Determinantes VG Etiopia

PLOS ONE
RESEARCH ARTICLE
Determinants of intimate partner violence

against women in Ethiopia: A multi-level
analysis
Tenaw Yimer Tiruye ID1,2*, Melissa L. Harris2, Catherine Chojenta2, Elizabeth Holliday3,
Deborah Loxton2
1 Public Health Department, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia,
2 Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of
Health and Medicine, the University of Newcastle, Newcastle, Australia, 3 School of Medicine and Public
a1111111111 Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
a1111111111
a1111111111 * [email protected], [email protected]
a1111111111
a1111111111
Abstract
Intimate partner violence (IPV) continues to be a major public health problem globally.
OPEN ACCESS
Although Ethiopia has a high prevalence of IPV, previous studies in this country have only
investigated individual-level determinants of IPV within small geographic areas. The current
Citation: Tiruye TY, Harris ML, Chojenta C, Holliday
E, Loxton D (2020) Determinants of intimate study aimed to identify the individual-, relationship-, community-, and societal-level determi-
partner violence against women in Ethiopia: A nants of IPV directed against women in Ethiopia since women are predominantly affected. A
multi-level analysis. PLoS ONE 15(4): e0232217. retrospective analysis of nationally representative data from the 2016 Ethiopian Demo-
https://doi.org/10.1371/journal.pone.0232217
graphic and Health Survey (EDHS) was conducted. A sample of 3,897 married women of
Editor: Kristin Dunkle, South African Medical reproductive age (15–49 years) who participated in the domestic violence module of the sur-
Research Council, SOUTH AFRICA
vey were included in the analysis. Three-level mixed-effects multilevel logistic regression
Received: November 25, 2019 models were used to estimate the individual-, relationship-, community-, and societal-level
Accepted: April 9, 2020 determinants of IPV. Variability at the community- and societal-level were also assessed.
Published: April 24, 2020 About 1,328 (34.1%) of 3,897 participants reported experiencing IPV (a composite measure
of physical, sexual and emotional abuse). In adjusted models, the odds of lifetime IPV expe-
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review rience were higher among women who were older, were married before the age of 18 years,
process; therefore, we enable the publication of witnessed inter-parental violence during their childhood, had a partner who drank alcohol,
all of the content of peer review and author and lived in a community with high IPV accepting norms. Alternatively, the odds of IPV were
responses alongside final, published articles. The
lower among women who had decision-making autonomy in the household, had the same
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0232217 or lower educational attainment as their partner, and lived in a community with low propor-
tions of educated women. These findings reveal that although individual-level factors were
Copyright: © 2020 Tiruye et al. This is an open
access article distributed under the terms of the significant determinants of IPV, higher level factors, including female education and IPV
Creative Commons Attribution License, which acceptance in the community, were also important influences on this major public health
permits unrestricted use, distribution, and issue in Ethiopia. These findings suggest combined interventions at different levels may
reproduction in any medium, provided the original
reduce IPV in this country.
author and source are credited.
Data Availability Statement: Data cannot be

shared publicly because data was provided by a
third party (the Ethiopian Demographic and Health
Survey). DHS data files are available for research/
analysis, at no cost, with the condition that the user
PLOS ONE | https://doi.org/10.1371/journal.pone.0232217 April 24, 2020 1 / 18

PLOS ONE Determinants of intimate partner violence against women in Ethiopia
provides an abstract or a description of any project Introduction

that will be using the data. Researchers can
request approval to access the data underlying this Intimate partner violence (IPV) is a ‘health hazard’ [1] that continues to be a global public
study for the DHS program through online health problem with higher prevalences in low-income countries [1, 2]. Globally, one in every
application. The application and data access three women has experienced at least one form of IPV during her lifetime [3]. IPV has been
procedures are explained below. For questions or found to be a universal problem across all contexts and countries, but the distribution of
comments about accessing The DHS Program
occurrence varies widely [2, 4]. A multicountry study showed that the prevalence of IPV was
data, users can email to [email protected]
and for general inquiries, they can contact high in sub-Saharan Africa, where the magnitude reaches 66% of women (95% CI: 54–78) [5].
[email protected]. Researchers must apply Ethiopia is one African country with a high prevalence of IPV, where the lifetime prevalence
for a download account before they can download has been estimated at 20% to 78% in different areas [6]. In the face of high gender inequalities,
datasets. To register for a download account, they IPV poses an increased burden on women’s health in Ethiopia. Although the consequences are
can go to: http://dhsprogram.com/data/new-user-
underexamined in this country, some existing evidence shows its potential for producing severe
registration.cfm and fill the following information: •
Email address, name, name of institution and
physical, emotional, and reproductive health problems [7–10]. Severe consequences of IPV
institution type, country, and phone number. • include reduced maternal health care utilization and adverse child health outcomes [10–13]. As
Project title, co-authors in the project, and abstract there are no IPV interventions in the country, comprehensive IPV intervention strategies are
or description of study (minimum of 300 words needed. This requires an understanding of the factors that are associated with IPV.
and maximum of 2500 words). • Region and Previous research conducted on IPV in different countries shows that risk factors for IPV
country they wish to do the research/analysis. For
extend beyond the characteristics of the individuals involved [14]. According to the ecological
this study, we have selected ‘sub-Saharan Africa’
and ‘Ethiopia’. • The type of data set (survey, GPS, framework, IPV occurs due to an interaction of factors at four levels: the individual, the rela-
HIV or SPA data) they wish to access. For our tionship, the community, and the societal [14]. According to this framework, some individual-
analysis, we have selected ‘survey’ data set. Once level factors alone such as a woman’s education and autonomy may not be sufficient to protect
the above information is completed, researchers against IPV unless these factors are communal and largely shared within the community
can submit the data set request. After access to the
where women live [15]. In addition, tolerant community norms regarding aspects of IPV,
data is approved, researchers can login and
download the data. Researchers will come across
including acceptance of male superiority and perceptions of IPV as inevitable within a rela-
the recoded survey data with different file names in tionship, are basic factors that not only underlie the occurrence of IPV [16–19] but allow it to
different file formats. For our study, ‘etir70dt’ was persist in society [5, 18] and reduce the effectiveness of intervention efforts [18]. Moreover, it
used. is believed that societal-level determinants such as poverty, gender inequality, and political
Funding: This study is partially funded by the contexts not only affect the distribution of IPV but also moderate community-, relationship-,
University of Newcastle, which has provided a and individual-level risk factors [14, 18]. Their influence could be direct or indirect by affect-
scholarship for the student researcher and ing institutional systems, family decisions and gender roles [20].
supported him in obtaining statistical support and The presence of hierarchical level causal factors necessitates the use of advanced analytical
training. Dr. Melissa Harris is funded by an
methods to accurately estimate the effect of IPV determinants in particular communities. This is
Australian Research Council Discovery Early Career
Research Award. principally helpful for countries like Ethiopia, which contains a population of over 80 ethnic
groups living in diverse contexts [21]. However, no previous study of IPV in Ethiopia has investi-
Competing interests: The authors have declared
gated how factors operate at different levels as most previous studies [22–26] were focused mainly
that no competing interests exist.
on individual characteristics. There is thus limited evidence regarding the effect of community-
and societal-level determinants of IPV. Prior studies [22–26] in this country were also small in
scale with inconsistent findings which lacked country-level representativeness for a large diverse
community. Moreover, these studies either did not include some important variables, such as atti-
tudes and norms around IPV, or did not use appropriate statistical models to reveal unbiased esti-
mates. Therefore, the focus of this research was to examine the individual-, relationship-,
community-, and societal-level determinants of IPV in Ethiopia using nationally representative
secondary data and appropriate statistical models to account for the hierarchical data structure.
Methods
Data source
This study was based on data from the 2016 Ethiopian Demographic and Health Survey
(EDHS), which was the year the domestic violence module was added. The EDHS was a

national survey conducted from January 18 to June 27, 2016. The EDHS data were collected
using five questionnaires (household, women, men, biomarker and health facility). The col-
lected data were recoded for easier access and analysis [27].
Sample size and sampling procedures

The EDHS used two-stage stratified cluster sampling. In the first stage, 645 primary sampling
units were sampled: 443 from rural areas and 202 from urban areas. In the second stage, on
average 28 households from each primary sampling unit was selected using systematic random
sampling. In total, 15,683 women aged 15–49 who reported ever being married (with a
response rate of 95%) participated in the survey. For the domestic violence module, only one
married woman per household was interviewed and 5,860 women (97% response rate) were
interviewed [27]. The current study included women who reported ever being married and
completed the IPV questionnaire (weighted sample = 3,897). The sampling weights used in the
EDHS account for the complex sampling procedures (multi-stage stratified cluster sampling)
that might cause an unequal probability of selection for certain areas or subgroups either due
to design or coincidence. Hence, sampling weights were adjusted for differences in probability
of selection and interview that allow extrapolation of results to the national level of representa-
tiveness [27].
Measurement and variables

Dependent variables. IPV was measured using women’s self-reported responses to ques-
tions based on the modified Conflict Tactic Scales of Straus [28]. Women were asked whether
or not they had experienced the following acts within their relationship, perpetrated by their
husband/partner for currently married women and recent husband/partner for previously
married women. Those women who were married more than once were further asked about
violence committed by any other husband/partner. Respondents were categorized as having
experienced lifetime IPV if they reported experiencing at least one act of IPV since the age of
15 years [27]. Table 1 presents the questions used to assess IPV and the form of IPV the ques-
tions measuring.
Independent variables. This study was based on the concept of an ecological framework,
which proposes that IPV occurs due to the interaction of factors at four levels: the individual,
Table 1. The tool used to assess IPV in the 2016 Ethiopian Demographic and Health Survey.
Question/item IPV type
Push you, shake you, or throw something at you? Physical IPV
Slap you?
Twist your arm or pull your hair?
Punch you with his/her fist or with something that could hurt you?
Kick you, drag you, or beat you up?
Try to choke you or burn you on purpose?
Threaten or attack you with a knife, gun, or any other weapon?
Physically force you to have sexual intercourse with him even when you did not want to? Sexual IPV
Physically force you to perform any other sexual acts you did not want to?
Force you with threats or in any other way to perform sexual acts you did not want to?
Say or do something to humiliate you in front of others? Emotional IPV
Threaten to hurt or harm you or someone close to you?
Insult you or make you feel bad about yourself?
https://doi.org/10.1371/journal.pone.0232217.t001

the relationship, the community and the societal. Accordingly, potential determinants of IPV
at each of the four levels were identified using previous similar research conducted globally
[14, 15, 29–31] and in Ethiopia [24–26, 32, 33].
Level 1 variables: Individual-level variables considered in the analysis were age, age at first
marriage, education, employment, religion, number of children, access to media, witness
inter-parental violence, substance abuse, attitude to IPV, and wealth index. Relationship vari-
ables comprised women’s decision-making autonomy (yes/no), who headed the household,
educational difference and age difference between male and female partners. The individual
and relationship level variables with their categories, measurement or definition are displayed
in Table 2.
Level 2 variables: Community characteristics, which in this study is represented by in-
dividuals living in the same cluster, were included as level 2 variables. Place of residence
was defined as urban or rural using original EDHS coding. Other variables were constructed
by aggregating individual- or relationship-level characteristics. The aggregates for clusters
were computed using mean (for normally distributed characteristics) and median (for vari-
ables that were not normally distributed) values for women in each category of a given vari-
able. Finally, each community level variable was re-grouped into lower and higher categories
(Table 2).
Level 3 variables: Two societal-level variables were also included in this analysis. These are
the Multi-dimensional Poverty Index (MPI) and the Gender Empowerment Index (GEI). MPI
is a measure of poverty that considers three dimensions of poverty (education, health and stan-
dard of living) and ten indicators with a given weight [34]. The data on the MPI for each of the
11 regions of Ethiopia were taken from the Oxford Poverty and Human Development Initia-
tive [34] and regions were classified as low or high MPI based on deviation from the national
average. The GEI is a composite measure of three dimensions and 15 indicators: women’s atti-
tude to IPV with 5 indicators, women’s social independence with 7 indicators that include
items related to women’s education, media exposure, employment and ages at first birth and
cohabitation, and women’s decision-making autonomy with 3 indicators [35]. Methodological
details on generating the three dimensions from 15 indicators can be obtained from the cited
reference [35]. In the current study, the three dimensions were further reduced using the prin-
cipal component analysis (PCA) to one continuous variable (GEI) and then classified as below
or above the national average (Table 2).
Data processing and analysis

Multilevel logistic regression models were used to estimate the effects of IPV determinants at
the three specified levels, using a sample of 3,897 women nested in 639 communities nested in
11 regions. On average, each cluster/community had 6 women (range, 2 to 13). Multilevel
analysis allows for the estimation of valid standard errors by adjusting for within-cluster corre-
lation of the response variable [36]. Multilevel analysis also enables the estimation of commu-
nity and regional variation in women’s experience of IPV [37].
Four models were constructed. In Model I, the empty or unconditional model, no covari-
ates were included. This model was used to estimate the random intercept at community and
region level and the variation in the odds of IPV experience between communities and
between regions. Then, subsequent models were constructed by adding covariates at each level
on the preceding model, that is, in Model II. Individual- and relationship-level variables were
included. Both individual- and relationship-level variables were considered as level one vari-
ables because in the EDHS only one woman per household was sampled [27] and hence house-
hold/relationship-level clustering may not exist. In Model III, community-level variables were

Table 2. List of variables, their categories and definitions.

Level Variable Category/Measurement/Definition
Level 1: Individual- level Age (years) The age of the woman categorized as 15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49.
variables Age at first marriage Grouped as <18 years and � 18 years.
Educational status Maximum educational level categorized as uneducated, primary, or secondary and above.
Employment status Current employment status of the woman classified as unemployed or employed.
Religion The religion that the respondent is following categorized as Christian, Muslim, or others.
Witness to inter-parental ‘Yes’ or ‘no’ based on their answer to the question, “As far as you know, did your father ever hit your
violence mother?”
Number of living children Grouped as one or less, two to three, and � four.
Substance abuse Classified ‘yes’ if respondent drinks alcohol, chews khat or smokes tobacco and ‘no’ otherwise.
Partner drinks alcohol Classified ‘yes’ if partner drinks alcohol and ‘no’ otherwise.
Attitude on IPV The attitude on IPV was measured based on the following five questions that men and women were
asked about whether situations of hitting or beating a wife is justifiable: if she goes out without telling
him; neglects their children; argues with him; refuses to have sex with him; and burns the food [27]. If
they said ‘yes’ to any one of the above questions, they were categorized as having an unfavourable
attitude and otherwise favourable attitude.
Access to media If respondent read a newspaper, listened to the radio, or watched television, they were categorized as
have access and otherwise no access.
Household wealth index Measured based on the number and kind of goods households have and housing characteristics
(drinking water, toilet facility, flooring material and availability of electricity) and was generated using
principal component analysis (PCA) and classified into quintiles from 1 (very poor) to 5 (very rich) [27].
Age of partner Categorised as under 25, 25–34, or �35.
Level Variable Category/Measurement/Definition
Level 1: relationship-level Women’s decision-making Labelled ‘yes’ if she was involved in all decisions regarding her own health care, major household
variables autonomy purchases and visits to her family or relatives [27].
Head of household Based on the gender of the head of the household and classified as either woman or man.
Educational difference The educational status of the woman compared to her partner’s educational status and classified as
equal, lower or higher.
Age difference The age of the woman compared to her partner’s age and classified as woman younger, same age,
husband older by �5 years, or husband older by more than 5 years.
Level 2: community-level Place of residence Defined as urban or rural using original EDHS coding
variables Early marriage Categorized as high if the proportion of women married before 18 years of age was 60.0–100% and low
if the proportion was 0–59.9%
Female literacy Categorized as low if the proportion of women who attended primary or secondary education was
0–36.4% and categorized as high if the proportion was 36.5–100%
Community’s level of acceptance Categorised as low if the proportion of women with an unfavourable attitude (having an IPV accepting
towards IPV attitude) in the community was 0–66.7% and categorized as high if the proportion was between 66.8%
and 100%
Women’s decision-making Categorized as low if the proportion of women’s decision-making autonomy in the community was
autonomy between 0–71.4% and high if the value ranged from 71.5 to 100%
Level 3: societal-level Multi-dimensional Poverty Regions were classified as low or high MPI based on deviation from the national average
variables Index (MPI)
Gender Empowerment Index Classified as below or above the national average
(GEI)
added to Model II, and in Model IV, societal-level (region) variables were added to Model III.
Model IV was the final model used to estimate measures of association.
The measures of association (fixed effects) were presented as odds ratios together with 95%
CI. Statistical significance was declared using a p-value <0.05. In addition, the measure of vari-
ance (random effects), which is the measure of residual errors at individual level and commu-
nity & regional variation, was reported in terms of the intra-class correlation coefficient (ICC)
[36] and proportional change in variance (PCV) [38].

Ethics statement
The original survey was conducted after being ethically approved by the National Research
Ethics Review Committee (NRERC) of Ethiopia (Ref. No: 3.10/114/2016). Prior to analysis, we
obtained permission from the Demographic and Health Survey program and ethical approval
from University of Newcastle Human Research Ethics Committee (Ref. No: H-2018-0055).
Results
General characteristics of respondents
In total, 3,897 (unweighted sample of 4,123) participants were included in the analysis. The
majority of study participants were aged 25–29 years (23.2%), married before 18 years of age
(62.2%), illiterate (61.5%), unemployed (50.1%), Christian (64.5%), married to a uneducated
(47.2%) partner, and had the same educational level as their partner (62.1%). In total, 70.7% of
participants had witnessed inter-parental violence during childhood and 67.3% had an IPV
accepting attitude. About 69% of participants reported having no decision-making autonomy
and 86% participants reported the husband was the head of the household. About 47.9% of
individuals described themselves as having a habit of substance abuse and 62.2% had no access
to media. Regarding community- and region-level characteristics, the majority of respondents
were living in a community with rural residence (83.8%), high early marriage (52.1%), low
female literacy (53.5%), low women’s autonomy (54.9%), and high IPV accepting norms
(52.0%) and in societies with high MPI (66.3%) and low GEI (86.6%) (Table 3). Table 4 shows
IPV experience by different variables.
Prevalence of different forms of IPV

Table 5 shows the estimated prevalence of different forms of IPV with 95% CI. The least preva-
lent form of IPV was sexual IPV (11.5%) and the most prevalent form was physical IPV
(23.3%). About one in every three (34.1%) women had experienced at least one form of IPV in
their lifetime.
Determinants of IPV
Table 6 presents the results of the multilevel logistic regression analysis, which shows the mea-
sure of association (fixed effects) and the random intercepts for the experience of IPV. Model I
(the empty or unconditional model) shows that there was a statistically significant variation in
the odds of IPV experience between communities (σ2 = 0.79, p-value <0.001) and between
regions (σ2 = 0.20, p-value <0.001). The ICC shows that IPV experience of women within the
same community has a higher clustering (ICC = 23.1%) while low degree of clustering in the
region (ICC = 4.6%).
In Model II, only individual- and relationship-level variables were added. The results
showed that higher age, early age at first marriage, witnessing inter-parental violence during
childhood, an IPV accepting attitude, higher educational attainment (compared to partner),
and having a partner who drank alcohol were positively associated with IPV, while having
decision-making autonomy was negatively associated with IPV. Adjusting for level one vari-
ables reduced the variance parameters; the PCV indicates that 25.1% and 5.0% of the variance
in IPV experience across communities and across societies respectively was explained by the
individual-level characteristics. The ICC in Model II indicated that after adjusting for individ-
ual and relationship factors, 19.2% and 4.7% of the variation in women’s IPV experience was
attributable to differences between communities and societies respectively.

Table 3. Characteristics of study participants (n = 3,897).

Factor Group Variable Class Weighted frequency Percent
Respondent characteristics Current age 15–19 222 5.7
20–24 592 15.2
25–29 903 23.2
30–34 827 21.2
35–39 631 16.2
40–44 424 10.9
45–49 298 7.6
Age at first cohabitation <18 years 2424 62.2
�18 years 1473 37.8
Educational status No education 2397 61.5
Primary 1067 27.4
Secondary+ 433 11.1
Employment status Not employed 1952 50.1
Employed 1945 49.9
Religion Christian 2512 64.5
Muslim 1313 33.7
Other 73 1.9
Witness inter-parental violence No 2755 70.7
Yes 1142 29.3
Number of living children One or less 920 23.6
2–3 1123 28.8
�4 1855 47.6
Substance abuse No 2031 52.1
Yes 1866 47.9
Wife beating attitude No 1273 32.7
Yes 2624 67.3
Partner characteristics Age of partner Below 25 200 5.1
25–34 1298 33.3
�35 2398 61.6
Partner’s educational status No education 1840 47.2
Primary 1397 35.9
Secondary+ 660 17.0
Partner drinks alcohol No 2750 70.6
Yes 1147 29.4
Household characteristics Access to media No 2424 62.2
Yes 1473 37.8
Wealth index Poorest 748 19.2
Poorer 792 20.3
Middle 799 20.5
Richer 733 18.8
Richest 824 21.2
Relationship level variables Decision-making autonomy No 1203 30.9
Yes 2694 69.1
Head of the household Male 3357 86.2
Female 540 13.9
Educational difference Women higher 379 9.7
Same 2421 62.1
(Continued )

Table 3. (Continued)
Factor Group Variable Class Weighted frequency Percent

Husband higher 1097 28.1
Age difference Women younger 121 3.1
Same age 83 2.1
Husband older by �5years 1555 39.9
Husband older by >5years 2137 54.9
Community/cluster level variables (n = 639) Place of residence Urban 200 31.3
Rural 439 68.7
Early marriage Low 344 53.8
High 295 46.2
Female literacy Low 289 45.2
High 350 54.8
Women decision-making Low 317 49.6
High 322 50.4
IPV acceptability Low 377 59.0
High 262 41.0
Societal/regional-level variables (n = 11) MPI Below national average 7 63.6
Above national average 4 36.4
GEI Below average 5 45.4
Above average 6 54.6
Abbreviations: MPI = Multi-dimensional Poverty Index; GEI = Gender Empowerment Index
In Model III, after community level variables were added to Model II, the findings in Model
II largely persisted, except IPV accepting attitude which lost its significant association with
IPV. The result also revealed that three community level variables were found to have signifi-
cant association with IPV–community level female literacy, community IPV accepting norm,
and women decision-making autonomy in the community. The PCV in Model III implied
that 63.3% of the variation in IPV experience between communities was explained by individ-
ual and community level characteristics. Likewise, 15.0% of the variation in IPV experience
between societies was explained by individual and community level characteristics.
In Model IV, the final model, societal-level variables were added to Model III. After control-
ling for factors at all levels, women’s age was significantly associated with IPV. Compared to
women aged 15–19 years, women in higher age groups were more likely to report experiencing
IPV. Effect sizes increased for higher ages. For example, compared to women aged 15–19
years, women aged 20–24 and 45–49 were about two (AOR 2.02, 95% CI: 1.35–3.07) and three
times (AOR 3.31, 95% CI: 2.03–5.40) more likely to report experiencing IPV. Alternatively,
being younger at first cohabitation was associated with an increased risk of IPV: women
aged < 18 years at first cohabitation had 28% higher (AOR 1.28, 95% CI: 1.08–1.52) odds of
IPV compared to women aged �18 years at first cohabitation.
Women who had witnessed inter-parental violence were about three and half times more
likely (AOR 3.33, 95% CI: 2.80–3.96) to report IPV compared to women who had not wit-
nessed inter-parental violence. Women with decision-making autonomy in the household
were 19% less likely (AOR 0.81, 95% CI: 0.68–0.97) to report experience of IPV compared to
women who had no decision-making autonomy. Regarding partner’s behaviour, women who
had a partner who drank alcohol were three times (AOR 3.00, 95% CI: 2.42–3.67) more likely
to report experience of IPV compared to women who had a partner who did not drink alcohol.

Table 4. IPV experience by different variables.

Factor Group Variable Class IPV (n = 3,897) P-Value�
No Yes
No (%) No (%)
Respondent characteristics Current age 15–19 168 (6.5) 54 (4.1) 0.238
20–24 402 (15.6) 191 (14.4)
25–29 616 (24.0) 287 (21.6)
30–34 527 (20.5) 300 (22.6)
35–39 402 (15.7) 228 (17.2)
40–44 277 (10.8) 147 (11.1)
45–49 178 (6.9) 120 (9.1)
Age at first cohabitation <18 years 1016 (39.6) 457 (34.4) 0.045
�18 years 1553 (60.4) 871 (65.6)
Educational status No education 1524 (59.3) 873 (65.8) 0.001
Primary 705 (27.5) 362 (27.2)
Secondary+ 340 (13.2) 93 (7.0)
Employment status Not employed 1319 (51.3) 633 (47.7) 0.196
Employed 1250 (48.7) 695 (52.3)
Religion Christian 1647 (64.1) 865 (65.2) 0.011
Muslim 893 (34.7) 420 (31.6)
Other 30 (1.2) 43 (3.2)
Witness inter-parental violence No 2028 (78.9) 727 (54.8) <0.001
Yes 542 (21.1) 601 (45.2)
Number of living children One or less 654 (25.5) 266 (20.0) 0.035
2–3 725 (28.2) 398 (30.0)
�4 1191 (46.3) 664 (50.0)
Substance abuse No 1413 (55.0) 618 (46.5) 0.005
Yes 1156 (45.0) 710 (53.5)
Wife beating attitude No 910 (35.4) 363 (27.3) 0.001
Yes 1659 (64.6) 965 (72.7)
Partner characteristics Age of partner Below 25 148 (5.8) 52 (3.9) 0.283
25–34 848 (33.0) 450 (33.9)
�35 1573 (61.2) 826 (62.2)
Partner’s educational status No education 1140 (44.4) 700 (52.7) <0.001
Primary 908 (35.3) 489 (36.8)
Secondary+ 521 (20.3) 139 (10.5)
Partner drinks alcohol No 1951 (75.9) 799 (60.2) <0.001
Yes 618 (24.1) 529 (39.8)
No Yes
No (%) No (%)
Household characteristics Access to media No 1531 (59.6) 893 (67.2) 0.007
Yes 1038 (40.4) 435 (32.8)
Wealth index Poorest 465 (18.1) 283 (21.3) <0.001
Poorer 504 (19.6) 289 (21.7)
Middle 484 (18.8) 315 (23.7)
Richer 491 (19.1) 242 (18.2)
Richest 625 (24.3) 199 (15.0)
(Continued )


No Yes
No (%) No (%)
Relationship level variables Decision-making autonomy No 739 (28.8) 464 (34.9) 0.024
Yes 1830 (71.2) 864 (65.1)
Head of the household Male 2200 (85.6) 1157 (87.1) 0.428
Female 369 (14.4) 171 (12.9)
Educational difference Women higher 208 (8.1) 171 (12.9) 0.010
Same 1631 (63.5) 790 (59.5)
Husband higher 730 (28.4) 366 (27.6)
Age difference Women younger 84 (3.3) 37 (2.8) 0.624
Same age 47(1.8) 36 (2.7)
Husband older by �5years 1030 (40.1) 526 (39.6)
Husband older by >5 years 1409 (54.8) 729 (54.9)
Community/cluster level variables (n = 639) Place of residence Urban 125 (36.2) 75 (25.5) 0.004
Rural 220 (63.8) 219 (74.5)
Early marriage Low 194 (56.2) 150 (51.0) 0.188
High 151 (43.8) 144 (49.0)
Female literacy Low 159 (46.1) 130 (44.2) 0.636
High 186 (53.9) 164 (55.8)
Women’s autonomy Low 155 (44.9) 162 (55.1) 0.010
High 190 (55.1) 132 (44.9)
IPV acceptability Low 223 (64.6) 154 (52.4) 0.002
High 122 (35.4) 140 (47.6)
Societal/regional-level variables (n = 11) MPI Below national average 4 (66.7) 3 (60.0) 0. 652¥
Above national average 2 (33.3) 2 (40.0)
GEI Below average 2 (33.3) 3 (60.0) 0. 392¥
Above average 4 (66.7) 2 (40.0)
�
P-value was based on chi-squared test; IPV = Intimate Partner Violence; MPI = Multi-dimensional Poverty Index
¥
P-value was based on Fisher’s exact test; GEI = Gender Empowerment Index
Regarding educational differences between spouses, women with the same educational attain-
ment as their partner were 55% (AOR 0.45, 95% CI: 0.26–0.79) and women with a lower edu-
cational level than their partner were 69% (AOR 0.31, 95% CI: 0.11, 0.89) less likely to have
experienced IPV compared to women who had a higher educational attainment than their
partner.
Table 5. Prevalence of different forms of IPV against women.

Form of IPV Weighted prevalence 95% CI
Physical IPV 23.3% (21.1%, 25.6%)
Sexual IPV 11.2% (9.4%, 13.1%)
Emotional IPV 22.7% (20.2%, 25.2%)
Physical, sexual or emotional IPV 34.1% (31.3%, 36.8%)
Abbreviations: IPV = Intimate Partner Violence; CI = Confidence Interval

Table 6. Multilevel logistic regression analysis of individual-, relationship-, community- and societal-level factors associated with IPV.
Group Variable Class Model I Model II Model III Model IV
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Level-I variables Current age 15–19 1 1 1
20–24 2.07 (1.37, 3.13) 2.02 (1.34, 3.06) 2.02 (1.35, 3.07)��
25–29 2.08 (1.39, 3.14) 2.05 (1.36, 3.08) 2.05 (1.37, 3.09)��
30–34 2.52 (1.66, 3.84) 2.45 (1.61, 3.73) 2.46 (1.62, 3.73)��
35–39 3.14 (2.05, 4.82) 3.04 (2.00, 4.68) 3.05 (2.00, 4.68)��
40–44 2.54 (1.59, 4.03) 2.43 (1.53, 3.86) 2.42 (1.52, 3.85)��
45–49 3.41 (2.09, 5.56) 3.32 (2.03, 5.41) 3.31 (2.03, 5.40)��
Age at first cohabitation <18 years 1.29 (1.08, 1.52) 1.28 (1.07, 1.53) 1.28 (1.08, 1.52)�
�18 years 1 1 1
Educational status No education 1 1 1
Primary 0.69 (0.42, 1.14) 0.66 (0.40, 1.08) 0.66 (0.40, 1.10)
Secondary+ 0.43 (0.17, 1.11) 0.42 (0.16, 1.06) 0.42 (0.17, 1.08)
Witness inter-parental violence No 1 1 1
Yes 3.37 (2.83, 4.01) 3.34 (2.81, 4.00) 3.33 (2.80, 3.96)��
Substance abuse No 1 1 1
Yes 1.20 (0.98, 1.46) 1.21 (0.99, 1.48) 1.21 (1.00, 1.48)
Wife beating attitude No 1 1 1
Yes 1.21 (1.01, 1.44) 1.16 (0.96, 1.40) 1.15 (0.96, 1.39)
Partner’s educational status No education
Primary 1.62 (0.96, 2.74) 1.58 (0.93, 2.66) 1.56 (0.92, 2.63)
Secondary+ 1.58 (0.64, 3.92) 1.50 (0.61, 3.71) 1.50 (0.60, 3.70)
Partner drinks alcohol No 1 1 1
Yes 3.03 (2.46, 3.74) 3.00 (2.43, 3.69) 3.00 (2.42, 3.67)��
Wealth index Poorest 1.05 (0.80, 1.38) 1.08 (0.82, 1.43) 1.08 (0.82, 1.43)
Poorer 0.83 (0.63, 1.09) 0.84 (0.64, 1.11) 0.84 (0.64, 1.11)
Middle 1 1 1
Richer 0.80 (0.59, 1.07) 0.80 (0.60, 1.08) 0.81 (0.60, 1.09)
Richest 0.72 (0.55, 1.03) 0.76 (0.48, 1.06) 0.74 (0.46, 1.05)
Decision-making autonomy No 1 1 1
Yes 0.77 (0.64, 0.91) 0.81 (0.67, 0.97) 0.81 (0.68, 0.97)�
Educational difference Women higher 1 1 1
Same 0.44 (0.25, 0.77) 0.45 (0.26, 0.78) 0.45 (0.26, 0.79)�
Husband higher 0.30 (0.11, 0.86) 0.31 (0.11, 0.88) 0.31 (0.11, 0.89)�
Group Variable Class Model I Model II Model III Model IV
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Level-II variables Place of residence Urban 1 −
Rural 0.80 (0.54, 1.19) −
Early marriage Low 1 −
High 1.00 (0.79, 1.26) −
Female literacy Low 0.74 (0.57, 0.96) 0.74 (0.57, 0.96)�
High 1 1
Women’s decision-making autonomy Low 1 1
High 0.79 (0.63, 0.99) 0.80 (0.64, 1.01)
IPV acceptability Low 1 1
High 1.22 (0.97, 1.54) 1.31 (1.06, 1.62)�
(Continued )

Level-III variables MPI Below national average 1

Above national average 0.58 (0.33, 1.01)
GEI Below average 1
Above average 0.85 (0.50, 1.44)
Random effects Model I Model II Model III Model IV
Community variance (SE) 0.79 (0.11)� 0.59 (0.10)� 0.29 (0.26)� 0.28 (0.26)�
Region variance (SE) 0.20 (0.13)� 0.19 (0.09)� 0.17 (0.09)� 0.12 (0.07)�
ICC in community (%) 23.1 19.2 12.3 10.9
ICC in region (%) 4.6 4.7 4.6 3.4
PCV_community (%) Reference 25.3 63.3 64.6
PCV_region (%) Reference 5 15 40
Test of Model fitness Model I Model II Model III Model IV
Likelihood ratio -2336.84 -2199.03 -2191.73 -2190.10
AIC 4679.68 4448.06 4447.16 4398.29
AOR = Adjusted Odds Ratio; CI = Confidence Interval; MPI = Multi-dimensional Poverty Index; GEI = Gender Empowerment Index; SE = Standard Error;
ICC = Intra-class Correlation Coefficient; PCV = Proportional Change in Variance; AIC = Akaike Information Criterion
�
P-value �0.05
��
P-value �0.01
��
P-value �0.001
Model 1 is the empty model or a baseline model without any determinant variables; Model 2 is adjusted for individual- and relationship-level factors; Model 3 is
adjusted for individual-, relationship-, and community-level factors; Model 4 is the final model adjusted for individual-, relationship-, community-, and societal-level
factors
Holding other variables constant, women residing in communities with a low proportion of
educated women had 26% lower (AOR 0.74, 95% CI: 0.57–0.96) odds of IPV compared to
women residing in communities with a high proportion of educated women. In addition,
women living in communities with high IPV accepting norms had 31% higher (AOR 1.31,
95% CI: 1.06–1.62) odds of IPV experience as compared to their counterparts. The remaining
factors in the model were not significantly associated with IPV.
After the inclusion of individual-, relationship-, community-, and societal-level characteris-
tics in Model IV, the variation in the odds of IPV experience between communities and socie-
ties still remained statistically significant with σ2 = 0.28, p-value <0.001 and σ2 = 0.12, p-value
<0.001, respectively. As shown by the estimated ICC, 10.9% and 3.4% of the variability in IPV
experience was attributable to differences between community and societal characteristics,
respectively. The PCV indicated that specified factors at the three levels explained 64.6% and
40% of the variation in IPV experience across communities and societies, respectively.
Discussion
In Ethiopia, about one in every three women has experienced IPV in their lifetime. This study
showed that determinants of IPV operate at different levels in the society. At the individual-
level, older age, early marriage, witnessing inter-parental violence during childhood, and an
IPV accepting attitude were positively associated with IPV. At the relationship level, no deci-
sion-making autonomy in the household, higher educational attainment than partner and hav-
ing a partner who drank alcohol were positively associated with IPV. At the community level,
women’s education and community acceptance of IPV as the norm increased the odds of IPV.

These findings reveals that multiple and inter-related factors have influence on IPV in Ethiopia
that suggest the need to initiate combined interventions at different levels to reduce IPV in this
country.
Women of higher age were more likely to report IPV. Different explanations have been sug-
gested for this finding. One suggestion is that older women report their cumulative experience
of IPV in their lifetime, that is, they have more time to potentially be exposed to IPV than youn-
ger women [2, 26]. On the other hand, older women might be more likely to report IPV because
younger women in Ethiopia are often expected to be submissive, quiet, disciplined and loyal to
their husbands and hence may have a lower probability of reporting IPV [39]. However, other
researchers have found that the risk of experiencing IPV increased with younger age [1, 31, 40].
One possible reason for the contradictory findings could be cultural- and area-level differences
between study samples because IPV reporting is highly dependent on the cultural acceptability
of IPV, which varies by community and region. Finally, Ethiopian women from rural areas, in
which the majority of them are uneducated, often do not know their exact age [27] and this
could contribute to discrepancies as a result of measurement error.
Another factor related to IPV was early age at first marriage, which in Ethiopia is often
arranged by families. Social practices of arranged marriage and/or early marriage are common
in Ethiopia where the median age at first marriage for women is 17.1 years, which is 6.6 years
less than the median age at first marriage for men [27]. These practices limit the education and
development of women, and further increases the risk of IPV at an early age [41]. In Ethiopia
which has a strong patriarchy and traditionally values early marriage, women who have inter-
nalized such social norms as a normal part of life might be at greater risk of IPV.
One of the views in IPV research is that IPV might be a learnt behaviour that is passed from
generation to generation (i.e., inter-generational effect of violence) [42]. In the current study,
women who witnessed inter-parental violence as a child were more likely to experience IPV
during adult life. The finding may be explained by a phenomenon whereby women exposed to
violence during early life develop attitudinal acceptance and normative understanding of vio-
lence [40]. Choi & Ting [43] described this as the ‘submissive hypothesis’ which implies that
women who are submissive to male dominance in the family are more likely to experience
IPV. Further analysis of this data using a chi-square test also revealed that there was significant
association between witnessing of inter-parental violence and IPV accepting attitude
(p = 0.036). Similarly, male partners exposed to violence as a child have an increased risk of
being a perpetrator at a later age. In studies from Serbia [44], Vietnam [17], and Egypt [40],
researchers revealed that men who witnessed IPV as a child were more likely to become perpe-
trators later in life.
In this study, women married to a partner who drank alcohol had increased odds of IPV. It
has been suggested in previous research that this is due to the strong influence of alcohol on
behaviour [1, 45]. For example, excessive alcohol intake may lead to thoughtless behaviour
such as reduced judgment and impair the ability to understand community norms, thus
increasing the chances of IPV [26, 46]. Extra expenditure on alcohol may also erode family
income and may contribute to conflict that could further lead to IPV [40]. In this study, wom-
en’s own substance abuse was not found to be significantly associated with IPV. This needs
further investigation as the relationship between women’s substance abuse and her experience
of IPV is often complex. There are also views that women use substances in response to experi-
ences of IPV, rather than their substance use being a reason of IPV.
Women’s decision-making autonomy in a relationship was found to be a protective factor
against IPV. In Ethiopia, a man has a mandate to control the family resources and make deci-
sions [14, 47] and if women question or argue with their partner about resources, they may

encounter frequent abuse [48]. Other researchers also indicated that conflict arising from
household finances were important predictors of spousal IPV [49].
The findings of this study revealed that neither women’s education nor partner’s education
alone had a significant influence on IPV. However, this study has shown that differential edu-
cation (women who had the same or lower education than their partner) was associated with
decreased odds of IPV. The effect of educational differences was explained by Choi & Ting
[43] with the ‘compensation hypothesis’ by which a man uses force against his wife to compen-
sate for his inability to achieve masculine gender expectations. Moreover, women living in
communities with a high prevalence of educated women were more likely to experience IPV.
This might be explained by women’s education being insufficient to counteract traditional
gender roles of male superiority and control over his wife [50, 51]. In such contexts, men do
not accept being dominated by their educated wife and may try to preserve their gender role as
powerful by abusing his wife [15]. This is because in more culturally conservative areas, wom-
en’s education, empowerment and autonomy are unable to change the rigid normative under-
standing of IPV [14, 15].
In this study, women living in communities with high IPV accepting norms were more
likely to have increased odds of IPV. These gender norms create a hierarchy in relationships
and inequalities that in turn affect behaviours [52]. Tolerant community norms regarding IPV
that disregard some acts of violence, norms of male superiority, and perceiving IPV as an inev-
itable part of a relationship are basic factors that not only underlie the occurrence of IPV [16–
19] but also allow it to persist in society [5, 18] and challenge intervention efforts [18]. These
community and cultural norms range to the extent that they devalue IPV reporting and stig-
matize women who report their abuse in order to preserve a moral order [20]. The community
also has a role in maintaining the normalization of IPV through proverbs [53]. In Ethiopia, for
example, proverbs such as ‘a woman and a mule behave the way they are trained’ are common
[53]. If a male cries, he is considered ‘girlish’, which shows the community’s attitude and toler-
ance towards girls suffering and crying as being normal and natural [54]. Moreover, traditional
norms and gender roles affect women even when they leave their communities. For example,
Ethiopian migrants living in Australia and Israel found significant patriarchal norms and IPV
accepting norms within the country in which they were displaced [32, 55]. Therefore, contrary
to the general perception, societal-level factors were not significantly associated with IPV,
rather community-level disparities in terms of education, decision-making autonomy and IPV
accepting norms were important to explaining the occurrence of IPV.
The findings of this study need to be interpreted in light of the following limitations. First,
the cross-sectional nature of the study makes it difficult to determine cause and effect relation-
ships. For example, women who are in a violent relationship might have less decision-making
autonomy or might have more chance of substance use. However, future research will be
needed to ascertain which event is the continuation of another. Second, despite the study
strictly following WHO strategies for domestic violence research that helps to minimize
under-reporting bias, under-reporting of IPV experiences may still occur due to fear of reper-
cussions, stigma, and shame. Third, all the variables, including partner characteristics, were
self-reported and might be subject to recall bias. Lastly, some factors of the ecological model
such as factors related to social support to victims, neighbourhood environment, laws, and
national policies were not assessed in this study due to these variables not being in the dataset.
Conclusion and implications

In summary, the results show that the proportion of women who had experienced IPV were
high in Ethiopia. This study reveals an important public health message that high IPV

prevalence was accountable to not only individual factors but also relationship- and commu-
nity-level characteristics. As this study is based on robust statistical analysis and on the most
representative national data, it has implications for policy makers and programmers. The evi-
dence can be taken into account when designing future IPV prevention programs that aim to
improve factors at different levels. The findings also suggest that interventions against IPV
require multisectoral collaborations. It also needs the involvement of different stakeholders
from communities as well as governmental and non-governmental organizations to end the
intergenerational cyclic effect of IPV.
Future studies should focus on qualitative studies that might explore how the social pro-
cesses cause and maintain IPV in communities. This is because even with the inclusion of
many variables across different levels, this study indicates that variability of IPV was not ade-
quately explained by the included community- and societal-level variables. This shows the
complexity of the occurrence of IPV and that some other arcane social processes might be
present.
Acknowledgments
We are grateful to the Central Statistical Agency of Ethiopia and Measure Demographic and
Health Survey program, which allowed us to access and use the data freely. We are also thank-
ful to the women who participated in the survey and shared their IPV experiences. We thank
the University of Newcastle, the Hunter Medical Research Institute, and the Research Centre
for Generational Health and Ageing for creating a quality research environment for us to
accomplish this work.
Author Contributions
Conceptualization: Tenaw Yimer Tiruye.
Formal analysis: Tenaw Yimer Tiruye.
Methodology: Tenaw Yimer Tiruye.
Supervision: Melissa L. Harris, Catherine Chojenta, Elizabeth Holliday, Deborah Loxton.
Writing – original draft: Tenaw Yimer Tiruye.
Writing – review & editing: Melissa L. Harris, Catherine Chojenta, Elizabeth Holliday, Debo-
rah Loxton.
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PLOS ONE

Determinants of intimate partner violence

Data Availability Statement: Data cannot be

PLOS ONE | https://doi.org/10.1371/journal.pone.0232217 April 24, 2020 1 / 18

provides an abstract or a description of any project Introduction

PLOS ONE | https://doi.org/10.1371/journal.pone.0232217 April 24, 2020 2 / 18

Sample size and sampling procedures

Measurement and variables

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Data processing and analysis

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Table 2. List of variables, their categories and definitions.

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Prevalence of different forms of IPV

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Table 3. Characteristics of study participants (n = 3,897).

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Factor Group Variable Class Weighted frequency Percent

Abbreviations: MPI = Multi-dimensional Poverty Index; GEI = Gender Empowerment Index

PLOS ONE | https://doi.org/10.1371/journal.pone.0232217 April 24, 2020 8 / 18

Table 4. IPV experience by different variables.

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Factor Group Variable Class IPV (n = 3,897) P-Value�

Table 5. Prevalence of different forms of IPV against women.

Abbreviations: IPV = Intimate Partner Violence; CI = Confidence Interval

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Level-III variables MPI Below national average 1

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Conclusion and implications

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PLOS ONE | https://doi.org/10.1371/journal.pone.0232217 April 24, 2020 15 / 18

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PLOS ONE | https://doi.org/10.1371/journal.pone.0232217 April 24, 2020 18 / 18

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