Intimate partner violence (IPV) is defined as the threat of, and/or actual, physical, sexual, psychological, or verbal abuse by a current or former spouse or nonmarital partner [
This paper presents the findings from a nurse-led, international, interdisciplinary project aimed at understanding the current situation of IPV in Ethiopia and developing recommendations for country-specific activities to address IPV. In particular, it reports the findings from a review of literature on IPV in Ethiopia, summarizes the process, discussions, and outcomes of an interdisciplinary forum with various stakeholders and a meeting with nursing faculty from several universities across Ethiopia, and makes recommendations for country-specific activities to improve response to IPV in Ethiopia through practice changes, education, and research. The findings may have applications to other low-income countries and/or “marginalized” populations in middle- to high-income countries.
Ethiopia is one of the oldest nations in the world and is characterized by great diversity in terms of its topography, climate, ethnicities, and languages, with more than 80 distinct cultural groups. With a population of approximately 75 million and an annual population growth rate of 2.6% (in 2007) [
The current government is focused on providing access to basic primary health care services to the whole population, using a decentralized system of health centres and health posts. An estimated 75% of urban homes and 42% of rural homes have access to health facilities [
Our collective interest in better understanding IPV in the Ethiopian context evolved from our previous research with Ethiopian immigrants living in Toronto (Hyman and Guruge) [
The project involved two phases. A review of the published literature was first conducted (in Phase 1) to understand the current state of knowledge about IPV in the Ethiopian context. The results of this review served as a launch for subsequent discussions in an interdisciplinary forum and a meeting with nursing faculty held (in Phase 2) in Addis Ababa to develop country-specific activities to improve responses to IPV through practice changes, education, and research. We have outlined the details of each phase below.
In phase one, a search and review of both academic and grey literature was conducted. The academic search was carried out by project assistants (Kassa and Refaie-Shirpak) with supervision from team members in Canada. MEDLINE and CINAHL databases were searched for literature published from 2000 to 2009, with the following keywords: intimate partner violence, domestic violence, harmful traditional practices, violence against women, abuse, and Ethiopia. The grey literature search, conducted by the Ethiopian project assistant (Kassa) with supervision from Ethiopian team members, included policy documents and statistics produced by or available from university libraries such as Addis Ababa University and governmental and nongovernmental organizations such as the Ethiopian Ministry of Women’s Affairs and Ministry of Health. It bears noting that access to such documents was not straight forward, often requiring permissions and presenting timing challenges.
Of the 53 reports collected, 35 were research studies with varying sample sizes (
Phase 2 was comprised of two meetings held in Addis Ababa in November, 2009: a full-day interdisciplinary forum and a half-day meeting with nursing faculty.
The list of invitees for the interdisciplinary forum was generated by the Ethiopian team members that targeted university departments and specific organizations in health, community, and legal services, as well as appropriate government ministries. Speakers for the forum were also arranged by Ethiopian team members and included researchers/academics and practitioners working in the area of IPV. The invitation letters included a brief description of the project, its aims, a detailed agenda, and logistics of the forum.
The forum was attended by lawyers, nurses, midwives, physicians, academics, and governmental and non-governmental agency staff who are engaged in addressing various aspects of violence against women. At the beginning of the forum, each attendee was given a detailed review of the literature and an executive summary. The following formal presentations were held in the morning: Public Health Perspectives on IPV, Social Services Work in IPV, Legal Services Work in IPV, Women’s Advocacy Work in IPV, Socio-cultural Perspectives on IPV and Health, and IPV and HIV/AIDS. These papers were based on research, practice, advocacy, and policy work being undertaken in Ethiopia. Speakers’ backgrounds ranged from public health, gender studies, law, psychiatry, and sociology. The afternoon was devoted to small group discussions guided by pre-determined questions on what attendees (
With three of our six-member project team (The PI (Guruge), the Co-PI (Bender), and a Co-I (Aga)) being nursing faculty, we chose to incorporate a nursing-specific dimension into our project. Because nurses represent the largest group of health care professionals, and nurses may be the only health care professionals immediately available to women in rural contexts, we wanted to learn about nurses’ knowledge about IPV and their skills in addressing IPV. Therefore, on the day after the interdisciplinary meeting, we held a meeting with a group of 14 nursing educators from various universities across Ethiopia who were enrolled in the master’s program at the Centralized School of Nursing at Addis Ababa University. The group was comprised of eight women and six men who lived and worked in different regions of the country. Eight of the 14 had moved to teaching roles directly after their baccalaureate; only six had both clinical and teaching backgrounds. Their teaching experience ranged from 1 to 20 years, and clinical experience ranged from 0 to 24 years.
The literature revealed findings about the forms and prevalence of IPV, health consequences of IPV, risk and protective factors and perceptions of IPV, and responses to IPV.
In Ethiopia, IPV is commonly referred to as domestic abuse or domestic violence, wife beating or battering, relationship violence, and spousal abuse. The literature also noted that IPV frequently occurs in the context of marriage or cohabitation, predomestic relationships such as dating relationships, and postdomestic relationships, as in the case of ex-partners who are no longer living together [
IPV should be understood and addressed within the broader context of violence against women. A number of studies (e.g., [
Different forms of violence occurring in Ethiopian women’s lifecycle [
Phase | Type of violence |
---|---|
Prebirth | Male preference |
Infancy | Preferential treatment for boys (e.g., stopping breastfeeding earlier for girls), female genital mutilation (FGM) |
Childhood | Food/nutritional misallocation, FGM, early marriage, sexual abuse, rape |
Adolescence | Food/nutritional misallocation, FGM, not sending girls to school, psychological abuse, sexual harassment, domestic violence (IPV), abduction, rape, trafficking |
Adulthood | Food/nutritional misallocation, domestic violence (IPV), sexual harassment, rape |
Old age | Food/nutritional misallocation, rape |
Several studies reported that IPV in Ethiopia was pervasive. Approximately 90 to 100% of participants in a national study reported that IPV was a common phenomenon in Ethiopia [
Other studies documented the main forms of IPV in different parts of Ethiopia. A study conducted in the Amhara region’s Bahir dar/Adet sites [
In Butajira, the Ethiopian site for WHO’s [
Consistent with the literature from other countries, the literature about IPV in Ethiopia reported a wide range of health consequences from IPV. The main physical health consequences identified were fractures, deep cuts on body parts, injury to eyes and ears [
Mental health consequences of IPV were identified [
The literature also revealed a number of risk factors for IPV. The risk of physical violence, in particular, was associated with the educational status of women and men, place of residence, religion, arranged marriage, parity, partner’s use of alcohol, and the woman’s having witnessed family violence as a child [
IPV appears to be tolerated under certain circumstances. For example, Mohamed [
Intergenerational transmission of patriarchal norms partially explains the gender-based violence that seems to manifest in many forms through the lifecycle [
In the WHO [
Minimal use of formal services may partly reflect a limited availability of services [
With the goal of ensuring “health for all,” the current Ethiopian health policy [
Other reasons for limited health service responses to IPV were identified as (1) lack of trained personnel in rural areas, (2) lack of reporting (or a reporting system) of “minor” injuries in the case of rape, (3) delay in the preparation of medical reports (or lacking reports altogether) due to kinship matters or corruption, and (4) expecting the woman to pay for the medical card and write her certificates in reporting the experience to the police [
The literature review highlighted the complexity and insidiousness of IPV—where, how, and to whom it happens, its effects, and the socio-cultural determinants that give root to its pervasiveness. The review also demonstrated that while IPV may receive comparatively little research attention as a health issue in Ethiopia, important studies have been conducted and the findings contribute to the understanding of IPV. More specifically, the review provided our larger project with a solid grounding for the discussions planned in Phase 2 to further critical reflection on the issue itself as well as on the priority needs for moving forward in IPV research and education and enhancing service provision.
The participants provided a critical appraisal of the research conducted to date. While the incidence and prevalence rates of IPV are well documented for Ethiopia, attendees noted that these studies had been carried out in limited areas of the country. Furthermore, while epidemiological data are vital, more qualitative research was perceived as necessary to deepen understanding of women’s lived experiences as well as why men commit abusive/violent acts against women. More broadly, public education was seen as critical to bringing about social change in this regard. Several attendees observed that the day focused on negative aspects of IPV and that future work is also needed to build on the successes of existing work being done in terms of awareness raising, violence prevention, and service provision as well as to identify the resilience of the abused women and their children.
Two significant themes emerged from the small group discussions: (1) the value of bringing together clinicians, advocates, educators, and researchers from multiple disciplines to share with and learn from each other and to build consensus on research gaps and identify priorities for interdisciplinary research on IPV in Ethiopia, as IPV spans many disciplines and will not be adequately addressed by individuals working separately within each discipline; and (2) the need for health care professionals to better understand their role and responsibilities in identifying IPV and taking steps to actively address it in practice. These two themes were framed within some assumptions of the need to think globally. Research about IPV in Ethiopia benefits, and is benefitted by, collaborative efforts across countries within Africa and around the world. Suggestions were made about the need to plan more regular forums such as this one and international workshops and seminars addressing IPV.
Discussions in this meeting focused on a set of questions that we developed based on themes from the literature review and issues raised at the interdisciplinary forum, including the following: What is intimate partner violence? How is it understood culturally, locally, in your own town/city? How is it a health issue? How is it an issue for nursing? What should be done about it? What is the nurse’s role in caring for women who have experienced IPV? What is the nurse’s role in preventing it? What is currently in your nursing school’s curriculum on violence, in general, and on IPV, in particular? What should be included in your curriculum?
This was generally a well-informed group of nurses who could easily define IPV and explain its key defining characteristics. Definitions generated by the group fit with those presented earlier in this paper: participants clearly identified the health issues associated with IPV and emphasized education and awareness raising as important strategies in addressing IPV. Like the interdisciplinary group, these nurses also stressed the sociocultural acceptance of the devaluation of women, generally, and IPV, specifically, as contextual elements in the overwhelming rates of violence against women, particularly in more rural areas of the country. As discussion shifted to the education of nursing students in this regard, different interpretations of the countrywide standardized nursing curriculum emerged. While IPV was understood by all to be a four-hour component of the “reproductive health” course, the content of these four hours varied. In the end, participants agreed that Ethiopia’s standardized nursing curriculum requires a stronger focus on violence against women to improve assessment, care, and prevention and that the onus is also on nursing schools and individual faculty members to make violence against women more explicit in class content.
The discussions in both meetings highlighted that, as in most countries around the world, there is a definite need to make the links between health and violence against women more explicit. To delineate this point further, it is vital to raise awareness of IPV amongst health care professionals in Ethiopia, to support them in learning more about IPV and its role in women’s health and to generate more coherent strategies for addressing IPV directly with women in care and for guiding them to appropriate resources. More broadly, there is a need to develop a more coordinated systemic response to abused women’s needs across sectors, including health and social services, the justice system, housing, economics, and faith communities. Moreover, immediate attention and adequate resources must be directed towards preventing violence and promoting health at community and population levels.
This project identified several gaps in health science research on IPV in Ethiopia, particularly the need for comprehensive interdisciplinary research. At the macrolevel, the diversity of Ethiopia’s population and the changes in gender relations brought about by urbanization, globalization, migration, and transient/migratory work require critical analysis of how these affect women’s responses to IPV and contribute to their vulnerability and resilience and how these change over time. Specifically, it is important to assess how such changes influence rates and experiences of IPV, and thereby how to best mitigate IPV. Related to this, individual, familial, community, and societal risk and protective factors need to be explored in order to have the greatest effect on the overall incidence of violence.
Important research into the health risks and consequences of IPV has begun; however, more is needed particularly in regions of Ethiopia that have not been captured in previous studies. Since large-scale epidemiological studies mainly capture data on prevalence and risk factors, qualitative research methods can help deepen understandings of, for example, the quality of life of women who are living in or have left abusive intimate relationships. Critical qualitative studies of the perceptions and attitudes of health care professionals toward IPV and the women who seek help can also identify the education, training, and support needs of these professionals.
The need for research in health services is also apparent, specifically, in terms of assessment, treatment interventions, care and support, and prevention. Further study into the assessment of IPV in clinical settings, focussing on the roles and responsibilities of health care providers other than physicians, can be a first step in the development of standardized screening tools for health clinics and hospitals. A more complete understanding of the accessibility issues faced by Ethiopian women seeking IPV-related services is needed to improve intersectoral collaboration at the point of contact. Finally, the role and the types of public education that can effectively challenge gender norms need to be examined in the interest of developing effective violence prevention campaigns.
In addition, our project identified the importance of focusing on practice and the education of health care professionals. Health care practitioners, from physicians and nurses to health extension workers and volunteers, need adequate and appropriate education about IPV. This includes learning how best to care for women in open, non-judgmental, and supportive ways and developing skills in therapeutic communication regarding the topic of IPV and advocacy.
Lastly, the findings of this project highlight the critical importance of (1) an interdisciplinary approach to this work, (2) systematic access to information as a starting point, and (3) being careful to reflect on assumptions of what is “known” about a topic or issue, particularly from an international perspective. This project brought people together who had never met before and created a starting point in working towards improving local responses to IPV through practice changes, education, and research.
Interdisciplinary research and practice initiatives can have far-reaching effects in understanding and addressing IPV. Nursing, medicine, public health, and law, as well as the social sciences, political science, gender studies, and the humanities all have dovetailing research interests in IPV that can lead to effective prevention and intervention programs. By adding international collaboration to this mix, through the creation of partnerships across countries, universities, and health care settings, IPV may be better understood as a global health issue and thereby the health of women in Ethiopia and the diaspora improved.
No conflict of interests has been declared by the authors.
The authors gratefully acknowledge the financial support for the project from a Meetings, Planning, and Dissemination grant from the Canadian Institutes of Health Research (CIHR). The first author also acknowledges the financial support she received (in the form of a New Investigator Award) for her work from CIHR’s Institute of Gender and Health.