 2012). Such inequities are evidenced by arranged marriages, a lack of representation of women in influential governmental positions, and failure to enact policies and laws against IPV (Olayanju et al., 2013). Thus, our finding that nearly three quarters of women had experienced controlling behavior aligns with societal paradigms.

Controlling behavior was highly predictive of single and cumulative exposure to IPV even when adjusting for potentially influential factors, thus corroborating results of prior studies in single African countries (Antai, 2011; Fidan & Bui, 2016; Wandera et al., 2015). These findings are likely a reflection of vulnerability to violence of women who are part of societies that are characterized by male-dominated power structures and encourage men to exercise control over women. While country-specific contextual factors likely contribute in meaningful ways to our understanding of IPV, valuable inferences may also be drawn from regional assessments. A growing emphasis on multinational collaboration within regions or subregions makes regional evaluations and estimates critical in discerning the most effective implementation for initiatives targeting this context (e.g., In Her Shoes, GBV Prevention Network, 2011). Resources, both financial and otherwise, are directed toward policy development and program intervention based on regional evaluations (Alliance for Accelerating Excellence in Science in Africa, 2017; Institute for Health Metrics and Evaluation, Human Development Network, & World Bank, 2013; United Nations Office for the Coordination of Humanitarian Affairs, 2017), making multinational assessments critical for advancing global health.

Among all analyses in this study, the effect size was the largest for our examination of controlling behavior and cumulative exposure to violence. Building on past research that has primarily assessed just one or two types of violence (Antai, 2011; Conroy, 2014; Graham-Kevan et al., 2012; Wandera et al., 2015), our findings indicate cumulative exposure may be a salient outcome. It may be that men who use controlling behavior have a greater tendency to express dominance not just through physical acts but also through sexual aggression and psychological abuse. Alternatively, women who experience controlling behavior may be less likely to seek help from formal avenues, as shown by Tenkorang et al. (2017), contributing to the continued cumulative exposure to violence over time. Cumulative exposure is linked with severe mental health outcomes, and victims may have unique needs for health and safety (Sundermann et al., 2013). Given the substantial effects of cumulative violence, it is important to understand implications for women who have experienced controlling behavior to effectively tailor interventions to meet their needs (Green et al., 2000).

Our findings indicate that not only is controlling behavior a unique predictor, but that justification of wife-beating and the intergenerational transfer of violence also increase the likelihood of IPV in an intimate relationship. Prior research of women’s attitudes regarding IPV in 25 African countries determined that over half of women in 15 of those countries believed wife-beating was justified in response to at least one of several behaviors, including neglecting the children, refusing sex, or burning food (Hindin, 2014). In many countries, women who condone violence or who have witnessed interparental violence during childhood experience greater risk of IPV in adulthood (Alio et al., 2011; Morrison & Orlando, 2004; Uthman, Lawoko, & Moradi, 2009). This early exposure may lead to normative understanding of violence as an appropriate means for conflict resolution (Jewkes, 2002), and violence becomes a learned behavior that is passed from generation to generation (Stith, Rosen, & Middleton, 2000). Some research indicates that elder women may actively discourage help-seeking among younger women experiencing IPV to enforce social norms (Chisale, 2016). Furthermore, qualitative evidence has shown that beating of wives may be an expected demonstration of love within the structure of marriage, and a husband who does not express jealousy, control, or violence may be seen as uncaring or weak (Chisale, 2016). Our findings indicate that the acceptance and socialization of violence across generations are pervasive throughout sub-Saharan Africa and are contributors to the perpetration of IPV. Initiatives may be informed by these indicators of IPV.

The evaluation of sociodemographic covariates in this research allowed for a unique picture of the experience of violence among women in sub-Saharan Africa. Women who were older, divorced or separated, lived in an urban setting, had an STI, or were employed in agricultural work/self-employed were at increased risk of experiencing IPV as assessed by one more of the outcomes in this study. When compared with the youngest age group (15-19 years), women in older age groups were at increased risk of violence. Considering that this research used a measure of lifetime violence, this result is may be due to the fact that older women have had more time to accumulate the experience of violence. However, the magnitude of this effect often decreased within older categories for physical and cumulative exposure to violence consistent with prior work (Capaldi, Knoble, Shortt, & Kim, 2012). Women who were divorced or separated were more likely to report IPV, potentially due to separation as an outcome of violence in a relationship. Divorce or separation may be used as coping strategies for IPV, and economic and social disadvantage in patriarchal cultures may reduce the likelihood of divorce as an option for women except in the most severe circumstances (Sedziafa, Tenkorang, & Owusu, 2018; Tenkorang et al., 2017). Incorporating severity of violence in future research may help to further understand when women turn to divorce in response to IPV. Prior research has found similar patterns in IPV by marital status, with higher reporting of IPV among women who are separated from their partners and also among those who were cohabitating but not married (Navarro-Mantas, Velasquez, Lemus, & Megias, 2021).

Few differences were found for the experience of emotional or sexual IPV between urban and rural residence. However, women residing in an urban setting had a greater likelihood of cumulative exposure to IPV and physical IPV, which is contrary to some recent research in single-country studies (Balogun, Owoaje, & Fawole, 2012; Nwabunike & Tenkorang, 2017). Our multinational sample provides additional insight into patterns of IPV based on residence location and is consistent with prior work (Abeya, Afework, & Yalew, 2011) and theories related to urbanization. McIlwaine (2013) in a review of the literature discusses the paradox of gender-based violence in which urban settings provide greater opportunities to cope with violence and access resources such as institutional support. Despite this, social relations can be more fragmented and other pressures may be more pronounced (e.g., poverty, occupation types, poor-quality living conditions, and the physical environment), which may increase the risk of IPV (McIlwaine, 2013).

Prior work has identified the link between STI risk and violence in an intimate relationship, which was corroborated in our research. In a sample of 10 countries in sub-Saharan Africa, Durevall and Lindskog (2015) found a consistent and strong associations between HIV infection in women and physical and emotional violence. They found that the presence of controlling behavior with IPV showed the strongest association with HIV status, and they theorized that dynamic relational control may be characterized by diminished protective factors and increased vulnerability to the contraction of HIV (Durevall & Lindskog, 2015). This illustrates the importance of considering the nuances of expression of violence between partners in research and future programs targeting violence and STIs, such as HIV.

Although increasing educational attainment and economic independence are commonly accepted as interventions to reduce violence against women, this research found little association between women’s educational attainment and IPV and a greater likelihood of IPV among women who reported clerical/sales/manual employment and agriculture/self-employment compared with women who were not working. Prior research has identified a mixed relationship between traditional metrics of women’s empowerment and IPV. Work by McCloskey, Williams, and Larsen (2005) and Ntaganir and colleagues (2008) found that women were less likely to experience IPV if they had higher levels of education. Conversely, research by Bazargan-Hejazi, Medeiros, Mohammadi, Lin, and Dalal (2013) found that women were less likely to experience IPV if they could not read compared with women who could read. Our findings are consistent with prior studies by Fidan and Bui (2016) and Nwabunike and Tenkorang (2017), which found higher rates of IPV among working women. Employment does not guarantee freedom from IPV as women may not have equal access to their earnings. Women leaving the domestic realm and entering the work force are stepping into traditionally masculine roles, and this shift can pose a threat to masculine identity and may increase risk of IPV (Atkinson et al., 2005). Furthermore, women working may be indicative of financial and other stressors in the home, which are risk factors for IPV (Chakraborty, Patted, Gan, Islam, & Revankar, 2016). Women may have sought to leave the home for work due to IPV (Sabri, Renner, Stockman, Mittal, & Decker, 2014).

Partner’s characteristics have been identified as important predictors of the perpetration of violence. According to the Actor–Partner Interaction Model, partner characteristics influence the other partner’s health and well-being (Kenny et al., 2006). We found that women who reported their current or former partner had a secondary education as opposed to a primary education were less likely to experience most types of and cumulative exposure to IPV. Employment in any type of occupation reduced the likelihood of physical violence. Tensions and assault within relationships can result when persons feel that their socially constructed identity is compromised, and persons who achieve economic or educational attainment that is consistent which such an identity are less likely to inflict violence (Stith, Smith, Penn, Ward, & Tritt, 2004).

It has been proposed that women’s social and economic advancement in society may have a counterintuitive effect on rates of IPV as gender roles are threatened and partners attempt to regain control through violence (Bazargan-Hejazi et al., 2013; Dworkin, Treves-Kagan, & Lippman, 2013; Taliep et al., 2021). Yet far from being a deterrent of further programs and policies to improve women’s status, these results may instead suggest that the effectiveness of interventions that empower women economically and socially may ultimately be dependent on their approach (Jewkes et al., 2017; Rothman, Hathaway, Stidsen, & de Vries, 2007). For instance, evaluations of past interventions that incorporated training and discourse on gender roles along with educational or economic opportunities have shown significant reductions in experiences of IPV and social acceptance of IPV (Abramsky et al., 2014; Pronyk et al., 2006). Furthermore, macro-level initiatives such as policy changes advancing the rights and empowerment of women may have comprehensive, enduring benefits (Brown, 1992).

This study had several limitations, including cross-sectional data preventing a demonstration of causality between controlling behavior and IPV. Yet the comprehensive and cohesive nature of the DHS data set allowed for consistent assessment of relationship control across a wide range of age groups and geographical regions. Second, the potential for underreporting of this highly sensitive and personal information due to self-reporting biases such as social desirability remains a possibility. However, many precautions are taken to maximize reporting of IPV while minimizing harm to ensure privacy and confidentially. Third, although IPV is itemized into discrete behaviors to enhance consistent understanding of what constitutes physical, emotional, and sexual IPV, differences in the perception of violence between cultures across eight countries may contribute to systematic differences in reporting. This may have been minimized by field worker training and precautions, as well as adaptations of standardized tools to country-specific linguistic needs. In addition, some elements of the DHS measurement of emotional IPV (i.e., whether an intimate partner made a woman “feel bad”) are less concrete than other specific measures of physical or sexual violence, and although widely accepted as part of the DHS program, we recognize this limitation. Fourth, the severity of violence may provide additional insight into the nature of controlling behavior and violence; thus, future work should examine violence severity in relation to IPV.

Despite these limitations, this study has contributed to our understanding of the etiology of IPV in a large sample of women in sub-Saharan Africa. We found that women who indicated that they had experienced controlling behavior by a partner, witnessed intergenerational violence, and justified beatings were more likely to report lifetime physical, emotional, and sexual violence and multiple types of violence in an intimate relationship. The results of this study suggest that control in relationships is an important component of IPV, even when adjusting for socioeconomic and demographic factors as well as partner characteristics. Initiatives to address IPV may need to take an ecological approach focusing on multiple levels as well as employing multifaceted strategies (Heise, 1998). From a macro-perspective, community gender norms may be central to perpetuating IPV, and initiatives expanding economic and educational opportunities have been identified as possible solutions (Jewkes et al., 2017; Pronyk et al., 2006). With some findings indicating that such initiatives may increase risk of IPV, attention to underlying gender ideologies and social norms may be essential to promote social equity and reduce IPV. Family- or individual-based interventions incorporating social and behavioral factors may need to include or enhance a focus on partner’s controlling behavior to effectively address IPV. Future research is needed to explore whether policies, programs, and education incorporating the prevention or modification of controlling behavior may reduce violence against women.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Marsha L. Trego

Author Biographies

Heather F. McClintock, PhD, MSPH, MSW, is an assistant professor and director of undergraduate programs in the College of Health Sciences at Arcadia University. Her research broadly focuses on the prevention, treatment, and management of chronic disease and disability globally. Recent research aims to understand and reduce the burden of intimate partner violence in sub-Saharan Africa. Prior to completing her doctorate, she served as a program officer at the United States Committee for Refugees and Immigrants and a senior project manager in the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania.

Marsha L. Trego, MPH, is a recent graduate of Arcadia University’s Master of Public Health program. Her research focuses on multiple facets of human behavior and public health, including the psychological, environmental, and economic factors that affect dietary behavior. She is interested in the way that policy, informed by sound scientific research, can be leveraged to support human health.

Evangeline M. Wang, BSc, is a public health major at Arcadia University. She is the president of the Public Health Society and has volunteered and interned with various public health agencies such as Prevention Point Philadelphia and HIPS in Washington D.C. She hopes to continue her career with graduate study in global public health.

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