Physical violence against women remains a major public health challenge and human rights issue Devries et al., 2013. Globally, more than 35% of women experienced either intimate partner violence or non-partner physical violence García-Moreno et al., 2013. Physical violence against women is an important risk factor for women’s poor health resulting in a wide range of short and long-term health consequences, including the incidence of unintended pregnancies Jeyaseelan et al., 2007; Pallitto et al., 2013, increased risk of reproductive and sexually transmitted infections García-Moreno et al., 2013; Durevall and Lindskog, 2015 and mental health issues for the victim Skogstad et al., 2014; WHO, 2014. Physical violence also has a significant impact on the family of abused women Widom et al., 2014 and considerable negative externalities such as psychological stress even for those witnessing the violence Geffner, 2014; Schiff et al., 2014.

Although physical violence against women manifests as a worldwide public health concern, up to 70% of women in low- and middle-income countries WHO, 2005 and more than 45% in Africa compared to 32.7% in high-income countries WHO, 2013 experience physical violence. In the Gambia, more than 40% of women aged 15–49 years experienced physical violence in the past 12 months in 2013, of which 24% sustained injuries GBoS/ICF, 2014. Previous studies have indicated that injuries from physical violence against women are perpetrated by known persons including spouses and friends in the home, during the night Hofner et al., 2009; Tingne et al., 2014, injured by fist punching, leg kicking or struck by an object Wong et al., 2014, injury to the head, neck, face and the upper limbs Brennan et al., 2006.

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Despite several African countries have documented violence against women Andersson et al., 2007; Abramsky et al., 2011, they seldom use injured victims from physical violence to investigate risk factors for physical violence in women. Thus, identifying risk factors associated with injury from physical violence in women is essential to developing interventions aimed at preventing violence. Commonly identified risk factors for physical violence against women include younger age, low education Trinh et al., 2016; Ahmadi et al., 2017, unemployment status Jeyaseelan et al., 2007, financial dependence Fageeh, 2014, low economic status Doku and Asante, 2015, alcohol consumption Devries et al., 2014, being married Kouyoumdjian et al., 2013 divorced or separated Mohsen et al., 2017, in a polygamous marriage Ali et al., 2014, being previously victimized McCoy et al., 2013; Sapkota et al., 2016 and been abused during childhood or brought up by a single parent Chan, 2014.

While the above-mentioned studies investigated injury patterns and risk factors for physical violence against women; it may be difficult to infer those results into the Gambian context due to differences in socioeconomic, environmental and cultural factors. Accordingly, we conducted a case-control study to determine injury patterns and identify risk factors associated with physical violence among women in the Gambia.

2. Methods

2.1. Study settings and participants

From October 2016 through May 2017, we conducted a case-control study with study participants recruited from emergency rooms (ERs) and outpatient departments (OPDs) of government-managed healthcare facilities located in six districts. These districts are located within the two local urbanized administrative regions (West Coast Region and Kanifing Municipality), which accounts for 60% of the country’s population GBoS, 2013. A simple random sample of eight health facilities were selected to represent the different tiers of the healthcare system in The Gambia, which included one tertiary health facility (Serrekunda General Hospital), one district hospital (Brikama District Hospital), one major health centre (Faji Kunda), and five minor health centers (Gunjur, Bakau, Banjul’nding and Serrekunda). These health facilities treat a broad range of conditions including patients with all injury types. Private healthcare facilities were excluded from the study because they do not offer 24-h ER/OPD services to all patients.

Cases were female patients aged ?15 years who sought medical treatment for injuries from physical violence during the study period. An injury from physical violence was defined as any injury or physical pain that had been intentionally caused by another person Hirschinger et al., 2003. Controls comprised of female patients aged ?15 years who sought treatment for injuries from traffic crashes, falls, sports, and other non-violence causes and were matched to each case by health facility, date of injury from physical violence and age and. Patients were excluded from the study if they were unable to verbally communicate with data collectors, unable recall details of the violent incident due to injury, could not provide a written consent or were minors. In total, 194 case-control pairs met the inclusion criteria and were included in the analysis.

All participants provided written informed consent before participating in the study. The study protocol was reviewed and approved by the University of The Gambia Research and Publication Committee and The Gambia Government/Medical Research Council Joint Ethics Committee on human subjects’ research. The Ministry of Health Social Welfare also granted approval to conduct the study at each participating health facility.

2.2. Procedure

ERs/OPDs staff trained on the administration of the questionnaire, collected information on sociodemographics (e.g. age, height, weight, ethnicity, marital status, educational level, employment status, household income level and childhood upbringing), injury characteristics (e.g. date and time of injury, place of injury, mechanism of injury, nature of the injury, body part injured, severity of the injury and physical violence perpetrator), lifestyle behaviors in the past week (i.e. cigarette smoking, alcohol consumption, and illicit drug use), experience of verbal abuse, physical threats or physical abuse in the past 12 months, social supports, and risk-taking behaviors. 

To ensure data quality, twice weekly visits by the researchers (PB and ES) were made to study sites to collect completed questionnaires, check for accuracy, and to ensure adherence to the study protocol. Questionnaires were doubled checked, double entered and cleaned in Microsoft Access.

2.3. Measures

Injury severity was assessed using the Kampala Trauma Score II (KTSII) which was developed in 1996 by the Injury Control Centre-Uganda Owor and Kobusingye, 2001. The KTSII scores five parameters during the patient’s assessment: age (in years), respiratory rate, systolic blood pressure, neurologic status and score for serious injuries on admission. The scores are further categorized into three levels:  mild (9~10), moderate (7~8) and severe (?6) injuries. The KTSII has been validated and found to be a good measure of injury severity in most sub-Saharan African countries Weeks et al., 2014; Haac et al., 2015; Seid et al., 2015.

Social support was assessed using the 12-item Multidimensional Scale of Perceived Social Support (MSPSS) which measures the level of support that an individual perceives in three domains (family, friends, and significant others) Zimet et al., 1988. The MSPSS has been used in the USA and Africa populations and reported to have high reliability (alpha coefficients of 0.91~0.94) Canty-Mitchell and Zimet, 2000; Stewart et al., 2014.

The revised Domain-Specific Risk-Taking Scale (DOSPERT) was used to assess risk-taking behaviors which evaluate the likelihoods that respondents might engage in behaviors from six risk domains (i.e., Ethical, Gambling, Investing, Health/Safety, Recreational, and Social) Blais and Weber, 2006. The DOSPERT has been validated and used in a wide range of settings, populations, and cultures, including South Africa Szrek et al., 2012 which has similar demographic characteristics to The Gambia. Three domains of Health/Safety, Recreational, and Social were used in this study. A high score indicates greater risk-taking level for each of the three domains.

2.4. Statistical analysis

Injury patterns of case patients were presented as numbers with percentages. Distribution of sociodemographics, lifestyle behaviors in the past week, the experience of verbal abuse,  physical threats and physical abuse in the past 12 months, social supports, and risk-taking behaviors were compared between cases and controls using Pearson’s Chi-squared test for categorical variables and Student’s t-test for the continuous variables. To avoid large type II errors in variable selection and biased inferences, variables with a p-value of ?0.25 in the bivariate logistic analysis were included in the multivariable analysis Maldonado and Greenland, 1993. A forward stepwise conditional logistic regression was used to identify independent relationships of potential risk factors for injuries from physical violence in which adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were computed. Matching variables of health facility, date of physical violence and age were forced into the multivariable model, and variables with p-values of