Partners’ controlling behaviors and intimate partner sexual violence among married women in Uganda

Background Studies on the association between partners’ controlling behaviors and intimate partner sexual violence (IPSV) in Uganda are limited. The aim of this paper was to investigate the association between IPSV and partners’ controlling behaviors among married women in Uganda. Methods We used the 2011 Uganda Demographic and Health Survey (UDHS) data, and selected a weighted sample of 1,307 women who were in a union, out of those considered for the domestic violence module. We used chi-squared tests and multivariable logistic regressions to investigate the factors associated with IPSV, including partners’ controlling behaviors. Results More than a quarter (27%) of women who were in a union in Uganda reported IPSV. The odds of reporting IPSV were higher among women whose partners were jealous if they talked with other men (OR = 1.81; 95% CI: 1.22-2.68), if their partners accused them of unfaithfulness (OR = 1.50; 95% CI: 1.03-2.19) and if their partners did not permit them to meet with female friends (OR = 1.63; 95% CI: 1.11-2.39). The odds of IPSV were also higher among women whose partners tried to limit contact with their family (OR = 1.73; 95% CI: 1.11-2.67) and often got drunk (OR = 1.80; 95% CI: 1.15-2.81). Finally, women who were sometimes or often afraid of their partners (OR = 1.78; 95% CI: 1.21-2.60 and OR = 1.56; 95% CI: 1.04-2.40 respectively) were more likely to report IPSV. Conclusion In Uganda, women’s socio-economic and demographic background and empowerment had no mitigating effect on IPSV in the face of their partners’ dysfunctional behaviors. Interventions addressing IPSV should place more emphasis on reducing partners’ controlling behaviors and the prevention of problem drinking.


Background
Sexual and gender-based violence is a major social and public health problem [1,2] with immediate and long-term negative consequences [3]. Sexual violence in particular leads to negative psychological, behavioral, physical, and reproductive health outcomes [1,4]. These include a heightened risk of HIV and sexually transmitted infections [5,6], gynecological and sexual disorders, pregnancy complications, miscarriages and low birth weight [7].
Worldwide, approximately 35% of women have experienced either physical or sexual violence, or both. Between 2006 and 2011, the percentage of Ugandan women who reported that they had ever experienced violence decreased from 39% to 28%. In the same period, the percentage of women who reported that they had experienced sexual violence in the twelve months preceding the survey decreased from 25% to 16%. The prevalence remains unacceptably high, however. In Uganda, 55% of ever married women identified intimate partners (husbands or male partners) as the perpetrators of sexual violence [8,9].
Intimate partner sexual violence (IPSV) is among the most common forms of gender-based violence in Uganda. Among women who were in a union, 27% had ever experienced IPSV from their current partner and about one in five (21%) had experienced sexual violence from an intimate partner in the 12 months prior to the survey [8].
IPSV is justified or tolerated in some cultures in South Africa [10] and Uganda [11]. This is because of associated beliefs that condone sexual violence within marriage and weak law enforcement [12,13]. In such contexts, women rarely report IPSV cases outside the family context. In Uganda, sexual violence ranked high among the types of violence where the majority of victims (65%) never sought help or told anybody [8].
In some contexts, demographic and socio-economic factors account for variations in IPSV occurrence. Significant predictors of IPSV include the woman's age, age at first sex, type of marriage relationship, level of education, wealth status, and geographical region [2,11,14]. In rural Uganda, IPSV was associated with being young, an early age at first sex, consensual unions, and a low level of education [11]. In addition, poor wealth status significantly increases the likelihood of IPSV. The need for economic support often results in early (and possibly coerced) sex and marriage [11,12,15]. In Uganda, the likelihood of reporting IPSV was higher in the eastern and western regions than in the northern region [15].
Patriarchal notions of masculinity permeate IPSV. These notions reinforce men's control over women and their belief in unconditional sexual entitlement in marriage. In addition, IPSV is a method of punishment for noncompliance with partners' demands in a relationship. The occurrence of sexual violence was positively associated with women's attitudes justifying wife beating and women earning more than their partners. Women who had decision-making autonomy had a lower likelihood of experiencing physical and sexual violence [12,16,17].
Socialization, particularly in family contexts in the formative years of life has a significant bearing on behavior during adulthood. In particular, witnessing parental violence during childhood is associated with re-victimization and an intergenerational cycle of violence for both girls and boys [12,18]. Intimate partner physical (battering) and sexual violence are closely related [19]. While several studies have established the relationship between witnessing physical intimate partner violence and experiencing physical violence [12,18,20], its association with sexual violence in Uganda is yet to be established.
Male partners' controlling behavior in unions, their alcohol consumption and women's fear of their partners have been associated with intimate partner violence [12,13,15,17]. Factors associated with intimate partner physical violence (IPPV) among women who are in a union in Uganda include women's occupation; wealth status; parity; witnessing parental violence and whether women were afraid of their partners. In addition, partners' controlling behaviorsincluding accusing women of unfaithfulness, denying them permission to meet their female friends, insisting on knowing their whereabouts, and getting drunk sometimes or oftenwere associated with IPPV [20].
Studies investigating IPPV usually combine both physical and sexual violence [6,14,21,22] yet contextual social perceptions of the two may differ [20]. On the other hand, studies that specifically address IPSV did not consider women's empowerment and male partners' controlling behaviors [23]. Therefore, this paper assessed the association between women's empowerment, partners' controlling behaviors, and intimate partner sexual violence among women who are in a union in Uganda.

Data source
We used the 2011 Uganda Demographic and Health Survey (UDHS) data, accessed with permission from the DHS Program website [24]. This was a cross-sectional nationally representative survey that used a stratified two-stage cluster sampling design [8] based on the sampling frame from the 2002 population and housing census [25]. A detailed description of the sampling procedure was reported in the 2011 UDHS report [8].
The sample for the domestic violence (DV) module was 2,056 ever-married women. From this sample, we extracted a weighted sample of 1,307 women who reported being in a union, for further analysis [8]. We used the domestic violence weighting variable (d005) included in the UDHS data and the Stata survey (svy) command to apply the weights during the analyses. Survey weighting is necessary to account for the complex survey design [26].
In this paper, women in a union included those who were married or cohabiting with their partners. The domestic violence module was based on a shortened and modified version of the Conflict Tactics Scale (CTS) [27]. The survey was carried out based on the World Health Organization's (WHO) ethical and safety recommendations for research on domestic violence [28].

Measures of outcome variable
In the DHS, intimate partner sexual violence (IPSV) was measured as having experienced any sexual violence from a current or former partner in the 12 months prior to the survey [29]. For IPSV, women in a union were asked the following questions: a) Have you ever been physically forced into unwanted sex by your husband/ partner? b) Have you ever been forced into other unwanted sexual acts by your husband/partner? c) Have you ever been physically forced to perform sexual acts when you did not want to? The binary responses from these three questions were merged into an aggregate measure of intimate partner sexual violence (variable d108 in DHS), which was coded as 0 = no, and 1 = yes.

Measures of explanatory variables
We classified independent variables into three categories: first, women's empowerment indicators, namely participation in decision-making, attitudes justifying physical violence, and economic empowerment indicators. The second group of variables comprised husbands/partners' controlling behavior, women's fear of their partners, and their partners' alcohol consumption. The third category of explanatory variables included women's socio-demographic factors such as having witnessed parental violence themselves. This categorization was used in our earlier publication [20]. The term "partner" in this paper includes husbands as well as partners in cohabiting unions.
Five indicators in the DHS measured women's participation in household decision-making. Earlier publications have used these indicators [20,29]. In this paper, we used all five measures of decision-making autonomy regarding who usually makes decisions about: a) how women's earnings are used; b) women's healthcare; c) large household purchases; d) visits to family or relatives; and e) what to do with the money the partner earns. Responses to these questions were recoded into two categories (1 = woman decides alone/jointly with partner, 0 = partner alone/others). The assumption was that women who made decisions either alone or jointly with their partners were more empowered than those in households where decisions were made by either their partners alone or other people [20,29].
Attitudes justifying physical violence were measured by questions concerning whether wife beating was justifiable if the wife: a) goes out without telling partner; b) neglects their children; c) argues with her partner and d) refuses to have sex with her partner. Responses to these variables were dichotomous (1 = "yes" or 0 = "no"). Although, some studies have aggregated these measures [29,30], we preferred individual measures of empowerment [29]; our aim was to investigate the contribution of specific empowerment measures in influencing IPSV in the Ugandan context.
As described elsewhere [20], "women's economic empowerment included occupation and ownership of property (a house). Ownership of a house was recoded into two categories: woman alone/jointly with the partner as the empowered category and partner alone/others as the other. Ownership of a house is included because it is an important and contested asset for women in the Ugandan context" [20].
Partners' behavior and controlling tendencies were analyzed using three variables: partners' controlling behavior and alcohol consumption, and the women's attitude towards their partners. To measure partners' control, women were asked whether their present partners: a) were jealous if respondents talked with other men; b) accused them of unfaithfulness; c) did not permit them to meet female friends; d) tried to limit respondents' contact with family and e) insisted on knowing where they were. All these variables had binary responses (0 = no and 1 = yes).
Partner's alcohol consumption was measured by two questions: a) Does your partner drink alcohol? This was coded as binary outcome (0 = No, 1 = Yes). The second follow up question was asked to those who said yes to drinking alcohol: b) How often does (did) he get drunk: often, only sometimes, or never? The response categories were; 0 = never, 1 = often, 2 = sometimes). We generated a new measure of alcohol consumption from the second question and included those who do not drink alcohol. The new variable had four categories (0 = does not drink, 1 = drinks, but never gets drunk, 2 = drinks and sometimes gets drunk and 3 = drinks and often gets drunk). We also included women's attitude towards their partnerswhether they were afraid of their partnersin this category of variables. Women were asked if they were afraid of their partners. This was categorized as 0 = never, 1 = sometimes and 2 = most of the time.
Women's socio-demographic characteristics included women's age group, women's education level, region, place of residence, wealth index, parity or number of children ever born and current marital status (married or cohabiting). Witnessing of parental intimate partner violence was measured by whether the respondent reported ever witnessing her father beating her mother (with a binary outcome of 0 = No, 1 = Yes). The analysis also included age at first sex and duration of the union.

Statistical analyses
We used frequency distributions to describe the characteristics of the women. Cross-tabulations with Pearson's chi-squared (χ 2 ) tests were used to examine the associations between IPSV and women's empowerment (economic empowerment, attitudes justifying physical violence, and decision-making autonomy), partners' behaviors, and women's socio-demographic factors. The level of statistical significance using p-values was set at p <0.05.
Finally, we conducted multivariable logistic regression analyses to examine the association between IPSV and the selected explanatory variables whose p-values were less than 0.05 during the chi-square tests. We presented the results in the form of Odds Ratios (OR) and their 95% confidence intervals. The level of statistical significance using p-values was set at p < 0.05. We estimated three models during the multivariable analysis. In the first step, IPSV was modeled with decision-making indicators and attitudes justifying wife beating. In the second model, we added partners' controlling behaviors and women's fear of their partners. In the final model, we adjusted for sociodemographic factors. We weighted all of the analyses to take into consideration the survey design, clustering and stratification [26].

Distribution of respondents by socio-demographic characteristics and measures of empowerment
From Table 1, 41% of the women were aged 25-34 years. There was nearly an even distribution of women by region, although more than a quarter (28%) were from the central region. Most (84%) of the women were rural residents. Most (70%) engaged in sex before they were 18 years. More than half (55%) were married and had been in a union for over 10 years (55%). Half (50%) of the women reported giving birth to between 1 and 4 children in their lifetime. More than half (60%) had primary education and 41% were from the richer and richest wealth quintiles. Close to half (46%) had witnessed their fathers beat their mothers during childhood.
Concerning measures of women's empowerment, just over half (53%) of the women were engaged in agriculture, more than half (57%) reported ownership of a house either alone or jointly. Participation in household decisionmaking among women in a union was as follows: how women's earnings were spent (44%); women's own healthcare (59%); large household purchases (56%); visits to women's family (58%); and how their partners' earnings were used (46%).
The prevalence of attitudes justifying physical violence varied. Wife beating was justified if the woman: went out without telling her partner (41%); neglected their children (48%); argued with her partner (30%); refused sex with her partner (24%); or burnt food (15%). Just over one in four (27%) women in a union reported having experienced IPSV in the 12 months preceding the survey.

The association between IPSV and women's socio-demographic characteristics and empowerment indicators
Results of the cross tabulations in Table 1 show that region, age at first sex, women's level of education, and whether the woman's father beat her mother were significantly associated with IPSV. Among the measures of empowerment, IPSV was only significantly associated with decision-making regarding the partner's income, and with attitudes towards wife beating only if the woman neglected their children, argued with her partner, or burnt food. However, some of the key measures of economic empowerment, such as property ownership and decisionmaking concerning large purchases were not significantly associated with IPSV (see Table 1). Table 2 presents male partners' background characteristics, their behavior (controlling tendencies and alcohol consumption) and women's fear of their partners. Over half (55%) of the partners were aged 35 years and above. Over a third (36%) had secondary or higher education. Concerning partners' controlling behavior, over half of the women reported that their partners were jealous if they talked with men (56%), and insisted on knowing where they were (55%). Less than one third reported that their partners accused them of unfaithfulness, did not permit them to meet female friends, and limited their contact with family (32%, 26% and 18% respectively). Four in ten (40%) of the women had partners who got drunk and 46% of the women were afraid of their partners.

The association between IPSV among women in a union and partners' behaviors
In Table 2, all measures of male partners' controlling behaviors, alcohol consumption, and women's attitudes towards their partners were strongly associated with reporting IPSV. IPSV was higher among women whose partners were jealous when they talked to other men (35%), accused them of unfaithfulness (41%), denied them permission to meet female friends (42%), limited contact with family (46%), and insisted on knowing their whereabouts (33%). IPSV was higher among women whose partners often got drunk (44%) and among women who were often afraid of their partners (39%). Partner's age and level of education were not significantly associated with IPSV. Table 3 shows the results of logistic regression of IPSV controlling for empowerment indicators and selected explanatory variables. In the first model, we adjusted for decision-making and attitudes justifying wife beating. Woman's participation in decision-making concerning the partner's income was the only significant predictor of IPSV. Women who participated in decision-making concerning their partners' incomes had reduced odds (OR = 0.63; 95% CI: 0.47-0.86) of experiencing IPSV in comparison to those who did not.

Multivariable results
In the second model, we added partners' behaviors and women's fear of their partners. Partners' behaviors and women's fear of their partner weakened women's participation in decision-making concerning their partners' income. Among partner's behaviors, significant predictors of IPSV were if the partner was jealous if the woman talked with other men, did not permit the respondent to meet female friends, tried to limit the woman's contact with family, and the frequency of the partner's excessive alcohol consumption. Whether the woman was afraid of her partner was also significantly associated with IPSV. The odds of reporting IPSV were higher among women whose partners were jealous if they talked to other men (OR = 1.93; 95% CI: 1.28-2.90), did not permit the respondent to meet female friends (OR = 1.53; 95% CI: 1.03-2.27), and tried to limit her contact with In the final model, we adjusted for socio-demographic factors. While most of the partners' behaviors and women's attitude towards their partners retained their significance, women's empowerment and socio-demographic variables were not significant. The odds of reporting IPSV were higher among women whose partners were jealous if they talked with other men (OR = 1.81; 95% CI: 1.22-2.68), accused them of unfaithfulness (OR = 1.50; 95% CI: 1.03-2.19) and did not permit them to meet with their female friends (OR = 1.63; 95% CI: 1.11-2.39). The odds of IPSV were also higher among women whose partners tried to limit their contact with family (OR = 1.73; 95% CI: 1.11-2.67) and often got drunk (OR = 1.80; 95% CI: 1.15-2.81). Women who were sometimes or often afraid of their partners had increased odds of reporting IPSV (OR = 1.78; 95% CI: 1.21-2.60 and OR = 1.58; 95% CI: 1.04-2.40 respectively).

Discussion
The aim of this study was to examine the association between women's empowerment, partners' controlling behaviors and IPSV. The prevalence of IPSV among women in a union was high.
Male partners' controlling behaviors were the main predictors of IPSV among women in a union in Uganda. Being jealous if their partner talked with other men, accusing her of unfaithfulness, not permitting her to meet with female friends, and trying to limit her contact with family, were associated with IPSV. Other studies elsewhere have reported an association between male partners' controlling behaviors and IPSV [12,13]. In the case of IPSV, women's empowerment as measured by the UDHS [8,9] and their socio-demographic characteristics  were not significant predictors of IPSV after adjusting for partners' controlling behaviors. It is apparent that IPSV would occur irrespective of women's empowerment or socio-demographic background, if their partners exhibit excessive controlling tendencies and alcohol consumption. Women's fear of their partners (which is most likely a result of partners' abusive behaviors) was associated with IPSV. Women who were afraid of their partners were less likely to say no to the sexual advances of their partners due to the threat of physical violence [20]. As noted earlier, their fear could also be a result of IPSV [19]. Excessive alcohol consumption (often getting drunk) remains a significant predictor of both intimate partner sexual and physical violence [20]. This finding has been reported in South Africa [12] and Rwanda [17].
In this paper, some of the predictors of IPSV varied from those of IPPV in other studies [12,13,18,20]. Significant predictors of IPPV, namely parity, wealth status, woman's occupation, experience of parental violence, and the partner insisting on knowing his wife's whereabouts did not have a significant relationship with IPSV. On the other hand, the significant predictors of IPSV in this paperthe partner being jealous if the woman talked with other men, and the partner trying to limit the woman's contact with her family -did not predict the occurrence of IPPV in another Ugandan study [20]. Our findings confirm that there are variations between predictors of IPSV and IPPV. The common predictors of IPPV and IPSV were accusing wives of unfaithfulness, not permitting women to meet female friends, getting drunk, and women's fear of their partners [20]. While witnessing parental physical violence was a significant predictor of IPPV [18,20], it did not predict the occurrence of IPSV. Although it is possible that witnessing parental IPSV could result in IPSV, the UDHS did not address this question (perhaps owing to its sensitivity).
None of the socio-demographic factors considered (age of the woman, age at first sex, type of union, level of education and region), were significant predictors of IPSV among women in a union Uganda. This is contrary to findings elsewhere in Africa [11,13,17]. While the duration of the union and women's control over their incomes were significant predictors of IPSV in Rwanda [17], this was not the case in Uganda. In addition, neither women's empowerment (including their participation in household decisionmaking, their attitudes towards wife beating, their control over their incomes, and their occupation) nor their household wealth status, were significant predictors of IPSV in the context of their partners' dysfunctional behaviors.

Conclusions
In Uganda, women's socio-economic and demographic backgrounds and empowerment had no mitigating effect on IPSV in the face of their partners' dysfunctional behaviours. Interventions addressing IPSV should target men, placing more emphasis on addressing the root causes of their controlling behavioral tendencies, and the prevention of problem drinking.