Essay: INTIMATE PARTNER VIOLENCE, ANXIETY AND POST TRAUMATIC STRESS DISORDER AMONG WOMEN IN ETHIOPIA

1.1 Introduction
Violence against women is one of the main forms of violation of human rights to life and health.it is a public health problem not determined by any social class, ethnicity marital status, education, which requires effort from various sphere for prevention and intervention (Mariana de O.et al, 2015:855-64). In this chapter background of the research problem, aim of the study, significance, theoretical foundation, the research problem, statement of the problem research design and methodology scope, structure of the study and concept definition will be present.
1.2 Background of the research problem
Intimate Partner Violence (IPV) is characterized by acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors, perpetrated by current or previous partners (Secretaria Nacional, 2011).
IPV will have a broad range of consequence to the woman’s interims of physical and psychological perspectives which include Sexual transmitted diseases, reproductive health related issues, depression, post-traumatic stress disorders, maternal death amnesia, suicidal attempt and stress(Eaton LA.et al, 2012 :208-16).
In Kenya, women’s were exposed to IPV at a significant level, which is a woman who exposed for emotional violence (24%), physical violence (38%) and reproductive consequence as a result of IPV (Eaton LA.et al, 2012:208-16).
Study finding in Madrid reveals that unperceived intimate partner violence is 2.6 times more frequent than perceived intimate partner violence and displayed a higher prevalence of PHQ-rated anxiety disorder (28.3-34.4%) (Michela S. et al, 2013:440-446).
According to the longitudinal study done on IPV on woman shows that depression, suicide, substance abuse, anxiety, low self-esteem, low self-efficacy, or poor assertiveness) associated with IPV, victims’ self-esteem, coping, personal control, empowerment, perceived safety or fear, anxiety, stress, social support/isolation(Carri Casteel and Laura Sadowski, 2010:1013).
Women whom experienced 3 or more times of GBV will increase the rate of mental disorder by 77.3% OR (10.06:95CI, (5.85-17.30), anxiety disorder 52.5% (OR, 3.59; 95% CI, 2.31-5.60), 56.2% (OR, 15.90; 95% CI, 8.32-30.20) for PTSD, 89.4% (OR, 11.00; 95% CI, 5.46-22.17) for any mental disorder(Rees S. et al, 2011:513-21). High levels of symptoms of perinatal depression, anxiety, and PTSD are significantly associated with having experienced domestic violence (Howard LM, et al, 2013: 1001452).
Women’s exposed to gender-based violence experienced mental health problem nearly two-fifths (37%) of any lifetime mental disturbance had onset in the year following women exposed to abuse (Rees S. et al, 2014:312).
1.3 The research problem
1.3.1 Source of the research problem
As a health professional, I was working within refugee community in Ethiopia .Moreover, for the past 5 years, I was working in a general hospital mental health unit for free service. While I work in the OPD I encountered a lot of women in the reproductive age comes with a different form of mental illness and at the same time. Currently, Ethiopia has a policy on violence against women but studied findings in Ethiopia shows that Violence towards women is prevalent.
Recently, there has been an increasing focus on IPV in sub-Saharan Africa, likely related to a greater interest in human rights issues, as well as a greater understanding of the individual and societal consequences of violence (Shahrzad Bazargan-Hejazia,et al, 2013: 38-50).
Worldwide studies show that IPV is the prevalent problem i.e. Leon, Nicaragua (27%), Republic of Korea (38%), and Palestinian women in the West Bank and Gaza Strip (52%) were affected by their Intimate partner violence (Feseha et al, 2012:125).
In Ethiopia, ever time physical and sexual violence is 70.9% and current violence is 53.7 %( Garcia-Moreno et al.:2005).Thus beyond the above assumption the researcher interested in investigating Intimate partner violence and its psychological consequence in terms of anxiety depression and posttraumatic disorder experience among women in the reproductive age groups. This will help to develop a strategy to address the need of women’s.
1.3.2. Background to the problem
1.4. Statement of the problem
To show knowledge gap in the particular topic area, formulate a research problem is the scientific approach in research (Burns & Grove 2005:70). Based on the statement of the problem the researcher show gaps, situation and significance of the study phenomenon (LoBiondo-Wood & Haber 2002:52), (Polit & Beck 2004:85).
According to 2013 World health organization (WHO) report, one in three women worldwide ever experiences physical or sexual violence by their intimate partner. (WHO: 2013).Worldwide, 20 to 50 % women experience domestic violence worldwide (UNICEF&WHO, 2014). Globally intimate partner violence is a huge proportion of problem. WHO estimates that 10-50% of women experience physical and sexual violence some point in their life (Nina B. Hansen et al: 2014, 5: 24797). Violence is a global public health problem which affects the health and well-being of women with an adverse effect of mental outcomes (Claudia G. et al: 2014). Common mental disorder compromise 90% of all psychiatric disorder most often symptom of depression, anxiety and somatic complaints, it is not well studied and addressed through research in regarding intimate partners violence (Reichenheim et al., 2014, 14:427)
Intimate partner violence against women is high in different parts of Ethiopia. Community-based studies showed that more than half (50.5 %, 78 %, 72 %, 64.7 %) of women experienced domestic violence (includes physical, sexual and psychological), respectively (Semahegn and Mengistie, 2015:78). The lifetime physical violence by the husband or intimate partner against women or wives ranged from 31 to 76.5 % in different parts of Ethiopia (Semahegn and Mengistie, 2015:78). Domestic violence against women results in physical, sexual, mental harm or suffering to women, including threats, coercion or arbitrary deprivation of liberty occurring in public or in private life (WHO, 2014:239).
Husband alcohol consumption, Khat chewing, family history of violence, partner education, lower educational status, decision-making power, residence (being rural, age<18 at first sex or marriage (Semahegn and Mengistie, 2015:78) is the risk factor for intimate partner violence. IPV contributed considerably to mental disorders. Thus, prevention of IPV should be considered as a public health priority, as its prevention would considerably reduce the prevalence of mental disorders (Umubyeyi et al, 2014:315).
Due to the fact that, Ethiopia government revises the family law in 2000 and criminal law in 2005 to protect women right. Ethiopia ratified the convention on the elimination of all forms of discrimination against women in 1981(Central Statistical Agency Ethiopia and ORC Macro, 2012), Africa for women right ratify and respect, 2014).Nevertheless, there is a high magnitude of domestic violence in Ethiopia. Moreover, there is little known about country wide evidence regarding intimate partner violence effect in psychological outcome against women in Ethiopia. Thus, this study will find out the status of intimate partner violence and its mental health effects. This deepens understanding of the situation will help to develop a strategy to the government policy on gender-based violence prevention and intervention program including provision of mental health service to the victims.
1.5. Aim of the study
1.5.1 Research purpose
Statement of the problems is the basis to develop the purpose of the study which helps to show the aims of the study (LoBiondo-Wood & Haber 2002:60; Burns & Grove 2005:36, 71). The purpose of this study was to give deep understanding on Intimate partner violence and its mental health effects interims of anxiety and post-traumatic stress disorder among woman in their reproductive age in rural Gamo Gofa Zone, Ethiopia. Additionally, the study contributes to design intervention strategy to address mental health needs of women.
1.5.2 Research objectives
At the end of the study, the researcher will be achieved is called specific objectives (Polit & Hungler 2004:65; Babbie 2007:114). Objectives formulate from the statement of the problem and clearly indicate the variables under investigations and the population in the study and also it must be write in present tense (Burns & Grove 2005:156). Based on the above assumption the specific objective of the current study is:
o Determine the magnitude of Intimate partner violence in the forms of physical, sexual, and emotional violence against women.
o To determine protective and risk factors which put women’s at risk for intimate partner violence.
o Determine mental health service practice by women’s after exposed to intimate partner violence.
o Effect of intimate partner violence on the outcome of anxiety and posttraumatic stress disorder.
o Develop practical intervention strategy to provide mental health service.
1.5.3 Research questions
In qualitative studies, research questions give an opportunity to the researcher to identify study variables, the relationship between the variables and the study population which the study will be undertaken (Polit & Hungler 2004:65).a formulating research question is part of the research process . Statement of the problem is the basis for formulating research question to fill knowledge gaps in the study topics (LoBiondo-Wood & Haber 2002:499), (Rubin & Babbie 2007:22).The study will answer the following question in order to address the problems.
 What are the extent and frequency of different forms of intimate partner violence among women in the age of 15-49 in the study setting?
 Are there any factors leads to intimate partner violence? What factors protect women’s from intimate partner violence?
 Does IPV have an effect on the development of anxiety and post-traumatic disorder?
 Does IPV lead to the development of anxiety and posttraumatic stress disorder?
 Does women’s go to the hospital to get mental health counseling?
 What strategy will address the mental health need of women’s in the study area?
1.6 significance of the study
The finding of the study will be used to make a recommendation for developing a strategy to address how to prevent IPV and how to provide mental health service to the women who suffer from the violence. This study will advance the situation that, the gender office of the government and non-government al origination to give emphasis on the problem of violence rooted by women partner. The finding also helps to develop training in order to address the mental health needs of women. The finding will be used for advocating behavioral change programs in the communities by emphasizing the effect of intimate partner violence on the mother, children, and the family as a whole. The finding also helps as supporting document for advocacy for the target group at national, regional and global levels for improving access to quality health and supportive services to promote women’s health in Ethiopia.
1.7 Theoretical foundation of the study
The study guided by a theoretical framework to organize the study. The theoretic lenses help the research finding to be scientific and guides literature review, data collection, and analysis. The epistemological approach and theoretical assumptions must be recognized by the researcher to use the evidence by others (Constance Sibongile Shumba: 2015:7).
1.7.1 Research paradigms
The prevalence study can be addressed through by positivistic approach (Ellsberg M, 2005:24) & (Creswell 2013:7) and can be determined by quantitative methodologies.
1.7.2 Theoretical grounding
on Violence against women, Positivistic Inquiry generally starts with a hypothesis and proceeds to test it in a systematic and linear way which is a good paradigm (Ellsberg M, 2005:50& Babbie & Mouton 2001:20 & Constance Sibongile Shumba: 2015:10). The positivist inquiry starts hypothesis that social and natural phenomenon are the same (Babbie & Mouton 2001:21; Creswell 2013:7).The positivist approach used tend to use quantitative methods and involve in the hypothesis testing (Ellsberg M, 2005:51). Positivism inquiry believe based science based or deductive inquiry and quantified the problem exist by using the quantitative research methodologies(Mouton 2001:21) and Ellsberg M, 2005:51),which allow for quantitative survey (Creswell 2013:7) to assess the magnitude of different form of intimate partner violence and the associated variables. The study aimed that to measure objectively about the magnitude of the problem (De Vos et al 2001:241) through the quantitative survey. The study will also depend on based on the feminist theoretical view by assessing the power difference will contribute for determining women’s health (Casselman 2008:72)
1.7.3 Conceptual framework
Ecological model is the preferred model to understand the circumstances, risk and protecting factors that affect IPV against women (Ellsberg M, 2005:24, Heise L., 1998: 262-290 ), (WHO: 2010:26) and Constance Sibongile Shumba: 2015:10). Building ecological model allows the researcher to see protective and risk factors from multiple dimension (WHO, 2010:26) and also shows ways for prevention and intervention of measures to protect women from violence (Dahlberg & Krug, 2002). The main approach of ecological model is, it indicate the interaction of risk factors within and between different levels and gives the opportunity to develop prevention policies and strategies cross-sectorial (WHO: 2010-26).
The ecological model combines each level of the factors and addresses the factors to the level of violence in different studies with different cultures to show why men violence on their partners, and also show the protecting and prevention strategies on women violence by their counterparts (Ellsberg M: 2005: 24).
Fig.1 Adopted ecological framework for explaining intimate partner violence (Heise, 1998)
To understand and develop knowledge on the variable under investigation, conceptual framework is a crucial part of the research work (LoBiondo-Wood & Haber 2002:490; Polit & Beck 2004:116; Burns & Grove 2005:128; Miles & Huberman 1994:18). The conceptual framework shows the relationship and the complexity of the variable under investigation.
The current conceptual framework by considering the ecological model(Heise L ;1998 ) from the viewpoint of IPV at the four level of interaction and adapted based on the WHO research guide for VAW (Ellsberg M, 2005:218).
A defined and concept about a phenomenon will develop a theory (Burns & Grove 2005:9; LoBiondo-Wood & Haber 2002:109; Polit & Hungler 2004:114).This can be developed from the abstract thought process, finding and lived experiences findings and lived experiences (Burns & Grove 2005:9). To develop a hypothesis, there is a need of theory which later converted to a hypothesis. The current study develops a conceptual framework from the ecological model (Heise 1998:265).After the research read and understand about IPV and its mental health impacts towards women and the conceptual framework developed to define IPV and its correlates as well as its outcomes. Conceptual frameworks give the images of the variables under investigation as in the form of dependent and independent variables. In the current study, intimate partner violence considered as a dependent variable.
Figure 2: Adapted conceptual framework understanding risks and impact of intimate partner violence (Ellsberg M, and Heise L. 2005).
1.8. Research design and methodology
Study area
The study will be conducted in GamoGofa zone, Arba Minch University DHS site, in Arba Minch Zuria woreda, South Ethiopia. It will be conducted among women of childbearing age group .Arbaminch Zuria woreda is one of the nearest woredas in Gamo Gofa Zone, located in the Southern Nations, Nationalities and Peoples Regional State in Ethiopia.
Gamo Gofa is a Zone in the Ethiopian Southern Nations, Nationalities, and Peoples’ Region (SNNPR). The administrative center of Gamo Gofa is Arba Minch. Gamo Gofa is bordered on the south by the Dirashe special woreda, on the southwest by Debub (South) Omo and the Basketo special woreda, on the northwest by Konta special woreda, on the north by Dawro and Wolayita, on the northeast by the Lake Abaya which separates it from the Oromia Region, and on the southeast by the Amaro special woreda. Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia (CSA), this Zone has a total population of 1,593,104, of whom 793,322 are men and 799,782 women; with an area of 18,010.99 square kilometers.
This study will be conducted in line with the framework of GamoGofa Zone health program. GGRHP was established in 2009 to develop continuous demographic and health surveillance system and to provide baseline population and sample frame. The program mainly run by Arba Minch University College of medicine and health science in collaboration with Ethiopian public health association.
Study design
Methodology means a framework of theories and principles on which methods and procedures are based (Holloway, 2005:293). Method refers to a way of obtaining, organizing and analyzing data (Polit and Hungler 2004:233).
According to WHO multicountry study, WHO VAW study, a study conducted against violence in women recommend to use both qualitative and quantitative study design in order to make reliable the finding(García-moreno n.d.2005:9,) Ellsberg M, and Heise L. 2005).
The study will apply both qualitative and quantitative research design through the sense of triangulating the quantitative finding by a qualitative study. The quantitative part will use cross-sectional and prospective study methods. The cross-sectional study design will be used since the study was quantitative study methods (Creswell 2013:234).The study will answer research questions regarding IPV through creating an understanding of women experience(Wisdom, Cavaleri, Onwuegbuzie & Green, 2012:723) and involves in two phases which are the quantitative phase and strategy formulation.
1.8.1. Quantitative phase
A quantitative cross-sectional population-based descriptive survey will be conducted for the study I, II and III. The study conducted in VAW by IPV at large (Ellsberg M, and Heise L. 2005:57) needs to apply at the community level. Cross-sectional studies provide a picture of a phenomenon for a specific period of time Ellsberg M, and Heise L. 2005:63).The quantitative phase will aim to describe and examining the relationship of the variable ((Burns & Grove 2005:71; Polit & Beck 2006:189; Creswell 2013:234).
The longitudinal study is the most common public health research design for collecting longitudinal data (Ellsberg M, and Heise L. 2005:65). The prospective study is will be used to determine the effect of violence on women mental health. Study IV will be assessed through prospective controlled cohort study to assess the effect of Intimate partner violence on anxiety and PTSD outcome of the women. At the time of the first study, once the case of anxiety &PTSD excluded, the remaining sample will be considered for Prospective cohort study .i.e. equally assigned the individuals for exposure to IPV and none exposed for non-Intimate partner violence. After the participant assigned for a cohort study, the researcher decides to follow the participant for two-phase due to financial constraints. There will be follow up at the first month after they recruit to the study and at a 6month period. During the cohort study, any violence will be assessed from none exposed group to avoid bias and if there is violence during the follow-up time, the non-exposed group will be excluded from the study. Further, any biological predisposing factors and previous history anxiety will be considered in the study.
1.8.2. Qualitative phase
The quantitative finding doesn’t give experience through word rather it gives in terms of measurement, statics and numerical measurement. Qualitative research is a systematic, subjective approach used to describe life experiences and give them meaning (Burns & Grove 2003:356; Morse & Field 1996:1999).
Qualitative data are available to support the interpretation of the quantitative findings in the study I, II&III. Triangulation of the finding will help the study to increase the validity and trustworthiness of the finding. It will include an interview with the key informant and survivor of Intimate partner violence. Key informant interview will be included governmental organization and none governmental organization which work on the issue of women needs associated with gender-based violence.
To understand the experience of violence, the way they respond, and how the survivor addresses their psychological need will be triangulated by interviewing the survivor in addition to the quantitative finding. Therefore, Ever married and who lived with the husband will be included in the sample of the study and at least 6 survivors will be included in the study. The in-depth interview will be prepared on the protective and risk factors of violence, the practice of mental health seeking behavior and general perception regarding intimate partner violence. The participant will be selecting through snowball sampling technique.
Target Population
The target population is defined as the population of interest to which the researcher would generalize the findings of their study and from which a representative sample is drawn. The study population is the subset of the population included in the sample and the actual group in which the study is conducted (Fletcher, 2014:6).
All women living in the GamoGofa demographic health survey area will be the overall source population.
Study population
All women who live in the study area with the age of 15-49 years and who are married and currently live with her husband will be study population of the study.
Inclusion criteria of the study
The study will be used an extended operational definition of the household in order to avoid participant bias. In the current study, a woman will be considered eligible for the study if she fulfilled one of the following conditions which are, if she will be aged between 15 and 49 years, ever married and currently live with her husband, If she will be normally lived in the household; If she will be a domestic servant who slept for five nights a week or more in the household and if she will be a visitor and she will be slept in the household for at least the past 4 weeks preceding the interview. The study will consider women whom work outside will be considered for the study to keep the reliability of the data. Revisited schedule will be arranged if the participant absent during data collection day i.e. not skip for the absence.
Sample size determination
Sampling is defined as the process of selecting study units from a defined study population. Sampling is important to minimize the cost of the study, make the study feasible, and improve the quality of data (Fletcher, 2014:6).
Sample size for descriptive cross- sectional survey will be determined by the assumption that current intimate partner violence is 53.7(Garcia-Moreno et al.:2005) with 5% marginal error and 95% CI. Furthermore, adding 10% of non-response rate. Based on the above assumption, the actual sample size for the study will be determined using the formula for a single population proportion.
n = (Z α ⁄2)2 p q
d2
Where n = Sample size, Zα ⁄2= Z value corresponding to a 95% level of significance = 1.96
p = expected proportion of current intimate partner violence is 53.7(Garcia-Moreno et al.:2005) =0.54
q = (1 – p) = (1-0.5) = 0.5, d = absolute precision (5%), none response rate =10%
The sample size will be 415 and by considering the non-response rate of 5% the final. The sample size for the prospective cohort study will be determined after the cross-sectional study will be conducted. The sample size for the qualitative in-depth interview will be drawn from selected keble.
Sampling procedure
In this study, the researcher will use a simple random sampling method to select the sample from the sample frame based on the eligibility criteria by lottery method.
Using sample frame from the list can be selecting all women who are ever married and currently lived with the partner with the age of 18-49 years through simple random sampling.
The database for each Keble was obtained from the Gamo Gofa DHS database from the focal site of Arbaminch University ,college of medicine and health science .Thus, women’s name, unique identity number, including a household number as a sampling frame. List of women from the database will be refined and reconciled by enumerators of the database to create a list of eligible women. Since 85% of the population resides in rural areas, the same proportion of the sample was taken from rural Keble. In order to keep the number of women equally distributed in each clustered Keble, women will be recruit in proportion to population size. After clustering eligible women according to their residence, women will be selected by simple random sampling using SPSS for windows software of the 11 clusters separately.
For the qualitative study, a purposive sampling technique will be employed to select adolescents to take part in the study. For prospective cohort study, the participant will be considered all women who satisfy the inclusion criteria and who didn’t develop anxiety and posttraumatic disorder.
Data collection Instrument
The quantitative aspect of the study will be undertaken by using WHO’s instrument for the Violence against women(VAW) study tool and Composite International Diagnostic Interview (CIDI Version 2.1) tool. WHO VAW tool is the widely used instrument to assess violence against women and it is a comprehensive instrument which addresses multiple factors associated with violence and validated and used in Ethiopia(Ellsberg M, and Heise L. 2005:100&(García-moreno;2005:174) .The Composite International Diagnostic Interview (CIDI Version 2.1) question associated to anxiety and Posttraumatic stress disorder(PTSD) symptoms with the International Classification of Disease (ICD-10) algorithms to screen for specific mental illnesses will be used to assess anxiety and PTSD .The CIDI tool is validated in Ethiopia (García-moreno;2005:174) and the combined domestic violence and mental health tool will be used in the study. In the question organization, the first part will be an IPV-related question and the second part will be anxiety and PTSD screening question. Additionally, some variable will be added to address the research question (Ellsberg M, and Heise L. 2005:116). For qualitative data collection, semi- structured questions will be used to probe the participants to give responses. Field notes will be taken and interviews will be recorded with an audio tape recorder at the permission of the respondents. Data collector who qualified as a diploma in Nursing with previous data collection experience will be recruited as a data collector. Training will be given on the data collection, interview skills and procedures. Data will be collected after pre-test conducted outside the study area.
Validity and reliability of the study
The quality of scientific research and the instruments used determined by their validity and reliability. In this specific research, the research will strictly follow the principles of both reliability and validity.
Reliability of the study
Reliability is the degree of consistency with which the instrument measures the attribute it is designed to measure. Reliable study instrument or tool produced the same value each time when it used repeatedly (Fletcher, 2014:34). To ensure the reliability in the study, the researcher will be adopted and plan to use WHO’s instrument for the Violence against women (VAW) study tool and Composite International Diagnostic Interview (CIDI Version 2.1) tool is used previously in Ethiopia. The questioner will be pretested and training will be given on the tool for the data collector.
Validity of the study
Validity describes an instrument’s ability to measure what it sets out to measure. Validity also refers to the extent to which data collected actually reflects the truth and this can be internally or externally. Internal validity refers to the degree to which results of a study are correct for the population being studied. External validity is the degree to which the results of the study can be held true in other settings.
The researcher will ensure validity by maintaining a high level of accuracy and precision in the measurements. The researcher will further develop consistency in administering the questionnaire to ensure accuracy.
Good qualitative research is anchored on rigor, which is so set to ensure that findings from a particular study are accurate from the perspectives of the reader, the participants and the study researcher (Cresswell 2013:202). The table below summarizes the steps that will be taken to ensure scientific rigor.
Construct Strategy Application
Credibility Prolonged engagement and persistent observation in the field
The researcher will spend enough time with participants on site
Explain the process of data collection to the participants detail
Provide responses to all questions and concerns of the participants
The aim and objectives of the research will be explained to the participants.
Triangulation
The data collection process will involve field note, audio-record and observation during discussion
Dependability Step-wise replication of the research methods The researcher will provide detail description of the process used to the process and reason of selection of participants, process and length of data collection procedure, data analysis and presentation
Code-recording of data Audio-recorded interviews and field notes will be kept in safe place
Dependability audit The research methods and protocol will be evaluated by the supervisory team. by supervisor and co-supervisor
Confirmability The researcher will remain faithful to academic and ethical requirement
The researcher will keep field notes, audiotape record in safe place even after the publication of the research
Transferability Purposeful sampling The participants will be selected by snowball method
Triangulation Use more than one methods of data collection and recording methods
Conduct in-depth analysis of interview transcripts
DATA MANAGEMENT AND ANALYSIS
The data analysis will be conducted by using SPSS version 23 windows. Individual women will be considered as unit analysis. Before conducting data analysis, the researcher will check and clean the data matrices by using frequency and graph to check the distribution of variables and cross tabulation to check data inconsistency (Persson and Wall, 2003).By looking the data matrix and cross tabulation, the researcher will check about any missing data, miscoded and missing value during data entry in the key variable and checked from the original questioner. By using a histogram, bar graph and pie chart variable distribution will be measured by frequency of observation in each category. Prevalence of IPV among abused women will be measured through percentage among women who experienced violence during the last 12 month period.
Chi-square (X2), odd ratio, relative risk test will be applied in the quantitative study. Confounding variables which misleading the impression factors of violence (Persson LÅ, Wall S., 2003). Common socio-demographic factors will be considered as possible confounders if they will be significantly associated with the outcome variable and included in a model of the multivariate analysis. Therefore, the study will use stratified and multivariate analysis to control the effect of confounding variables. Statistical significance will be considered when P-value <0.05.Furthermore, thematic analysis will be considered for the qualitative part of the data. For qualitative data, thematic analysis (Polit & Beck 2012:562) will be applied to analyses the data. The interventional strategy will be develop based on the finding of the research output.
Ethical consideration
Although no known risks associated with the conduct of the study, the researcher shall observe and be guided by ethical principles outlined in Polit & Beck 2012: throughout the conduct of the study. To ensure the right of participants and protect them from harm the researcher will comply with the ethical principle of world medical association declaration of Helsinki (WMADH, 2008) to protect the life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of personal information of research subjects. World health organization develop ethical and safety guidelines for research on gender-based violence (Ellsberg M, and Heise L.2005; 36) to protect the safety of the respondent, the researcher and the data quality. The participants treated equally, share benefit and burden and the inclusion and exclusion criteria will be predetermined in a representative manner.
The researcher will prepare and give pamphlet to all women participate in the study which contains service information referral for care and support (Ellsberg M, and Heise L.:2005; 36) and all women were offered the pamphlet after being asked if it would be safe for them to receive it (cases have been reported where women have been beaten when a partner found informational material addressing violence). As the research conducted in the rural area there might be lack of facility to address the mental health need of women, thus, the researcher will recruit psychologist to work along with the research team and manage the cases in the nearby health center (Gossaye Y, Deyessa N, Berhane Y, et al, 2003; 1-49).
The researcher will plan to minimize the risk towards field staff. The following will be considered to minimize risks in the field staff which are, avoiding the dangerous area at the stage of the sampling process, all data collector will have a cell phone, joining male driver with female data collectors in the area of dangerous areas. In the middle of an interview if a male partner comes at household, and if he creates quarrel with data collectors based on the training given regarding data collection, there will be use mixed questioner or use dummy questions (Jewkes R, Watts C, Abrahams N, Penn-Kekana L,Garcia-Moreno C. 2000;93-103).
Study participant in nonjudgmental approach (Ellsberg M, and Heise L.:2005) in order to get quality data. In none nonjudgmental technique, telling a story also helps the study subjects get relief from here emotional state i.e. the interview by itself therapy (Ellsberg M, and Heise L.:2005). A study conducted in violence against women(VAW) needs to be scientifically sound (CIOMS :2002).The current study has adequate sample size, statement of the problems which depends on the current knowledge of the problem to expand, sampling procedure ,design , the disseminatemanner of questions, training of interviewer( Ellsberg M, Heise L, Peña R, Agurto S, Winkvist A. 2001;1-16). The study fidisseminatesfor ongoing advocacy, policy making, and intervention activities for intervene IPV against women and to minimize the effect of Intimate partner violence on women mental health.
The study will reflect the principle of autonomy and protection of vulnerability. The researcher team will inform the study participants about the purpose of the research and will get voluntary based informed consent.
Consensus on whether the informed consent process for violence against women studies should explicitly acknowledge(Ellsberg M, and Heise L.:2005;36) the study will include questions on violence or whether it is sufficient to warn participants that sensitive topics will be raised. The study also guarantees the participant to end the interview or skip any question that they don’t want to answer. Before starting an interview, a detail explanation will be given to the study participant and basically, non-sensitive question will be structured at the first section of the instrument (Ellsberg M, and Heise L.:2005:36). During data collection, if necessary and the study subject request support, the researcher will report any suspected case of abuse to the authorized body or to service (Ellsberg M, and Heise L.:2005; 36).
A community leader will be contacted to explain the overall objective of the research in the study area (Ellsberg M, and Heise L.:2005). This will help the researcher to get the research participant, for the safety of the participant and to prevent the tendency of men banned their wife not to join in the study.
A more detailed explanation of the nature of the questions on violence was provided directly before the violence questions, and respondents were asked whether they wanted to continue and were again reminded of their option not to answer. It is a good idea to prepare a list of responses for questions that a woman might ask about the study, such as how she was selected for the study, what will the study be used for, and how her responses will be kept secret.
The study will ensure the safety of the study participant by interviewing only the study participant in the household. Interviewing only one woman per household (to avoid alerting other women who may communicate the nature of the study back to potential abusers and not informing the wider community that the survey includes questions on violence (Ellsberg M, and Heise L.:2005; 36).The privacy of the study participant will be kept confidentially and when in a case privacy difficult to be insured, the felid data collector must postpone to other time.
WHO recommend that research conducted on violence must be kept in complete privacy ((Ellsberg M, and Heise L.:2005; 36). If somebody entered into the interview room, use dummy question which are non-violence related questions to keep the privacy of the study subjects. Training will be given to the data collector in order to how to handle the emotional state of the study participant because some question has a potential to create and provoke emotional distress (Ellsberg M, and Heise L.; 2005;36).
During dissemination activity, the respondent will not be identified. Furthermore, at the end of the interview, the interviewer will end up with a constructive note that shows the respondent strength and capacities to address their own problems. After transcription of the interviewing data, it will be erased to minimize the risk of the data might be out by others.
1.11 Definition of concepts
A conceptual framework is important to direct attention towards specific conditions and help to concentrate on the relationships of specific variables (Giday, Aseffa & Kidanemariam, 2014:4-5). In this research, the magnitude of intimate partner violence , anxiety and Posttraumatic stress disorder will be assessed then intervention strategy will be developed to address the effect of violence on women.
The key concept in this study is intimate partner violence, physical violence, sexual violence, psychological violence, anxiety, and post-traumatic stress disorder.
Intimate partner violence (IPV) is a form of violence against women. IPV defines as any behavior within an intimate relationship cause physical, psychological or sexual harm to women (Constance Sibongile Zumba: 2015:15).violence can be seen from the perspective of physical, psychological and sexual deprivation. The study focused on violence inflicted by male partners of women.
Physical violence is violence occur by intimate partner and a minimum list of acts of physical violence consists of the following which are slapping her, throwing something at her that could hurt, pushing or shoving or pulling her hair, hitting her with something, hitting her with fists or other objects, kicking, biting or dragging her, beating her, choking or burning her, threating her with a knife, gun or other weapon, using a knife, gun or other weapon against her and throwing stone(United Nation, 2014; 15).
Sexual violence is any sort of harmful or unwanted sexual behavior that is imposed on someone. It includes acts of abusive sexual contact, forced engagement in sexual acts, attempted or completed sexual acts with a woman without her consent, sexual harassment, verbal abuse, threats, exposure, unwanted touching, incest(United Nation, 2014; 16).
Psychological violence includes a range of behaviors that encompass acts of emotional abuse and controlling behavior (United Nation, 2014; 16). Which are.
Emotional abuse:
– Insulting her or making her feel bad about herself
– Belittling or humiliating her in front of other people
– Deliberately scaring or intimidating her
– Threatening to hurt her or others she cares about.
Controlling behavior:
– Isolating her by preventing her from seeing family or friends
– Monitoring her whereabouts and social interactions
– Ignoring her or treating her indifferently
– Getting angry if she speaks with other men
– Making unwarranted accusations of infidelity
– Controlling her access to health care
– Controlling her access to education or the labor market. Psychological violence needs to be limited to violence in the past 12 month period and recommended to be limited to psychological violence perpetuated by current or past intimate partner violence.
Operational definition
Having physical violence considered , if women experienced at least one act of the five violent acts including; being slapped, shoved, hit with a fist or something, beaten or kicked, being chocked or burnt and threatened using knife or gun(Garcia-Moreno et al. 2006; Gossaye et al. 2003b).(Dear professor this part will be further reorganized i.e. not complete)