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Spousal violence and its determinants among married adolescent girls in Upper Egypt

Spousal violence and its determinants among married adolescent girls in Upper Egypt Introduction: In Egypt, many girls are still married before the age of 18, which is a fundamental violation of the girls’ human rights. Early marriage is associated with an alarmingly elevated risk of all types of intimate partner violence that have various negative consequences. The purpose of this study was to identify the predictors of exposure to spousal violence among the early married girls in rural Upper Egypt. Methods: A household survey was carried out and covered 23 villages in Assiut and Sohag governorates reaching to a sample of 729 married girls before the age of 20. Listing and enumeration of 4 districts was done to identify the study participants. Data was collected by personal interviews using a structured questionnaire. Bivariate and stepwise regression analyses were performed to identify the predictors of exposure to spousal violence. Results: It was found that 15.2% of the study participants were exposed to physical violence while 17.8% were exposed to sexual violence and 7.3% were exposed to both types. Girls married before the age of 18 were more exposed to spousal violence. Stepwise regression analysis found that girls’ acceptance to get married was a protective factor against exposure to physical (β = − 1.07, OR 0.34) and sexual (β = − 0.68, OR 0.51) violence. The perceived attitude of husbands and mothers-in-law about considering wife beating “a husband's right” was found to be a risk factor of exposure to physical and sexual violence. Longer duration till the first pregnancy was also associated with more exposure to sexual violence (β = 0.04, OR 1.04). Conclusion: Married adolescent girls (MAGs) are highly exposed to physical and sexual violence. This is mainly due to ignoring girls’ preference to postpone their marriage, cultural concepts of accepting violence against women, and low sexual satisfaction. This study shows that most determinants of spousal violence were related to culture issues. Identifying these determinants is required to combat such a crucial public health problem that has serious consequences on adolescent health. Keywords: Spousal violence, Upper Egypt, Early marriage, Married adolescent girls 1 Introduction The 2014 Survey of Young People in Egypt (SYPE) re- In Egypt, despite the legislation of the Child Law of 2008 vealed that 1.7% of married female youth aged 25–29 in which sets the minimum age of marriage at 18 years for 2014 had been married before age 15, 4.2% before age females and males, many girls are still married before 16, and 21.1% before age 18 which is the legal age of the age of 18, which is a fundamental violation of the marriage in Egypt. Moreover, child marriage remains to girls’ human rights [1]. be common in some parts of the country; 33.3% of mar- ried female youth aged 25–29 residing in rural Upper Egypt were married before age 18, compared to just * Correspondence: amirafathy@aun.edu.eg; elgazzar44@yahoo.com below 10% of those in the Urban Governorates and Public Health & Community Medicine, Faculty of Medicine, Assiut University, urban Lower Egypt [2]. Assiut 71515, Arab Republic of Egypt © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 2 of 9 Early marriage has been associated with withdrawal collection were invited to participate in the study. Enu- from school and low opportunity for employment and so- meration of all households in the selected communities cial mobility [3, 4]. Hence, those girls usually enter mar- and listing married inhabitants of these households were riage with low levels of education and limited knowledge conducted by a trained team to identify the households and skills needed to negotiate adult marital roles [5]. with at least one MAG. The team was escorted by com- Furthermore, evidence suggests that early marriage is munity outreach workers to facilitate their entry into the associated with an elevated risk of intimate partner vio- houses and alleviate the tension of the locals. The heads lence [6–8]. The 2014 Egypt Demographic and Health of the households were approached by the members of Survey (EDHS) showed that one in four married ado- the enumeration and listing team asking them to list all lescent girls (MAGs) in Egypt (15–19 years) was ever married women in the household together with their exposed to some form of spousal violence while 5.5% ages and duration of marriage and data was validated were exposed to sexual violence [9]. A qualitative using the identity cards of the listed married women. study among MAGs in three villages in Assiut re- The listing process yielded only 730 MAGs, who were vealed the presence of poor husband-wife communi- all included in the study rather than applying random cation, especially on matters related to achieving selection. The interviews were conducted at a quiet sexual satisfaction, thus leading to physical and sexual area at the MAG’s house or a place of her choice (e.g., violence [10]. Moreover, a study in Iran has shown health center) and lasted for about 1 h. Field training of that spousal violence was significantly associated with data collectors involved pilot testing of the instrument low income, women age ≤ 20 years, unemployment, among 20 MAGs in two villages that were not selected low education, being non-pregnant and non-house for the study. owners, and rural residence [11]. Spousal violence is a major public health concern, 2.3 Questionnaire since it is documented to be associated with poor health All the study participants were interviewed using a outcomes including injuries, sexual/reproductive health structured questionnaire divided into sections cover- problems, anxiety, and depression [12]. ing all the variables that we hypothesized to be associ- While rural Upper Egypt has the highest levels of ated with exposure to spousal violence. The first section spousal violence [9], little is known about its predictors. of the questionnaire detailed the socio-demographic The current study was designed and implemented to characteristics. The second section assessed the practices measure the extent of MAGs’ exposure to physical and related to asking the girls’ opinion before marriage, pre- sexual violence in rural Upper Egypt and identify more marital counseling, marital sexual relation, pregnancy, and precisely the predictors of such exposure. Results of the delivery. The third section explored the social support to study would help the policy makers to design evidence- the MAGs by their husbands and mothers-in-law including based interventions and programs to ameliorate the her social mobility and participation in decision-making as negative effects of early marriage on their health and well as the attitudes of husbands and mothers-in-law about that of their children. violence as reported by the MAGs. The fourth section dis- cussed the exposure of MAGs to physical and sexual vio- 2 Methodology lence in the year preceding data collection. 2.1 Study design Data was collected using a household survey of married 2.4 Statistical analysis adolescent girls (MAGs) in Assiut and Sohag governor- Data were analyzed using SPSS Statistics for Windows ates, which are among the poorest and most conserva- (version 21.0, NY). Descriptive analysis was performed tive governorates in Egypt [13, 14]. The survey covered for the participants’ socio-demographic data. Frequen- 23 villages in Assiut and Sohag reaching to a sample of cies of exposure to physical and sexual violence were 729. Data was collected by personal interview using a calculated. structured questionnaire after taking the consent of the The MAGs were considered to be exposed to physical girls and their husbands (when required). The study was violence if responded “Yes” to any of the following: being conducted in selected rural communities of Assiut and slapped or having something thrown at you that could Sohag governorates that were nominated by the health hurt you; being pushed or shoved; being hit with a fist directorates in the two governorates based on the high or something else that could hurt; being kicked, dragged, prevalence of early marriage. or beaten up; being choked or burnt on purpose; and/or being threatened with, or actually, having a gun, knife, 2.2 Recruitment of the study population or other weapon used on you. While the MAGs were Married adolescent girls (under 20 years) who had been considered to be exposed to sexual violence if responded married for at least 3 months at the time of data by “Yes” to any of the following: practicing sex against El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 3 of 9 will, having a sexual relation when the husband was year. Exposure to physical violence was 15.2% (21.0% in drunk or drugged, and being forced to do sexual acts Assiut and 10.6% in Sohag), while exposure to sexual that she was not comfortable with. violence was slightly higher 17.8% (24.7% in Assiut and Decision-making index was created by using 10 ques- 12.3% in Sohag). tions expressing the girls’ participation in taking differ- Table 3 shows that exposure of MAGs to physical and ent decisions. The response was given a score of “1” if sexual violence was significantly related to living with the girl participated in the decision and “0” if she did the husband alone, longer duration of marriage, and lon- not. Social mobility index was also created by using vari- ger duration till the first pregnancy, while acceptance of ables expressing the free mobility of the MAGs; 12 ques- marriage timing and sexual satisfaction were significantly tions were used including the ability of the MAG to go associated with less exposure to both types of violence. to different places unescorted such as the doctor, family It also shows that the agreement of the husbands and house, friend’s house, and market. The score “1” mothers-in-law that wife beating is a “husband right” expressed the ability to go to the place and “0” as inabil- was significantly associated with more exposure to phys- ity to go. Cronbach’s alpha for both scales was calculated ical and sexual violence. Moreover, sexual violence was as 0.7 and 0.6 respectively. significantly associated with marriage at age less than 18 In the previous indices, an additive score was com- while receiving pre-marital counseling was protective. puted by summing the scores and the mean score per- Table 4 shows that by backward regression analysis, it cent was calculated as score/optimal score × 100. was found that acceptance of marriage timing, living Reported sexual satisfaction was assessed using a single with other family members, and sexual satisfaction were question which asks about the overall sexual satisfaction the significant protective factors against exposure to and was graded along a Likert scale ranging from 1 to 5, physical and sexual violence. Moreover, considering wife where the score “1” denoted the least sexual satisfaction beating as “a husband right” was associated with more and the score “5” denoted the highest satisfaction. exposure to physical and sexual violence, and longer T test and chi-square test were used to identify the sig- duration till first pregnancy was associated with more nificant factors associated with exposure to physical and exposure to sexual violence. sexual violence. All significant variables on bivariate ana- lysis were considered for inclusion in the backward re- 4 Discussion gression analysis. P value < 0.05 was considered as In Egypt, 30% of ever-married women aged 15–49 re- significant. ported having been ever subjected to at least one epi- sode of physical, sexual, and/or emotional violence 3 Results inflicted by their current or most recent spouse; how- Table 1 shows the socio-demographic characteristics of ever, sexual violence was only reported by 4% of the the studied sample. The survey included 729 (324 in participants [9]. In Alexandria, a cross-sectional sur- Assiut and 405 in Sohag) married girls. The majority got vey found that more than three-quarters of the partic- married (89.7%) under the age of 18. In both governor- ipants (77%) reported experiencing spousal violence. ates, married girls shared similar socio-demographic Emotional violence was the most commonly reported characteristics. The mean age of girls was 18 years, and form (71.0%), followed by physical (50.3%) and sexual the husbands' mean age was 26.86 ± 6.4 years in Assiut violence (37.1%) [15]. and 25.69 ± 4.5 in Sohag with an average age difference Despite the fact that all married women from all age between the husband and wife of 7–8 years. Almost all groups are at risk of spousal violence, married adoles- girls in both governorates were housewives. Consanguin- cent girls are at much higher risk of exposure to violence eous marriages were high among the studied group (59% and its consequences [16]. In Egypt, one in every four and 67% in Assiut and Sohag respectively). Overall, the adolescent married girls has been ever exposed to some educational level among Sohag girls was less than that form of spousal violence while 5.5% have been exposed among Assiut girls. The husband’s educational status to sexual violence [9]. was better than their spouses. The mean duration be- Early marriage is still common in Upper Egypt, and tween marriage and first pregnancy was 4.48 months for most (89.7) of the participants in this study got married the total sample. under the age of 18. Since the legal age of marriage in The norm for the studied MAGs in the early years of Egypt is 18 years, girls who married before completing their marriage is to live in an extended family (the hus- their 18th birthday were in discordance with the law and band’s family): 84% and 91.6% in Assiut and Sohag are more liable to be exposed to spousal violence. Ac- respectively. cording to our study, 15.2% of the study participants Table 2 shows the percentage of exposure of the stud- were exposed to physical violence while 17.8% were ex- ied MAGs to physical and sexual violence in the last posed to sexual violence in the last year (prior to the El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 4 of 9 Table 1 Socio-demographic characteristics of the married adolescent girls (MAGs), Upper Egypt Variable Assiut Sohag Total N = 324 (%) N = 405 (%) N = 729 (%) Age at marriage (years) < 18 293 (90.4) 361 (89.1) 654 (89.7) ≥ 18–20 31 (9.6) 44 (10.9) 75 (10.3) Mean ± SD 16.67 ± 1.40 16.47 ± 1.64 16.6 ± 1.5 Age at time of study Mean ± SD 18.33 ± 1.32 18.47 ± 1.42 18.4 ± 1.38 Duration of marriage (months) Mean ± SD 19.2 ± 13.9 23.5 ± 17.0 21.6 ± 15.9 Girls educational level Illiterate 21 (6.5) 81 (20.0) 102 (13.9) Basic education 89 (27.5) 143 (35.3) 232 (31.8) Secondary education 121 (37.3) 127 (31.4) 248 (34.0) > Secondary education 93 (28.7) 54 (13.3) 147 (20.3) Work status Work for cash 6 (1.9) 2 (0.5) 7 (1.0) Not working 318 (98.1) 403(99.5) 721 (99.0) Parity 0 180 (55.6) 217 (53.6) 397 (54.5) 1 119 (36.7) 133 (32.8) 252 (34.6) 2 25 (7.7) 46 (11.4) 71 (9.7) 3 0 (0) 9 (2.2) 9 (1.2) Duration of marriage till first pregnancy n = 521 (247 Assiut, 274 Sohag) Mean ± SD 4.05 ± 5.9 5.2 ± 8.1 4.6 ± 7.1 Husband age Mean ± SD 26.86 ± 6.4 25.69 ± 4.5 26.2 ± 5.4 Husband education Illiterate 17 (5.3) 40 (9.9) 57 (7.8) Basic education 44 (13.6) 76 (18.8) 120 (16.5) Secondary education 26 (8.0) 52 (12.8) 78 (10.7) > Secondary education 237 (73.1) 237 (58.5) 474 (65.0) Consanguineous marriage Yes 189 (58.3) 260 (64.2) 449 (61.6) No 135 (41.7) 145 (35.8) 280 (38.4) Co-residence Lives with husband alone 52 (16.0) 34 (8.4) 86 (11.8) Lives with others 272 (84.0) 371 (91.6) 643 (88.2) year of data collection). This percentage would have Studies found that violence is frequently viewed as been definitely higher if we asked about exposure the husband’s right to discipline his wife [17]. More- throughout the marital life. over, a study conducted between 1998 and 2001 from Our study showed that spousal violence was associ- seven countries found that male acceptance of wife ated with various cultural factors. In many cultures, it beating ranged from 26% in Kazakhstan to 56% in is acceptable for men to control their wives’ behavior Turkey [18]. As shown in our study, male attitudes and those women who refuse may be punished. condoning partner violence is a crucial predictor of El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 5 of 9 Table 2 Exposure of the married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt Types of violence Assiut Sohag N = 729 (%) N = 324 (%) N = 405 Physical violence Exposed 68 (21.0) 43(10.6) 111 (15.2) Non-exposed 256 (79.0) 362 (89.4) 618 (84.8) Sexual violence Exposed 80 (24.7) 50 (12.3) 130 (17.8) Non-exposed 244 (75.3) 355 (87.7) 599 (82.2) Exposed to both physical and sexual violence 35 (10.8) 18 (4.4) 53 (7.3) exposure to physical and sexual violence. This was con- Moreover, a study done in Jordan to identify the role sistent with various studies where men who justified wife of the extended family on women’s risk of intimate part- beating and held more gender inequitable attitudes were ner violence using mixed-methods study found that resi- more likely to abuse their wives [19, 20]. dence with the respondent’s in-laws act as a protective Taking the girls’ acceptance about the timing of getting factor against conflict and intimate partner violence be- married and the person she will marry not only is a human tween a husband and wife [23]. However, some studies right, but also significantly affects her exposure to physical found that a wife’s in-laws act as instigators of conflict and sexual violence. Multivariable logistic regression ana- between husband and wife or a direct source of conflict lysis in our study showed that girls’ acceptance of the mar- with the wife and thus contributing to violence even if riage timing was a significant protective factor against they do not live with or were near the couple [24, 25]. In exposure to physical and sexual violence. This was consist- addition, the focus group discussions (FGDs) of a study ent with a study conducted in Turkey to identify factors as- done in Jordan revealed that families were not always an sociated with domestic violence. The study found that the effective source of assistance [23]. prevalence of domestic violence was significantly lower Sexual satisfaction is an integral part of marital life that af- among women whose marriage was by mutual agreement fects the couple’srelationship[26]. Our study found a signifi- [21]. This is probably due to the similarity between the cant association between violence and reported sexual Egyptian and Turkish culture, as usually the spouses will satisfaction; the higher the sexual satisfaction score of the have no chance to know each other before getting married. MAG, the less was the exposure to physical and sexual vio- Moreover, women especially MAGs that are forced to get lence. Previous studies have repeatedly shown this associ- married are mostly those without economic independence ation between sexual satisfaction and spousal violence. Ulloa and thus are less able to overcome violence. and Hammett [27] reported a negative correlation between It is common in rural Upper Egypt for married couples intimate partner violence and satisfaction. Also, a study con- to live in extended families specially married adolescent ducted in Iran showed a significant association between part- girls, 88.2% of our study sample lived in extended fam- ner violence and all aspects of women’s sexual function [28]. ilies. The extended family can significantly affect the The norm of Egyptian society is not postponing preg- marital relationship of a couple, especially in the early nancy of the first child especially in rural communities. years of their marriage, and can play a positive as well as Failure to conceive directly after marriage affects the psy- a negative role. Bivariate and multivariable logistic re- chological state of the husband, which leads to violence. gression analyses in our study showed that exposure of Violence against women experiencing delayed pregnancy MAGs to physical and sexual violence was significantly is an important health problem with serious consequences associated with living with the husband alone while living for their physical and mental health [29]. Our study re- with other family members was a significant protective vealed that longer duration till having the first baby was factor against exposure to physical and sexual violence. associated with more exposure to sexual violence. Consistent with our study, a qualitative study done in Consistent with our study, a systematic review on the Pakistan and the UK indicated that the husband’s family relationship between infertility, sub-fertility, and intimate can have a positive effect by minimizing conflict through partner violence found that infertility (inability to be- offering the couple personal time and helping the wife to come pregnant)/sub-fertility (inability to maintain a adjust to her new family and the wife’s family could con- pregnancy) are associated with violence in low- and tribute by helping their daughter to adjust to her new middle-income countries [30]. Moreover, many studies extended family [22]. found that fertility and sub-fertility could be risk factors El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 6 of 9 Table 3 Factors affecting exposure of married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt Variables Physical violence Sexual violence Exposed Non-exposed Exposed Non-exposed Age at marriage (years) Below 18 101 (15.4) 553 (84.6) 124 (19.0)* 530 (81.0) 18 and above 10 (13.3) 65 (86.7) 6 (8.0) 69 (92.0) Girls’ education Illiterate 16 (76.2) 5 (23.8) 7 (33.3) 14 (66.7) Lower than secondary education 169 (80.5) 41 (19.5) 58 (27.6) 152 (72.4) Secondary education and above 71 (76.3) 22 (23.7) 15 (16.1) 78 (83.9) Parity Mean ± SD 1.1 ± 0.7 1.0 ± 0.4 1.2 ± 0.6 1.0 ± 0.5 Husband’s age Mean ± SD 26.6 ± 3.9 26.9 ± 6.8 26.0 ± 4.4 27.2 ± 6.9 Husband’s education Illiterate 6 (35.3) 11 5 (29.4) 12 (70.6) Lower than secondary education 19 (27.1) 51 23 (32.9) 47 (67.1) Secondary education and above 43 (18.1) 194 52 (21.9) 185 (78.1) Consanguineous marriage Yes 40 (21.2) 149 (78.8) 50 (26.5) 139 (73.5) No 27 (20.6) 104 (79.4) 29 (22.1) 102 (77.9) Co-residence Living with husband alone 26 (30.2)*** 60 (69.8) 25 (29.1)** 61 (70.9) Living with others 85 (13.2) 558 (86.8) 105 (16.3) 538 (83.7) Pre-marital factors Girl’s opinion about timing of marriage Agree 61 (11.5)*** 471 (88.5%) 75 (14.1)*** 457 (85.9) Disagree 50 (25.4) 147 (74.6) 55 (27.9) 142 (72.1) Receiving pre-marital counseling Received 27 (12.2) 194 (87.8) 27 (12.2)** 194 (87.8) Not received 84 (16.5) 424 (83.5) 103 (20.3) 405 (79.7) Marital factors Duration of marriage (months) Mean ± SD 25.3 ± 17.4** 20.9 ± 15.5 25.1 ± 16.8** 20.8 ± 15.6 Duration of marriage till the first pregnancy (months) Mean ± SD 6.2 ± 8.1* 4.4 ± 6.9 6.97 ± 9.8*** 4.1 ± 6.3 Perceived husband's attitude towards wife beating Agree 91 (20.8)*** 346 (79.2) 92 (21.1)** 345 (78.9) Disagree 20 (6.8) 272 (93.2) 38 (13.0) 254 (87.0) Perceived mother-in-law's attitude towards wife beating Agree 82 (18.8)** 355 (81.2) 91 (20.8)* 346 (79.2) Disagree 29 (9.9) 263 (90.1) 39 (13.4) 253 (86.6) Sexual satisfaction score Mean ± SD 3.96 ± 0.9*** 4.3 ± 0 .5 4.1 ± 0.89** 4.31 ± 0.53 Social mobility score Mean ± SD 0.8 ± 1.1* 0.6 ± 0.9 0.7 ± 0.96 0.6 ± 0.97 El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 7 of 9 Table 3 Factors affecting exposure of married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt (Continued) Variables Physical violence Sexual violence Exposed Non-exposed Exposed Non-exposed Decision-making score Mean ± SD 4.7 ± 2.2 4.6 ± 2.1 4.5 ± 2.5 4.7 ± 2.04 *P value < 0.05, **P value < 0.01, ***P value < 0.001 for intimate partner violence [29–33]. Also, infertile (CAPMAS) approval of the study to assure them that women are exposed to higher levels of marital violence they were only research-participants. compared to fertile women [34]. 5 Conclusion Girls married before the age of 18 are exposed to spou- 4.1 Limitations of the study sal physical and sexual violence. Taking the girls’ opin- This large survey investigated an important and rela- ion at the time of marriage and obtaining their tively unspoken issue but has some limitations; If acceptance are protective against exposure to physical husbands and mothers-in-law were interviewed, more and sexual violence. Moreover, cultural beliefs that con- insight on the problem would have been given, but sider spousal violence acceptable defiantly increase the this was very difficult in such conservative societies. risk of girls being exposed to violence. Many families denied the presence of MAGs during In rural communities, young girls that lived with their the listing process since the legal age of marriage in husbands alone were more exposed to violence, which Egypt is 18 years and families of MAGs who were could be attributed to their inability to be totally inde- below 18 years might face legal penalties if the case pendent. This study clearly illustrates the need for en- was reported to the authorities. To overcome this forcement of laws as well as raising the community challenge, the enumeration and listing team members awareness to delay the age of marriage and respect “the were escorted by outreach workers from the local girl’s will” to delay her marriage until she is more au- communities to establish rapport with the families tonomous, able to participate in decision-making, and and enable the team to clarify that the collected data more capable of bearing other marital responsibilities. In will be used for scientific purpose, will never be addition, mass media campaigns and public educational shared with the authorities, and that the filled ques- sessions directed towards the elimination of gender dis- tionnaires will have no identifiers, will not be linked crimination should be widely used in order to change to the developed lists, and the results will be pre- the cultural concepts that consider wife beating a “hus- sented in an aggregate form. Moreover, the data col- band right.” Incorporation of sexual counseling within lectors were provided with identification cards the MCH services and making it available for couples is affiliated to Assiut University and copies of the Cen- required to improve sexual satisfaction, conflict reso- tral Agency for Public Mobilization and Statistics lution skills, and other life skills. Table 4 Predictors of exposure of married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt Predictors Exposure to physical violence Exposure to sexual violence β Odds ratio CI β Odds ratio CI Perceived husband attitude about practicing physical violence 0.80* 2.24 1.5–4.7 0.82** 2.270 1.4–8.2 Co-residence − 0.82* 0.46 0.1–0.78 − 0.75* 0.48 0.21–0.57 Girl's opinion about marriage timing − 1.07*** 0.34 0.13–0.61 − 0.68** 0.51 0.3–0.7 Reported sexual satisfaction − 0.77*** 0.46 0.31–0.88 − 0.39* 0.68 0.31–0.85 Duration till first pregnancy 0.02 1.03 0.97–1.1 0.04** 1.04 1.01–1.08 Duration of marriage 0.01 1.01 0.98-1.0 0.06 1.0 0.9–1.0 Perceived mother-in-law's attitude about practicing physical violence 0.07 0.93 0.71–1.2 0.13 1.14 0.51–2.58 Social mobility score 0.02 1.02 0.95–1.1 − 0.009 0.99 0.92–1.06 Age at marriage (below 18) –– – 0.037 1.03 0.22–4.7 *P value < 0.05, **P value < 0.01, ***P value < 0.001 El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 8 of 9 Abbreviations 7. Hindin M, Kishor S, Ansara D. Intimate partner violence among couples in MAGs: Married adolescent girls 10 DHS countries: predictors and health outcomes. Macro International: Calverton, Maryland, USA; 2008. 8. Speizer I, Pearson E. Association between early marriage and intimate Acknowledgements partner violence in India: a focus on youth from Bihar and Rajasthan. J We acknowledge the population council specifically Dr. Nahla abdel Tawab Interpers Violence. 2011;26(10):1963–81. and Dr. Doaa Oraby for the logistic support during data collection of this 9. Ministry of Health and Population [Egypt], El-Zanaty and Associates [Egypt], survey as well as the married adolescent girls who volantarly participated in and ICF International. Egypt demographic and health survey 2014. Egypt this survey. and Rockville, Maryland, USA: Cairo; 2015. Authors’ contributions 10. Darwish M, Hamza W, Aziz M, El-Gazzar A. Sexual and reproductive health OE conceived the idea of the study, wrote the protocol, supervised the data experiences of married adolescent girls in rural Upper Egypt”. In Abdel- collection, and revised the questionnaire. MMD participated in designing the Tawab N, Saher S, El Nawawi N, Editors. Chapter 6: Breaking the silence: questionnaire, data collection, and analysis. AFE-G participated in designing learning about youth sexual and reproductive health in Egypt. Cairo: the questionnaire, data collection, and analysis; wrote the “Discussion” sec- Population Council; 2013. tion; and revised the final manuscript. HMM participated in designing the 11. Faramarzi M, Esmailzadeh S, Mosavi S. Prevalence and determinants of questionnaire, data collection, and analysis as well as writing part of the “Dis- intimate partner violence in Babol City, Islamic Republic of Iran. East cussion” section. MMA participated in the data collection and analysis as well Mediterr Health J (EMHJ). 2005;11:870-9. as writing the “Introduction,”“Methodology,” and “Results” sections. The au- 12. Raj A. Public health impact of marital violence against women in India. thors read and approved the final manuscript. Indian J Med Res. 2019;150(6):525–31. 13. UNFPA. Localizing the targets of the sustainable development goals at Funding governorate level. United Nation, Egypt, 2018. https://egypt.unfpa.org/en/ This study was funded by the population council, Cairo office. publications/localizing-targets-sustainable-development-goals-governorate- level. 14. Human Development Index. List of governorates of Egypt. https://en.m. Availability of data and materials wikipedia.org/wiki/List_of_governorates_of_Egypt_by_Human_ Available on reasonable request. Development_Index. 15. Mamdouh H, Ismail H, Kharboush I, Tawfik M, El Sharkawy O, Abdel Baky M, Ethics approval and consent to participate et al. 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[Internet]. icddr,b Special Publication No. Consent for publication 135. http://www.partners4prevention.org/sites/default/files/resources/final_ No individual details, images, or videos were included in the manuscript. report_bangladesh.pdf. 21. Gokler M, Arslantas D, Unsal A. Prevalence of domestic violence and Competing interests associated factors among married women in a semi-rural area of western No conflict of interest. Turkey. Pak J Med Sci. 2014;30(5):1088–93. 22. Ali P, O’Cathain A, Croot E. Influences of extended family on intimate Received: 9 November 2019 Accepted: 15 September 2020 partner violence: perceptions of Pakistanis in Pakistan and the United Kingdom. J Interpers Violence. 2018:1–29. 23. Clark C, Silverman J, Shahrouri M, Everson-Rose S, Groce N. The role of the References extended family in women's risk of intimate partner violence in Jordan. Socl 1. UNICEF. Child marriage in the Middle East and North Africa – Egypt Country Sci Med. 2010;70(1):144–51. 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Med J Islam Repub Iran. 2014;28:152. 34. Ameh N, Kene T, Onuh S, Okohue J, Umeora O, Anozie O. Burden of domestic violence amongst infertile women attending infertility clinics in Nigeria. Niger J Med. 2007;16(4):375–7. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Spousal violence and its determinants among married adolescent girls in Upper Egypt

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Abstract

Introduction: In Egypt, many girls are still married before the age of 18, which is a fundamental violation of the girls’ human rights. Early marriage is associated with an alarmingly elevated risk of all types of intimate partner violence that have various negative consequences. The purpose of this study was to identify the predictors of exposure to spousal violence among the early married girls in rural Upper Egypt. Methods: A household survey was carried out and covered 23 villages in Assiut and Sohag governorates reaching to a sample of 729 married girls before the age of 20. Listing and enumeration of 4 districts was done to identify the study participants. Data was collected by personal interviews using a structured questionnaire. Bivariate and stepwise regression analyses were performed to identify the predictors of exposure to spousal violence. Results: It was found that 15.2% of the study participants were exposed to physical violence while 17.8% were exposed to sexual violence and 7.3% were exposed to both types. Girls married before the age of 18 were more exposed to spousal violence. Stepwise regression analysis found that girls’ acceptance to get married was a protective factor against exposure to physical (β = − 1.07, OR 0.34) and sexual (β = − 0.68, OR 0.51) violence. The perceived attitude of husbands and mothers-in-law about considering wife beating “a husband's right” was found to be a risk factor of exposure to physical and sexual violence. Longer duration till the first pregnancy was also associated with more exposure to sexual violence (β = 0.04, OR 1.04). Conclusion: Married adolescent girls (MAGs) are highly exposed to physical and sexual violence. This is mainly due to ignoring girls’ preference to postpone their marriage, cultural concepts of accepting violence against women, and low sexual satisfaction. This study shows that most determinants of spousal violence were related to culture issues. Identifying these determinants is required to combat such a crucial public health problem that has serious consequences on adolescent health. Keywords: Spousal violence, Upper Egypt, Early marriage, Married adolescent girls 1 Introduction The 2014 Survey of Young People in Egypt (SYPE) re- In Egypt, despite the legislation of the Child Law of 2008 vealed that 1.7% of married female youth aged 25–29 in which sets the minimum age of marriage at 18 years for 2014 had been married before age 15, 4.2% before age females and males, many girls are still married before 16, and 21.1% before age 18 which is the legal age of the age of 18, which is a fundamental violation of the marriage in Egypt. Moreover, child marriage remains to girls’ human rights [1]. be common in some parts of the country; 33.3% of mar- ried female youth aged 25–29 residing in rural Upper Egypt were married before age 18, compared to just * Correspondence: amirafathy@aun.edu.eg; elgazzar44@yahoo.com below 10% of those in the Urban Governorates and Public Health & Community Medicine, Faculty of Medicine, Assiut University, urban Lower Egypt [2]. Assiut 71515, Arab Republic of Egypt © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 2 of 9 Early marriage has been associated with withdrawal collection were invited to participate in the study. Enu- from school and low opportunity for employment and so- meration of all households in the selected communities cial mobility [3, 4]. Hence, those girls usually enter mar- and listing married inhabitants of these households were riage with low levels of education and limited knowledge conducted by a trained team to identify the households and skills needed to negotiate adult marital roles [5]. with at least one MAG. The team was escorted by com- Furthermore, evidence suggests that early marriage is munity outreach workers to facilitate their entry into the associated with an elevated risk of intimate partner vio- houses and alleviate the tension of the locals. The heads lence [6–8]. The 2014 Egypt Demographic and Health of the households were approached by the members of Survey (EDHS) showed that one in four married ado- the enumeration and listing team asking them to list all lescent girls (MAGs) in Egypt (15–19 years) was ever married women in the household together with their exposed to some form of spousal violence while 5.5% ages and duration of marriage and data was validated were exposed to sexual violence [9]. A qualitative using the identity cards of the listed married women. study among MAGs in three villages in Assiut re- The listing process yielded only 730 MAGs, who were vealed the presence of poor husband-wife communi- all included in the study rather than applying random cation, especially on matters related to achieving selection. The interviews were conducted at a quiet sexual satisfaction, thus leading to physical and sexual area at the MAG’s house or a place of her choice (e.g., violence [10]. Moreover, a study in Iran has shown health center) and lasted for about 1 h. Field training of that spousal violence was significantly associated with data collectors involved pilot testing of the instrument low income, women age ≤ 20 years, unemployment, among 20 MAGs in two villages that were not selected low education, being non-pregnant and non-house for the study. owners, and rural residence [11]. Spousal violence is a major public health concern, 2.3 Questionnaire since it is documented to be associated with poor health All the study participants were interviewed using a outcomes including injuries, sexual/reproductive health structured questionnaire divided into sections cover- problems, anxiety, and depression [12]. ing all the variables that we hypothesized to be associ- While rural Upper Egypt has the highest levels of ated with exposure to spousal violence. The first section spousal violence [9], little is known about its predictors. of the questionnaire detailed the socio-demographic The current study was designed and implemented to characteristics. The second section assessed the practices measure the extent of MAGs’ exposure to physical and related to asking the girls’ opinion before marriage, pre- sexual violence in rural Upper Egypt and identify more marital counseling, marital sexual relation, pregnancy, and precisely the predictors of such exposure. Results of the delivery. The third section explored the social support to study would help the policy makers to design evidence- the MAGs by their husbands and mothers-in-law including based interventions and programs to ameliorate the her social mobility and participation in decision-making as negative effects of early marriage on their health and well as the attitudes of husbands and mothers-in-law about that of their children. violence as reported by the MAGs. The fourth section dis- cussed the exposure of MAGs to physical and sexual vio- 2 Methodology lence in the year preceding data collection. 2.1 Study design Data was collected using a household survey of married 2.4 Statistical analysis adolescent girls (MAGs) in Assiut and Sohag governor- Data were analyzed using SPSS Statistics for Windows ates, which are among the poorest and most conserva- (version 21.0, NY). Descriptive analysis was performed tive governorates in Egypt [13, 14]. The survey covered for the participants’ socio-demographic data. Frequen- 23 villages in Assiut and Sohag reaching to a sample of cies of exposure to physical and sexual violence were 729. Data was collected by personal interview using a calculated. structured questionnaire after taking the consent of the The MAGs were considered to be exposed to physical girls and their husbands (when required). The study was violence if responded “Yes” to any of the following: being conducted in selected rural communities of Assiut and slapped or having something thrown at you that could Sohag governorates that were nominated by the health hurt you; being pushed or shoved; being hit with a fist directorates in the two governorates based on the high or something else that could hurt; being kicked, dragged, prevalence of early marriage. or beaten up; being choked or burnt on purpose; and/or being threatened with, or actually, having a gun, knife, 2.2 Recruitment of the study population or other weapon used on you. While the MAGs were Married adolescent girls (under 20 years) who had been considered to be exposed to sexual violence if responded married for at least 3 months at the time of data by “Yes” to any of the following: practicing sex against El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 3 of 9 will, having a sexual relation when the husband was year. Exposure to physical violence was 15.2% (21.0% in drunk or drugged, and being forced to do sexual acts Assiut and 10.6% in Sohag), while exposure to sexual that she was not comfortable with. violence was slightly higher 17.8% (24.7% in Assiut and Decision-making index was created by using 10 ques- 12.3% in Sohag). tions expressing the girls’ participation in taking differ- Table 3 shows that exposure of MAGs to physical and ent decisions. The response was given a score of “1” if sexual violence was significantly related to living with the girl participated in the decision and “0” if she did the husband alone, longer duration of marriage, and lon- not. Social mobility index was also created by using vari- ger duration till the first pregnancy, while acceptance of ables expressing the free mobility of the MAGs; 12 ques- marriage timing and sexual satisfaction were significantly tions were used including the ability of the MAG to go associated with less exposure to both types of violence. to different places unescorted such as the doctor, family It also shows that the agreement of the husbands and house, friend’s house, and market. The score “1” mothers-in-law that wife beating is a “husband right” expressed the ability to go to the place and “0” as inabil- was significantly associated with more exposure to phys- ity to go. Cronbach’s alpha for both scales was calculated ical and sexual violence. Moreover, sexual violence was as 0.7 and 0.6 respectively. significantly associated with marriage at age less than 18 In the previous indices, an additive score was com- while receiving pre-marital counseling was protective. puted by summing the scores and the mean score per- Table 4 shows that by backward regression analysis, it cent was calculated as score/optimal score × 100. was found that acceptance of marriage timing, living Reported sexual satisfaction was assessed using a single with other family members, and sexual satisfaction were question which asks about the overall sexual satisfaction the significant protective factors against exposure to and was graded along a Likert scale ranging from 1 to 5, physical and sexual violence. Moreover, considering wife where the score “1” denoted the least sexual satisfaction beating as “a husband right” was associated with more and the score “5” denoted the highest satisfaction. exposure to physical and sexual violence, and longer T test and chi-square test were used to identify the sig- duration till first pregnancy was associated with more nificant factors associated with exposure to physical and exposure to sexual violence. sexual violence. All significant variables on bivariate ana- lysis were considered for inclusion in the backward re- 4 Discussion gression analysis. P value < 0.05 was considered as In Egypt, 30% of ever-married women aged 15–49 re- significant. ported having been ever subjected to at least one epi- sode of physical, sexual, and/or emotional violence 3 Results inflicted by their current or most recent spouse; how- Table 1 shows the socio-demographic characteristics of ever, sexual violence was only reported by 4% of the the studied sample. The survey included 729 (324 in participants [9]. In Alexandria, a cross-sectional sur- Assiut and 405 in Sohag) married girls. The majority got vey found that more than three-quarters of the partic- married (89.7%) under the age of 18. In both governor- ipants (77%) reported experiencing spousal violence. ates, married girls shared similar socio-demographic Emotional violence was the most commonly reported characteristics. The mean age of girls was 18 years, and form (71.0%), followed by physical (50.3%) and sexual the husbands' mean age was 26.86 ± 6.4 years in Assiut violence (37.1%) [15]. and 25.69 ± 4.5 in Sohag with an average age difference Despite the fact that all married women from all age between the husband and wife of 7–8 years. Almost all groups are at risk of spousal violence, married adoles- girls in both governorates were housewives. Consanguin- cent girls are at much higher risk of exposure to violence eous marriages were high among the studied group (59% and its consequences [16]. In Egypt, one in every four and 67% in Assiut and Sohag respectively). Overall, the adolescent married girls has been ever exposed to some educational level among Sohag girls was less than that form of spousal violence while 5.5% have been exposed among Assiut girls. The husband’s educational status to sexual violence [9]. was better than their spouses. The mean duration be- Early marriage is still common in Upper Egypt, and tween marriage and first pregnancy was 4.48 months for most (89.7) of the participants in this study got married the total sample. under the age of 18. Since the legal age of marriage in The norm for the studied MAGs in the early years of Egypt is 18 years, girls who married before completing their marriage is to live in an extended family (the hus- their 18th birthday were in discordance with the law and band’s family): 84% and 91.6% in Assiut and Sohag are more liable to be exposed to spousal violence. Ac- respectively. cording to our study, 15.2% of the study participants Table 2 shows the percentage of exposure of the stud- were exposed to physical violence while 17.8% were ex- ied MAGs to physical and sexual violence in the last posed to sexual violence in the last year (prior to the El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 4 of 9 Table 1 Socio-demographic characteristics of the married adolescent girls (MAGs), Upper Egypt Variable Assiut Sohag Total N = 324 (%) N = 405 (%) N = 729 (%) Age at marriage (years) < 18 293 (90.4) 361 (89.1) 654 (89.7) ≥ 18–20 31 (9.6) 44 (10.9) 75 (10.3) Mean ± SD 16.67 ± 1.40 16.47 ± 1.64 16.6 ± 1.5 Age at time of study Mean ± SD 18.33 ± 1.32 18.47 ± 1.42 18.4 ± 1.38 Duration of marriage (months) Mean ± SD 19.2 ± 13.9 23.5 ± 17.0 21.6 ± 15.9 Girls educational level Illiterate 21 (6.5) 81 (20.0) 102 (13.9) Basic education 89 (27.5) 143 (35.3) 232 (31.8) Secondary education 121 (37.3) 127 (31.4) 248 (34.0) > Secondary education 93 (28.7) 54 (13.3) 147 (20.3) Work status Work for cash 6 (1.9) 2 (0.5) 7 (1.0) Not working 318 (98.1) 403(99.5) 721 (99.0) Parity 0 180 (55.6) 217 (53.6) 397 (54.5) 1 119 (36.7) 133 (32.8) 252 (34.6) 2 25 (7.7) 46 (11.4) 71 (9.7) 3 0 (0) 9 (2.2) 9 (1.2) Duration of marriage till first pregnancy n = 521 (247 Assiut, 274 Sohag) Mean ± SD 4.05 ± 5.9 5.2 ± 8.1 4.6 ± 7.1 Husband age Mean ± SD 26.86 ± 6.4 25.69 ± 4.5 26.2 ± 5.4 Husband education Illiterate 17 (5.3) 40 (9.9) 57 (7.8) Basic education 44 (13.6) 76 (18.8) 120 (16.5) Secondary education 26 (8.0) 52 (12.8) 78 (10.7) > Secondary education 237 (73.1) 237 (58.5) 474 (65.0) Consanguineous marriage Yes 189 (58.3) 260 (64.2) 449 (61.6) No 135 (41.7) 145 (35.8) 280 (38.4) Co-residence Lives with husband alone 52 (16.0) 34 (8.4) 86 (11.8) Lives with others 272 (84.0) 371 (91.6) 643 (88.2) year of data collection). This percentage would have Studies found that violence is frequently viewed as been definitely higher if we asked about exposure the husband’s right to discipline his wife [17]. More- throughout the marital life. over, a study conducted between 1998 and 2001 from Our study showed that spousal violence was associ- seven countries found that male acceptance of wife ated with various cultural factors. In many cultures, it beating ranged from 26% in Kazakhstan to 56% in is acceptable for men to control their wives’ behavior Turkey [18]. As shown in our study, male attitudes and those women who refuse may be punished. condoning partner violence is a crucial predictor of El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 5 of 9 Table 2 Exposure of the married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt Types of violence Assiut Sohag N = 729 (%) N = 324 (%) N = 405 Physical violence Exposed 68 (21.0) 43(10.6) 111 (15.2) Non-exposed 256 (79.0) 362 (89.4) 618 (84.8) Sexual violence Exposed 80 (24.7) 50 (12.3) 130 (17.8) Non-exposed 244 (75.3) 355 (87.7) 599 (82.2) Exposed to both physical and sexual violence 35 (10.8) 18 (4.4) 53 (7.3) exposure to physical and sexual violence. This was con- Moreover, a study done in Jordan to identify the role sistent with various studies where men who justified wife of the extended family on women’s risk of intimate part- beating and held more gender inequitable attitudes were ner violence using mixed-methods study found that resi- more likely to abuse their wives [19, 20]. dence with the respondent’s in-laws act as a protective Taking the girls’ acceptance about the timing of getting factor against conflict and intimate partner violence be- married and the person she will marry not only is a human tween a husband and wife [23]. However, some studies right, but also significantly affects her exposure to physical found that a wife’s in-laws act as instigators of conflict and sexual violence. Multivariable logistic regression ana- between husband and wife or a direct source of conflict lysis in our study showed that girls’ acceptance of the mar- with the wife and thus contributing to violence even if riage timing was a significant protective factor against they do not live with or were near the couple [24, 25]. In exposure to physical and sexual violence. This was consist- addition, the focus group discussions (FGDs) of a study ent with a study conducted in Turkey to identify factors as- done in Jordan revealed that families were not always an sociated with domestic violence. The study found that the effective source of assistance [23]. prevalence of domestic violence was significantly lower Sexual satisfaction is an integral part of marital life that af- among women whose marriage was by mutual agreement fects the couple’srelationship[26]. Our study found a signifi- [21]. This is probably due to the similarity between the cant association between violence and reported sexual Egyptian and Turkish culture, as usually the spouses will satisfaction; the higher the sexual satisfaction score of the have no chance to know each other before getting married. MAG, the less was the exposure to physical and sexual vio- Moreover, women especially MAGs that are forced to get lence. Previous studies have repeatedly shown this associ- married are mostly those without economic independence ation between sexual satisfaction and spousal violence. Ulloa and thus are less able to overcome violence. and Hammett [27] reported a negative correlation between It is common in rural Upper Egypt for married couples intimate partner violence and satisfaction. Also, a study con- to live in extended families specially married adolescent ducted in Iran showed a significant association between part- girls, 88.2% of our study sample lived in extended fam- ner violence and all aspects of women’s sexual function [28]. ilies. The extended family can significantly affect the The norm of Egyptian society is not postponing preg- marital relationship of a couple, especially in the early nancy of the first child especially in rural communities. years of their marriage, and can play a positive as well as Failure to conceive directly after marriage affects the psy- a negative role. Bivariate and multivariable logistic re- chological state of the husband, which leads to violence. gression analyses in our study showed that exposure of Violence against women experiencing delayed pregnancy MAGs to physical and sexual violence was significantly is an important health problem with serious consequences associated with living with the husband alone while living for their physical and mental health [29]. Our study re- with other family members was a significant protective vealed that longer duration till having the first baby was factor against exposure to physical and sexual violence. associated with more exposure to sexual violence. Consistent with our study, a qualitative study done in Consistent with our study, a systematic review on the Pakistan and the UK indicated that the husband’s family relationship between infertility, sub-fertility, and intimate can have a positive effect by minimizing conflict through partner violence found that infertility (inability to be- offering the couple personal time and helping the wife to come pregnant)/sub-fertility (inability to maintain a adjust to her new family and the wife’s family could con- pregnancy) are associated with violence in low- and tribute by helping their daughter to adjust to her new middle-income countries [30]. Moreover, many studies extended family [22]. found that fertility and sub-fertility could be risk factors El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 6 of 9 Table 3 Factors affecting exposure of married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt Variables Physical violence Sexual violence Exposed Non-exposed Exposed Non-exposed Age at marriage (years) Below 18 101 (15.4) 553 (84.6) 124 (19.0)* 530 (81.0) 18 and above 10 (13.3) 65 (86.7) 6 (8.0) 69 (92.0) Girls’ education Illiterate 16 (76.2) 5 (23.8) 7 (33.3) 14 (66.7) Lower than secondary education 169 (80.5) 41 (19.5) 58 (27.6) 152 (72.4) Secondary education and above 71 (76.3) 22 (23.7) 15 (16.1) 78 (83.9) Parity Mean ± SD 1.1 ± 0.7 1.0 ± 0.4 1.2 ± 0.6 1.0 ± 0.5 Husband’s age Mean ± SD 26.6 ± 3.9 26.9 ± 6.8 26.0 ± 4.4 27.2 ± 6.9 Husband’s education Illiterate 6 (35.3) 11 5 (29.4) 12 (70.6) Lower than secondary education 19 (27.1) 51 23 (32.9) 47 (67.1) Secondary education and above 43 (18.1) 194 52 (21.9) 185 (78.1) Consanguineous marriage Yes 40 (21.2) 149 (78.8) 50 (26.5) 139 (73.5) No 27 (20.6) 104 (79.4) 29 (22.1) 102 (77.9) Co-residence Living with husband alone 26 (30.2)*** 60 (69.8) 25 (29.1)** 61 (70.9) Living with others 85 (13.2) 558 (86.8) 105 (16.3) 538 (83.7) Pre-marital factors Girl’s opinion about timing of marriage Agree 61 (11.5)*** 471 (88.5%) 75 (14.1)*** 457 (85.9) Disagree 50 (25.4) 147 (74.6) 55 (27.9) 142 (72.1) Receiving pre-marital counseling Received 27 (12.2) 194 (87.8) 27 (12.2)** 194 (87.8) Not received 84 (16.5) 424 (83.5) 103 (20.3) 405 (79.7) Marital factors Duration of marriage (months) Mean ± SD 25.3 ± 17.4** 20.9 ± 15.5 25.1 ± 16.8** 20.8 ± 15.6 Duration of marriage till the first pregnancy (months) Mean ± SD 6.2 ± 8.1* 4.4 ± 6.9 6.97 ± 9.8*** 4.1 ± 6.3 Perceived husband's attitude towards wife beating Agree 91 (20.8)*** 346 (79.2) 92 (21.1)** 345 (78.9) Disagree 20 (6.8) 272 (93.2) 38 (13.0) 254 (87.0) Perceived mother-in-law's attitude towards wife beating Agree 82 (18.8)** 355 (81.2) 91 (20.8)* 346 (79.2) Disagree 29 (9.9) 263 (90.1) 39 (13.4) 253 (86.6) Sexual satisfaction score Mean ± SD 3.96 ± 0.9*** 4.3 ± 0 .5 4.1 ± 0.89** 4.31 ± 0.53 Social mobility score Mean ± SD 0.8 ± 1.1* 0.6 ± 0.9 0.7 ± 0.96 0.6 ± 0.97 El-Gazzar et al. Journal of the Egyptian Public Health Association (2020) 95:28 Page 7 of 9 Table 3 Factors affecting exposure of married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt (Continued) Variables Physical violence Sexual violence Exposed Non-exposed Exposed Non-exposed Decision-making score Mean ± SD 4.7 ± 2.2 4.6 ± 2.1 4.5 ± 2.5 4.7 ± 2.04 *P value < 0.05, **P value < 0.01, ***P value < 0.001 for intimate partner violence [29–33]. Also, infertile (CAPMAS) approval of the study to assure them that women are exposed to higher levels of marital violence they were only research-participants. compared to fertile women [34]. 5 Conclusion Girls married before the age of 18 are exposed to spou- 4.1 Limitations of the study sal physical and sexual violence. Taking the girls’ opin- This large survey investigated an important and rela- ion at the time of marriage and obtaining their tively unspoken issue but has some limitations; If acceptance are protective against exposure to physical husbands and mothers-in-law were interviewed, more and sexual violence. Moreover, cultural beliefs that con- insight on the problem would have been given, but sider spousal violence acceptable defiantly increase the this was very difficult in such conservative societies. risk of girls being exposed to violence. Many families denied the presence of MAGs during In rural communities, young girls that lived with their the listing process since the legal age of marriage in husbands alone were more exposed to violence, which Egypt is 18 years and families of MAGs who were could be attributed to their inability to be totally inde- below 18 years might face legal penalties if the case pendent. This study clearly illustrates the need for en- was reported to the authorities. To overcome this forcement of laws as well as raising the community challenge, the enumeration and listing team members awareness to delay the age of marriage and respect “the were escorted by outreach workers from the local girl’s will” to delay her marriage until she is more au- communities to establish rapport with the families tonomous, able to participate in decision-making, and and enable the team to clarify that the collected data more capable of bearing other marital responsibilities. In will be used for scientific purpose, will never be addition, mass media campaigns and public educational shared with the authorities, and that the filled ques- sessions directed towards the elimination of gender dis- tionnaires will have no identifiers, will not be linked crimination should be widely used in order to change to the developed lists, and the results will be pre- the cultural concepts that consider wife beating a “hus- sented in an aggregate form. Moreover, the data col- band right.” Incorporation of sexual counseling within lectors were provided with identification cards the MCH services and making it available for couples is affiliated to Assiut University and copies of the Cen- required to improve sexual satisfaction, conflict reso- tral Agency for Public Mobilization and Statistics lution skills, and other life skills. Table 4 Predictors of exposure of married adolescent girls (MAGs) to physical and sexual violence, Upper Egypt Predictors Exposure to physical violence Exposure to sexual violence β Odds ratio CI β Odds ratio CI Perceived husband attitude about practicing physical violence 0.80* 2.24 1.5–4.7 0.82** 2.270 1.4–8.2 Co-residence − 0.82* 0.46 0.1–0.78 − 0.75* 0.48 0.21–0.57 Girl's opinion about marriage timing − 1.07*** 0.34 0.13–0.61 − 0.68** 0.51 0.3–0.7 Reported sexual satisfaction − 0.77*** 0.46 0.31–0.88 − 0.39* 0.68 0.31–0.85 Duration till first pregnancy 0.02 1.03 0.97–1.1 0.04** 1.04 1.01–1.08 Duration of marriage 0.01 1.01 0.98-1.0 0.06 1.0 0.9–1.0 Perceived mother-in-law's attitude about practicing physical violence 0.07 0.93 0.71–1.2 0.13 1.14 0.51–2.58 Social mobility score 0.02 1.02 0.95–1.1 − 0.009 0.99 0.92–1.06 Age at marriage (below 18) –– – 0.037 1.03 0.22–4.7 *P value < 0.05, **P value < 0.01, ***P value < 0.001 El-Gazzar et al. 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