The Role of Structural Factors in Support-Seeking Among Women Experiencing Intimate Partner Violence (IPV) in Mwanza,Tanzania: Findings From a Qualitative Study

Abstract

In this qualitative study of women participating in an intimate partner violence (IPV) prevention trial, experiences of IPV and the context that shapes support-seeking were explored through in-depth interviews and focus groups discussions. Decisions to seek support were influenced by a range of factors including fear of further abuse, shame, acceptance of IPV as normal, belief that IPV is a private matter between the couple, economic dependence on male partners, and a poorly responsive legal and justice system. Gender empowerment programs need to intervene at the social, cultural, political, and economic levels that shape justification and meanings attached to IPV and women’s decisions in seeking support.

Keywords

intimate partner violence disclosure of violence support seeking structural factors Africa

Background

Violence against women is both a human rights concern and a global public health problem (Daher, 2002; Devries et al., 2013; García-Moreno et al., 2015). It is estimated that worldwide about 30% of women will experience physical and/or sexual violence from an intimate partner during their lifetime with reported rates highest in southeast Asia, the Mediterranean region, and sub-Saharan Africa (Devries et al., 2013). Intimate partner violence (IPV) has far-reaching consequences for women's physical and mental health and social well-being (Devries et al., 2011; Dillon et al., 2013; García-Moreno et al., 2013; Mahenge et al., 2013). Women who experience IPV show more physical symptoms of poor health, injuries, and more days out of work than women who have not been abused (Coker et al., 2005; Dillon et al., 2013; Ellsberg et al., 2008). They frequently struggle with despair, distrust, hopelessness, and anger (Riger et al., 2002; Sackett & Saunders, 1999), with such feelings often becoming deeply entrenched. The impact on women's mental health is considerable with studies indicating high rates of depression, anxiety, symptoms of post-traumatic stress disorder (Dillon et al., 2013; Ellsberg et al., 2008; Golding, 1999; McGarry et al., 2017), and increased risk of suicide (Devries et al., 2011; Mitchell & Hodson, 1983). Furthermore, the psychological consequences of IPV can persist long after an abusive relationship has ended (Adkins & Dush, 2010).

Studies suggest that women experiencing IPV often do not seek support, or even tell anyone about their experiences (Hatcher et al., 2016; Katiti et al., 2016; Paul, 2016). The WHO multi-country study on women's health and domestic violence against women found that in all 10 participating countries, the interviewer was often the first person to whom abused women had spoken about their experiences. For example, at both sites in Bangladesh, around two-thirds of the women who reported physical abuse had not told anyone. Even if women had talked to someone about the violence they were experiencing, relatively few across all study sites had reported it to people in positions of authority, such as religious and traditional leaders, health care professionals, police, counselors, or women's non-governmental organizations (NGOs) (Garcia-Moreno et al., 2005; World Health Organization, 2005).

Seeking support for violence and abuse may buffer against stress in several ways, such as enhancing self-esteem, influencing perceptions of stressful events, and increasing knowledge of coping strategies (Canty-Mitchell & Zimet, 2000; McNutt et al., 2002). Studies have shown that among women experiencing IPV (allowing for IPV frequency), higher social support scores are associated with a significantly reduced risk of poor perceived mental health, suicidal thoughts, and the risk of facing more violence (Bybee & Sullivan, 2005; Coker et al., 2002; Goodman et al., 2005; Kaslow & Thompson, 2001; Liang et al., 2005; Thompson et al., 2000).

In Tanzania, population surveys indicate high levels of IPV against women (Garcia-Moreno et al., 2006; Tanzania National Bureau of Statistics, 2011) For example, the WHO multi-country study on women's health and domestic violence against women found that almost 30% of ever-partnered women in a rural area of Tanzania had experienced physical and/or sexual violence from a partner in the year prior to the survey (Garcia-Moreno, 2005). This is similar to the findings of the most recent Tanzania Demographic and Health Survey conducted in 2015, which reported that around 30% of ever-partnered women, aged 15–49 years old, had experienced physical or sexual IPV in the previous 12 months (Ministry of Health (MoH) [Zanzibar], 2015).

MAISHA Study

The MAISHA study was implemented in Mwanza city, northwestern Tanzania, by the Mwanza Intervention Trials Unit, National Institute for Medical Research and the London School of Hygiene & Tropical Medicine (LSHTM) to evaluate a violence prevention intervention, and to gain further insights into the different forms and consequences of violence and the drivers of violence perpetration. This study was conducted in Mwanza city because of a high level of violence against women in the city (Kapiga et al., 2017). As part of the study, a cluster randomized controlled trial was conducted to evaluate the impact on women's past-year experience of IPV of a 10-session social empowerment intervention integrated into an established group-based microfinance loan scheme.

The trial methodology is described in detail elsewhere (Harvey et al., 2018). Briefly, the trial was conducted between September 2014 and January 2018 in collaboration with BRAC, an established microfinance provider in Tanzania. Microfinance loan groups were only enrolled in the trial if at least 70% of members consented. For each microfinance group enrolled, only members who provided informed consent participated in trial procedures and activities. A total of 66 microfinance loan groups, with an average of around 15 women per group, were enrolled in the trial. At baseline, before randomization, women were invited to participate in an interview following a structured questionnaire (baseline survey) that included questions on experiences of violence adapted from the WHO Violence Against Women instrument (World Health Organization, 2005).

Across the 66 microfinance groups enrolled, there were 1,049 women who consented to take part in the trial. Of these, 1,021 completed the baseline survey. Among these women, 61% reported having experienced physical and/or sexual IPV in their lifetime, with nearly a third (27%) having experienced it in the previous 12 months. Partner controlling behavior was the most prevalent type of abuse with 82% experiencing it in their lifetime, and 63% in the preceding 12 months. Other common types of abuse were past-year emotional abuse, reported by 39% of women, and economic abuse, reported by 34% of women (Kapiga et al., 2017). Overall, most women who had ever experienced physical and/or sexual IPV reported that they had disclosed it to someone (n = 539/621, 86%). Nearly three-quarters (72%) of women had told a family member about the violence they had experienced; 58% told a member of their partner's family. When women were asked if they had ever sought help, around a third (31%) said that they had, usually from local (n = 94/621, 15%) or religious (n = 99/621, 16%) leaders, or the police (n = 82/621, 13%). Among the 270 women who reported past-year physical and/or sexual IPV, around a fifth (19%) reported that they had sought help in the past year.

A longitudinal qualitative study was embedded in the MAISHA trial and conducted with a sub-sample of trial participants. Drawing on a theoretical framework, the qualitative data were analyzed to explore women's support-seeking behavior for IPV in Mwanza city, northwestern Tanzania (Liang et al., 2005). In this article, we seek to explore women's experiences of IPV and the context that shapes support-seeking behavior, including how women navigate socio-cultural systems to access support.

Methods

For this article, we analyzed baseline data from the longitudinal qualitative study. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted after randomization, before the start of the intervention.

Participants

Following randomization, the trial data manager randomly selected 18 trial participants (12 interventions and six control arms) to be invited to take part in IDIs as part of the qualitative study. Six women who had reported past-year IPV and six women who had not reported past-year IPV during the baseline survey were randomly selected from the intervention arm, and then six women were randomly selected from the control arm, irrespective of whether they had reported past-year IPV. The social scientists who conducted the IDIs (VS and SL) were not aware which of the women had reported past-year IPV but were aware of which arm of the trial (intervention or control) the woman's microfinance group had been allocated.

Members of six microfinance loan groups allocated to the intervention arm and three allocated to the control arm were randomly selected by the trial data manager to take part in FGDs. For each of the nine groups, only members who had provided informed consent for the trial were invited to take part in the FGDs.

In total, 112 women, aged between 23 and 59 years old, participated in either baseline IDIs (n = 18) or in baseline FGDs (n = 94). During the IDIs and FGDs, we explored women's life stories, social networks, experiences of microfinance, perceptions of violence, personal experiences of violence, including its impact on them and their families, and their hopes for the future. These data were collected between February and June, 2015.

In addition, we conducted interviews at baseline with 10 key informants (KIIs), as follows: healthcare workers (n = 2), community influencers (n = 2), local political leaders (n = 2), religious leaders (n = 2), and representatives from local women's rights NGOs (n = 2). These interviews explored attitudes of those in positions of authority, their actions, and reactions towards perpetrators and victims of IPV, and the challenges they encounter in addressing IPV in their routine work.

Procedures

Prior to conducting the IDIs, FGDs, and KIIs, informed consent was obtained from participants following approved procedures. For the IDIs and KIIs, participants were interviewed in private at a place of their choosing, usually at their home or workplace. We conducted all interviews in Swahili following a topic guide, and audio recorded them with the consent of the participant. For the FGDs, participants selected the venue, usually the same venue used for their microfinance loan group meetings. Discussions were recorded with the consent of all participants.

Analysis

This analysis is based on data from IDIs, FGDs, and KIIs conducted at the trial baseline. The audio recordings were transcribed and translated verbatim into English. The transcripts were then analyzed by using a thematic coding framework via NVivo 12 qualitative analysis software. A conceptual framework was used to guide the coding and analysis of data on help-seeking among survivors of IPV (Liang et al., 2005). This framework suggests three processes or stages of help-seeking, which are (1) defining the problem; (2) deciding to seek help; and (3) selecting a source of support. However, these stages are not distinct and do not follow a linear process. Liang et al. (2005) argue that the process of support-seeking behavior is multi-layered and varies depending on a broad range of individual, interpersonal, and sociocultural factors, including individual trauma histories, coercion and intimidation by an abusive partner, identification with cultural and religious groups, access to economic resources, perceptions of and exposure to mainstream formal support networks, access to informal support networks, and general beliefs about seeking help.

Drawing on the framework approach, VS developed an initial coding scheme based on the research questions, which were iteratively revised by SL and GM, and new codes added that reflected additional themes, topics, and frames that emerged from the data. Coding reports were printed and a series of meetings were held among authors to build a more complex coding framework. Using NVivo 12, all the data were coded by following Liang et al.'s (2005) three stages of help-seeking behavior (i.e., defining the problem; deciding to seek help; and selecting a source of support). This allowed data to be compared and contrasted across different themes and perspectives and facilitated the identification of associations between themes, which can provide an explanation for the findings.

Ethics

Ethical approval for the MAISHA study, including the longitudinal qualitative study, was obtained from the Tanzanian Medical Research Coordinating Committee and the London School of Hygiene & Tropical Medicine research ethics committee. The trial was conducted following the WHO's guidelines on researching violence against women to minimize the risk of potential harm to women participating in the study (World Health Organization, 2016). All participants were provided with information regarding the study and approved participation through signed consent. Participants who reported violence and other forms of abuse during the study were offered counseling by a trained member of the study team and were referred to an appropriate organization for ongoing support.

Findings

Women, Poverty, and Inequality

In Tanzania, while there have been some improvements in women's access to income generation in the past few decades, inequalities between women and men still exist in access to education, work, land, and property (Meena et al., 2009). These disparities start early with more boys (12%) than girls (8%) completing secondary-level education (fhi360, 2012). As women are less educated, they are less likely to work as wage employees (Fox, 2016). Instead, they primarily work in agriculture, and increasingly in the trade sector, especially hotel and food services as well as petty businesses. In terms of income, men earn more than women, whether as paid employees or self-employed (Tanzania National Bureau of Statistics, 2017). Furthermore, only 20% of women own titled land, and the landmass they own is, on average, smaller than that owned by men (Harris-Coble, 2016). The women who participated in the MAISHA trial were members of a BRAC microfinance loan scheme. While there is some evidence in Tanzania that such schemes have had a positive impact on women's success as entrepreneurs (Cooper, 2014; Kato & Kratzer, 2013), it remains to be seen whether microfinance will have an impact on poverty, given the mixed evidence for the impact of microfinance loan schemes in resource-poor contexts (Mckenzie et al., 2009).

The participants in this qualitative study were between 21 and 59 years old. Twenty percent were educated to the secondary-school level, with the rest having completed only basic primary school education. The majority of women (87%) were married (see Table 1). All participants were self-employed, working in petty business selling commodities such as fish, water, roasted groundnuts, maize, pre-prepared food, locally brewed alcohol, or second-hand clothes.

Table 1.

Characteristics of IDI and FGD Participants (n = 112 Individuals^a).

Individual study participants		n (%)^b
Age (years)	Mean (sd) [range]	38.5 (7.9) [21–59]
Marital status	Married	87 (78%)
	Divorced/separated	12 (11%)
	Widowed	12 (11%)
	Never married	1 (1%)
Partnered in past year		105 (94%)
Highest level of education completed	None/incomplete primary	14 (13%)
	Completed primary	76 (68%)
	Attended secondary/higher	22 (20%)
Partner’s age (years)	Mean (sd) [range]	44.5 (9.0) [28–70]
Number of children (< 18 years) respondent has	None	9 (8%)
	1-2	35 (31%)
	3-4	45 (40%)
	5 +	23 (21%)
Experienced physical and/or sexual IPV in lifetime		64 (57%)

Four participants were excluded, three of whom were not enrolled in the MAISHA CRT and one of whom was enrolled but lacked baseline data.

Except for respondent’s age and partner’s age where mean, standard deviation, and range are presented.

Defining the Problem

Accepting and Tolerating Violence

Among the women and stakeholders interviewed, there was agreement that though women do not generally accept the use of violence by men, there are certain situations in which it is considered acceptable. For example, when physical violence is used by men to discipline women who have not fulfilled their expected roles as wives, such as not completing household chores (e.g., cooking, cleaning the house, taking care of the children), being disobedient to their partners, or having (or thought to be having) extra-marital affairs.

That is not oppression, ee or maybe, I mean you haven’t told your husband where you have gone, you have just left and you come late, you aren’t reachable, you have come back and find that he is already in, if he beats you, is it a mistake? I mean, you can even tell your colleagues, I mean I have been beaten but that is my fault. (FGD, Kirumba, Microfinance Group 2, Baseline, April 2015)

There are some women it is true, you find that even if she is beaten, she is rightly beaten. For example, you find that the husband has come home and waits but [his wife] has not yet lit the stove. … This is fair. (FGD, Kilimahewa Microfinance Group 3, Baseline, June 2015)

As well as violence being normalized as a means of disciplining women, there is an expectation that women should tolerate violence. Several women and key informants described how in their communities' speaking out about experiences of violence are considered unacceptable, and that violence within relationships should be tolerated.

No, there isn’t anything that she can do because we have already formed in ourselves that those are just normal things. (IDI, tailor aged 41, Kirumba, April 2015)

Mm, the main challenge is "the social acceptance" of violence, that people move forward and move backwards, therefore you find that they have many justifications that what will happen if you imprison your husband, you will imprison him then afterwards you come back and live with him; therefore you find yourself being hounded as a result of legalizing the violence; therefore there are still those norms and traditions which uphold violence as a way of punishing your wife or these are not matters to be taken in public; still it is a challenge. (KII, Male GBV NGO 1, February 2015)

Violence between intimate partners is seen as a private matter, as with all other aspects of an intimate relationship. Participants reported that through social and cultural practices, women learn not to expose marriage issues publicly; rather, they should be resolved within the family. Almost all the women and key informants interviewed acknowledged that, generally, women do not take any action against violence because of this social expectation that intimate relationships should be kept private.

These who are not reporting the incidences are those affected by the norms and customs that you should not reveal your household issues, revealing your household issues it is like disclosing yourself … (FGD, Kirumba Microfinance Group 4, Baseline, March 2015)

Therefore, there are still those norms and traditions which uphold violence as a way of punishing your wife or these are not matters to be taken in public; still it is a challenge. (KII, Male GBV NGO1 February 2015)

Because I have never seen here, maybe if someone is beaten and injured she runs to the police. However, they are few; very often she just nurses herself, even her partner himself will be massaging her with water and things will be over. (IDI, small restaurant owner aged 32, Nyakato, February 2015)

This explanation was often supported by service providers during KIIs, as some stakeholders acknowledged that women were discouraged from seeking support and told to return home and resolve their marriage issues with their partners. As noted by one of the NGO staff interviewed:

But it is because of the polices themselves; they say that, aa you are married and you want to imprison your husband, think twice. … Aa go and talk with your husband at home ee. (KII, Female GBV NGO 2, February 2015)

Deciding to Seek Help

Although taking action against violence or seeking support is not common, women described situations where there would be a good justification for a woman taking action against her partner. These include a woman suffering severe physical injuries, or if her partner was frequently violent towards her.

… it depends with how much you were beaten, if you’re beaten to the point where the leg is broken, then that will be seen as something wrong but if perhaps is just a slap, aa then you just apologies to each other and then it's done … (FGD, Kilimahewa Microfinance Group 1, Baseline, June 2015)\

There are some which every day you will be seeing them as annoyances, you just remain quiet, you put up with them, but when a bigger one springs up you report it to the elders. (IDI, small restaurant owner aged 32, Nyakato, February 2015)

Data from the baseline survey indicated that women tend to share their experiences of IPV with family members or friends. During IDIs and FGDs, women did not always express their need for support, but when asked from whom they seek support, they described family members and friends as the main sources. However, if violence became extreme, they said they would go outside of the family and involve local government leaders or church leaders.

Actually for me when he was doing that to me I would go even to my friend or to the area chairman, I would explain to him that this man did this and this to me. (FGD, Kilimahewa Microfinance Group 2, Baseline, June 2015)

Even so, not all women experiencing extreme violence will decide to seek formal help for the reasons outlined below.

Fear of Violent Repercussions

Fear of violent repercussions from their partner was a concern for many women. Several women reported that they did not seek support because of fear of more beatings or being forced to leave the house once the partner found out that she had reported his behavior. During FGDs, women commented:

The other reason is that he can beat you there in the house. Now if you try to tell your friend and your friend speaks about it to another person and your husband hears about it, he comes home prepared: “I told you not to talk about it, but you didn’t listen to me.” He then starts beating you up again. (FGD, Kilimahewa Microfinance Group 2, Baseline, June 2015)

I stayed with one woman. That woman was beaten by her husband, and there was no one who went to separate them, he was carrying something like a stool and beat her with it. … After that he told her "I shouldn’t see you going anywhere [for help], if you will leave here and go anywhere then you shouldn’t return here, if you return here then you should know that I won’t let you live anymore." (FGD, Kilimahewa Microfinance Group 2, Baseline, June 2015)

Concern for the Children

Another major concern that dissuades women from seeking help and support is their children's welfare. Many women described scenarios where a man found out that his partner had reported his violent behavior and he subsequently forced her to leave the house and her children, who are then left in the care of a stepmother or other relatives.

… sometimes you just take easy, sometimes you become furious of his behavior, but you don’t leave, who will stay with the children? You have to put up with the situation. (FGD, Kirumba Microfinance Group 3, Baseline, April 2015)

The family, the children, she starts thinking that who will help me to care for the children if I will take that information? (FGD, Kirumba Microfinance Group 6, Baseline, April 2015)

Financial Dependence on the Partner

Linked to concerns about their children's welfare is women's financial dependence on their partners. Almost all the participants agreed that a major barrier to women reporting IPV is a lack of independent financial means to support themselves. They argued that if a woman is forced by her partner to leave her home, with or without her children, she will not be able to support herself or her children financially.

… you have five children, and that man has beaten you. Now you want to report him as an intelligent woman. I will first think after reporting him, what decision will he make when he comes back? How will the children be raised? Because he may chase you away. That is the reason most women decide to endure violence in the marriage. (FGD, Kirumba Microfinance Group 6, Baseline, April 2015)

Imprisonment of a violent partner would also lead to a woman's loss of financial support.

She said that, why should I go [seek support], my husband would be imprisoned, and my children wouldn’t go to school. (KII, Female GBV NGO 2, February 2015)

Now how would the children think of me and who would help me take care of the children, that contributes too, you find that one is being oppressed but they don’t fight for their rights because of poverty, she knows that she depends on [her husband]. (KII, Female GBV NGO 2, February 2015)

Lack of Community Support and Fear of Stigma

Lack of support from the community (both real and perceived) also discourages women in violent relationships from seeking help. Much of this stems from the belief that IPV is a private issue that should be resolved by the couple. Thus, local leaders and the community more widely do not support or encourage women to seek help.

Even if you see her being beaten up, chasing each other to the outside of the house they tell you that: “They are husband and wife, they do know each other, can you interfere in husband and wife’s matters? They do know each other they will solve it by themselves.” So even if someone is passing by and sees that one is being beaten up they cannot help her. (FGD, Kirumba Microfinance Group 4, Baseline, April 2015)

In addition, almost all of the participants agreed that women also fear being stigmatized by their community for reporting violent behavior by a partner. They described how women who have taken action or sought formal support are labeled by the community as “bad wives” (“mwanamke ambaye hafai katika jamii”) who bring shame to their partners and families. As one IDI participant said:

The society that surrounds us, when you take a man to the police, first of all the men’s family can even bewitch you, they think that you have humiliated them, what kind of a woman takes her husband to the police, you have been sleeping in a bed together, the father of your children. Many questions are asked, "How come a woman takes her husband to the police?” (IDI, clothes vendor aged 27, Kirumba, March 2015)

Key informants reported that stigma often leads women to withdraw their complaints, or to not attend court proceedings to provide evidence. Hence, most reported cases of IPV are dismissed in the early stages of the legal process.

Sometimes they afraid of being labelled as bad people, they are threatened so you could find that one doesn’t come back, she files if it is a case, it ends up with no response, that or she comes and cancel the case so you find that some people lose their rights. (KII, Male Health Care Worker 2, February 2015)

Violence happens but many people don’t report, some of them afraid. … Many women aren’t ready to disclose their problems in the legal services because if she has filed a case against her husband, she will be seen as a person who has oppressed him. (KII, Female GBV NGO 2, February 2015)

Lack of Knowledge of What Action Can Be Taken

A common reason for many women not taking action against violent partners is not knowing what to do. Although women often share their IPV experiences with family and friends, they are usually encouraged to just persevere with the situation, rather than receiving help to access appropriate help and support. This is probably because of a combination of attitudes about IPV being a private matter, as well as a general lack of knowledge within the community about services for women experiencing violence.

I didn’t do anything, I remained quiet. … I had no alternative, what could I do apart from keeping quiet? (IDI, fish vendor aged 25, Kirumba, April 2015)

In fact, I was taking the responsibility of asking him for mercy because I had no alternative, I didn’t have anywhere to run to, I just ran from here and there then I sat down. (IDI, food vendor aged 37, Kirumba, March 2015)

… you involve his relatives you see; they are even not understandable; sometimes maybe his relatives know his habit, even if they tell him he doesn’t listen, they decide to leave him and tell you to go persevere. (FGD, Kilimahewa Microfinance Group 2, Baseline, June 2015)

Selecting a Source of Support

For women who do decide to seek help, selecting an appropriate source of support brings more challenges. These include not only the availability of services, but also the quality of those services.

Available Services for Victims of Gender-Based Violence

During KIIs, a range of services providing support for victims of gender-based violence (GBV) were identified, including services provided by NGOs, health systems, government organizations, and religious institutions. The types of services available vary according to the specific goals of the organization or institution. For example, NGOs may be focused on mobilizing communities against GBV, as well as providing help for IPV victims in the form of emotional support and legal advice, whereas religious institutions will focus on counseling for individuals and couples and providing spiritual support. There is very little community outreach in Mwanza city, with most services operating from a central point, such as an NGO’s district office. We found that most women taking part in MAISHA were unaware that such services exist. The lack of community outreach makes accessing services very challenging; many of the women who were referred reported that the services were far away and they could not afford the transport costs.

Quality of Available Services

Key informants emphasized the lack of funds for GBV services as a key challenge in supporting victims. Many of the women expressed concerns about the quality of some service providers, specifically where they had reason to believe that individual service providers were themselves perpetrating violence in their relationships. As one of the FGD participants commented:

… you find that a larger percent of them use to beat their wives too, and you bring your case here you have nothing to advise me than oppressing and torturing me. (FGD, Kirumba Microfinance Group 4, Baseline, April 2015)

Most of the discussions during IDIs and FGDs focused on legal services (police and the courts), as women had very little personal experience of other types of services, such as health systems and counseling services. Despite the rollout of Gender Desks¹ in police stations across Mwanza city, many women criticized the quality of police investigations into cases of GBV (including IPV), which they felt was a result of poor resources and insufficient investment in services. They also pointed to a lack of gender-sensitive training, which impacts the timely provision of emergency support to victims of violence, and in identifying and gathering evidence from perpetrators. Women and key informants also highlighted the lack of investment in the legal system more generally. As a result, there are often delays in following up cases that frequently take months or years to be resolved. A GBV service provider commented that these extended investigations and delays cause some women to abandon their cases:

But the issue of investigation takes a very long time. You find that violence has been perpetrated against a woman, maybe she needs justice within three days. Now you find the investigation there, according to the police system, “we are still investigating, we have not yet arrested the suspect, maybe we went there but we did not find him.” (KII, Male GBV NGO 1, February 2015)

For those cases that are pursued, women were critical of the weak punishments. They described how perpetrators of IPV who have been taken to court have received very light punishment or are not punished at all. Added to the multiple barriers described above, this further discourages many women from taking action against violent partners.

… because there comes a time when that affected person sees that there is nothing which has been done. … She sees that there is no reason of going to report, she uses the example of a woman who went to report, “why is the concerned person of that incident just free?”(KII, Male Health Care Worker 1, February 2015)

Women and some stakeholders were also critical of corruption that they perceive exists within the legal system. A typical example given was of a victim being denied their right to redress because the perpetrator is able to pay a bribe and avoid conviction.

But bribes are rife at the court, there is corruption in the court, corruption in the village leadership, corruption in the police force. … It is an obstacle in dealing with these cases. More often men are favored for the basis of corruption. (KII, Male GBV NGO 1, February 2015)

Discussion

In this urban setting in northwestern Tanzania, we found that most women who experience IPV do not seek formal help and support, or are not given appropriate help when they do seek it. Quantitative data from the trial baseline survey indicated that 86% of women who had ever experienced IPV had told someone about their experiences. However, though many women told family members, including their partner's family, very few had sought help outside of the family. Those who did tended to seek help from local or religious leaders or from the police. These findings align with women's accounts during the IDIs and FGDs. This qualitative study has enabled us to explore in depth what drives women to seek help, or not, and to better understand the social, political, cultural, and economic factors that influence decisions made by women.

We found that women tended to seek informal support from family members, friends, and neighbors. Women who have suffered serious injuries or experienced frequent physical violence from a partner may be more likely to report their partner's behavior and seek help from people in positions of authority, such as religious and traditional leaders, health care professionals, police, counselors, women's NGOs. Other studies have reported similar findings, whereby women seek help when they can no longer endure repeated violent assaults, or if the violence is severe and leading to serious injuries or is life-threatening. Victims of IPV are more likely to tolerate the violence that is less severe to avoid negative consequences associated with seeking help, including social stigma and partner retaliation (Fanslow & Robinson, 2010; McCleary-Sills et al., 2016; Parvin et al., 2016; Sigalla et al., 2018).

This study has shown that women in Mwanza who seek help for IPV face multiple challenges in doing so. These observations are consistent with findings from other studies, which have shown that a number of factors (e.g., fear of violent repercussions, social norms, economic dependence on a man, and an unresponsive legal and justice system) hinder most women from seeking formal support for violence (McCleary-Sills et al., 2016; Nyamhanga & Frumence, 2014; Paul, 2016; Rodriguez et al., 1996; Sigalla et al., 2018; Vyas & Heise, 2016).

Many women in this study seemed to accept a certain level of physical violence as a form of discipline, and so were unlikely to define the violence they were experiencing as a problem requiring help. Furthermore, they expressed the belief that IPV is a private matter. They did describe situations, however, where there would be a good justification for a woman taking action against her partner. These include a woman suffering severe physical injuries, or if her partner was frequently violent towards her. Other studies have noted that individuals respond to problems in a variety of ways depending upon how they define or label those problems (Mitchell & Hodson, 1983; Parvin et al., 2016; Tsogia et al., 2001) and evaluate their severity (Sigalla et al., 2018). However, social and cultural factors also shape the way an individual defines and labels the problem (Liang et al., 2005). The mental health help-seeking literature (Cauce et al., 2002) suggests two internal conditions that are fundamental for seeking support: (1) recognizing a problem as undesirable, and (2) seeing the problem as unlikely to go away without help from others. However, even when women define the problem (of their partner's violent behavior), they are resistant to seeking help because of concerns for both their own and their children's welfare. Most women described fear of losing shelter and financial support from their partner. Similarly, a study conducted in Moshi, northern Tanzania, found that the majority of study participants stayed in violent relationships because their priority was to maintain the marriage in order to keep the family together for the sake of the children (Sigalla et al., 2018). This suggests that women-centered support services need to focus on women's long-term social support and financial needs, rather than being merely crisis-oriented (García-Moreno, 2002; Rodriguez et al., 1996; Sigalla et al., 2018).

Women are also unlikely to seek help because they are unaware of available services or sources of support, or they are not confident that they will be supported by their community, and may be stigmatized (Hadeed, 2016; McCleary-Sills et al., 2016). Our study also found that in Mwanza city, most of the IPV services focus on individuals or couples, but do not address the social, cultural, political, and economic context in which violence is perpetrated and experienced. According to Goodman and Smyth (2011), most violence prevention interventions have failed to acknowledge that IPV is a problem of the community rather than a problem between two individuals. Most mainstream domestic violence service models have not prioritized ongoing engagement of survivors’ informal social support networks as a core part of their work. Yet, perpetration of intimate partner violence occurs within a community context that contributes to the maintenance or alleviation of the problem (Goodman & Smyth, 2011). This study found that most women do not seek support, not because they do not want to, but rather because of the fear of negative consequences, which include being stigmatized, their children being put at risk, and lack of financial support. Further to this, in Mwanza city, most IPV support services are office-oriented, whereby women who have suffered abuse have to seek support from providers based in centralized offices, which may be far away. There is a lack of community outreach, which would facilitate women's access to services, as well as making services more visible to women in the community.

Women also perceived the legal and justice system to be flawed with very little focus on the needs of IPV victims. Findings from the present study reveal that many women are dissatisfied with services that either they, or others have received, and as a result, they have little confidence in the legal and justice system. According to Liang et al. (2005), the support a woman chooses will influence how she defines the problem and whether she chooses to seek help again. There is a dynamic between women's agency in seeking formal support for violence and the structural context in which their lives are embedded. Thus, understanding women's decisions to seek formal support requires not only focusing on women's agency in seeking support but also the social, cultural, political, and economic context in which their violence experiences are embedded (Cauce et al., 2002; Rodriguez et al., 1996).

Conclusion

The findings from this study conducted in northwestern Tanzania reveal that support-seeking behavior among women who experience IPV is shaped by social, cultural, economic, and political factors. The women in this study represent a group of economically poor women in a context where considerable gender inequalities are the norm. Further qualitative research is needed to understand the role of the informal sector in support seeking among women who experience violence and its implication in reducing IPV against women.

There is a need to design interventions to challenge these structural factors that shape justification and meaning attached to IPV, and decisions to seek support. This must also be accompanied by changes in social norms that perpetuate and condone violence against women. Additionally, women's perspectives regarding services need to be studied and taken into account, since they are the ultimate beneficiaries. This would allow support services that are more flexible and adaptive in both meeting women's real needs and expanding the range of choices for women seeking support. Finally, because most women seeking help do so informally through family, friends, or neighbors, it would be helpful if information related to IPV and access to formal support services could be made available across different social networks within communities.

Footnotes

Acknowledgments

First and foremost, we wish to thank all study participants for their time and commitment. We are also grateful to the MAISHA trial team for their contribution and tireless dedication to implementing the trial in Tanzania and to the administration teams at MITU and LSHTM for their support.

Declaration of Conflicting Interests

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

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Anonymous donor and STRIVE Consortium funded by UK Aid.

ORCID iDs

Veronica Selestine

Shelley Lees

Notes

Author Biographies

Veronica Selestine is a social scientist, who has been working with the National Institute for Medical Research (NIMR)/Mwanza Intervention Trials Unit (MITU), Tanzania for more than 12 years. Throughout the period working with this research institution, she has carried out a number of studies on HIV/AIDS, male circumcision, Human Papilloma Virus (HPV), STIs, chronic diseases, gender, and intimate partner violence (IPV).

Sheila Harvey is an epidemiologist with experience in HIV prevention, gender-based violence, critical care, and child health research. Her current work in Tanzania is focused on evaluating interventions to prevent violence against women, understanding better the drivers of violence perpetration, and gaining further insights into the consequences of violence for women and their families.

Gerry Mshana is a principal research scientist at the National Institute for Medical Research (NIMR) in Mwanza, Tanzania, and a senior researcher at the Mwanza Intervention Trials Unit. He is a medical anthropologist with more than 17 years of research experience on adolescent sexual and reproductive health, the socio-cultural aspects of HIV/AIDS, male circumcision, stroke, Parkinson's disease, and epilepsy.

Saidi Kapiga is the current scientific director of the Mwanza Intervention Trials Unit (MITU) and a Professor of Epidemiology and International Health at the London School of Hygiene & Tropical Medicine (LSHTM). He has more than 28 years of public health research experience, with particular interests in investigating the individual risk factors and underlying structural factors associated with HIV in Africa, and evaluation of prevention strategies.

Shelley Lees is a medical anthropologist and professor of Anthropology of Public Health at LSHTM. The focus of her research has been on gender and health in Tanzania. She is currently conducting anthropological research on violence against women and children with a number of different projects in Tanzania. Her research as part of an intimate partner violence study in Tanzania, for which she is co-principal investigator (MAISHA), focuses on the political economy and feminist perspectives.

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