1152425 HEBXXX10.1177/10901981231152425Health Education & BehaviorTenkorang et al. research-article2023 Original Manuscript Health Education & Behavior Intimate Partner Violence and Health 1 –12© 2023 Society for Public Health Education Outcomes Among Women Living With Article reuse guidelines: sagepub.com/journals-permissions HIV/AIDS in Ghana: A Cross-Sectional DhtOtpsI:/ /1d0o.i1.o1r7g/71/01.10197071/1908910219381125321415225425journals.sagepub.com/home/heb Study Eric Y. Tenkorang, PhD1 , Adobea Y. Owusu, PhD2, Mariama Zaami, PhD2, Susan Langmagne, PhD2, and Sylvia Gyan, PhD2 Abstract Intimate partner violence (IPV) is known to have negative health consequences for victims. For women living with HIV/ AIDS, whose health may be compromised, exposure to IPV can be devastating. Yet few (if any) studies have explored the health implications of exposure to IPV among HIV-positive women. We begin to fill this gap by examining the effects of various dimensions of IPV (physical, sexual, psychological/emotional, and economic) on the cardiovascular, psychosocial, and sexual reproductive health outcomes of HIV-positive women in Ghana. Data were collected from a cross-section of 538 HIV-positive women aged 18 years and older in the Lower Manya Krobo District in the Eastern Region. We used logit models to explore relationships between IPV and health. The findings indicate high prevalence of IPV in our sample: physical violence (61%), sexual violence (50.9%), emotional/psychological violence (79.6%), and economic violence (66.8%). Generally, participants with experiences of IPV reported cardiovascular health problems, unwanted pregnancies and pregnancy loss, and poor psychosocial health. Our findings suggest the importance of screening for IPV as part of HIV care in Ghana. Keywords IPV, HIV/AIDS, women, Ghana, health IPV against women is a pervasive and significant public limited our understanding of IPV risks among HIV-positive health problem. Although a global phenomenon, IPV against women—a group that is highly marginalized and susceptible women is more pronounced in sub-Saharan Africa, where to IPV risks. As a result, fewer initiatives have sought to meet the lifetime prevalence has been estimated at 36.6% of the the needs of HIV-positive women who are also victims of IPV female population, much higher than North America (29.8%) in sub-Saharan Africa generally, and in Ghana specifically. or Europe (25.4%) (World Health Organization [WHO], The relationship between IPV and HIV infection is recip- 2013). In Ghana, about one third of women in intimate rela- rocal and complex. First, victims of IPV are known to have tionships have experienced physical and/or sexual violence increased risk of HIV infection (Campbell et al., 2008; Osinde (Bowman, 2003; Tenkorang et al., 2013). IPV is particularly et al., 2011; Silverman et al., 2008; Van der Straten et al., high among women living with HIV/AIDS. Evidence from 1998). There is a direct relationship between sexual violence the United States and Canada shows IPV rates are higher for and HIV infection, as victims may be exposed to cuts and HIV-positive persons than the general population (Campbell lacerations during sexual intercourse (Van der Straten et al., et al., 2008; Gielen et al., 2000). While data on the prevalence 1998). There is also an indirect relationship; victims of IPV of IPV among HIV-positive women in sub-Saharan Africa are arguably more likely to engage in risky sexual behaviors, are scant, anecdotal evidence from Tanzania, Swaziland, and with implications for HIV transmission (Maman et al., 2000; Uganda suggests similar trends. Data on Ghana are particu- larly scant (Mulrenan et al., 2015; Osinde et al., 2011). We 1Memorial University of Newfoundland, St. John’s, Newfoundland, Canada suggest the dearth of scholarship can be partially explained by 2University of Ghana, Accra, Ghana the fact that previous work in this area has tended to use IPV as a risk factor for HIV transmission rather than an outcome Corresponding Author:Eric Y. Tenkorang, Department of Sociology, Memorial University of or consequence of HIV infection (Campbell et al., 2008). Newfoundland, St. John’s, Newfoundland, Canada A1C 5S7. This omission in previous research in sub-Saharan Africa has Email: ytenko@yahoo.com 2 Health Education & Behavior 00(0) Van der Straten et al., 1998). Second, upon diagnosis and We focused on HIV-positive women given their unique disclosure of the HIV status to their sexual partners, HIV- vulnerabilities. Living with HIV/AIDS can have negative positive women may have an increased risk of experiencing physical and psychosocial health consequences, even before IPV. Chappell (2015) and Hale and Vazquez (2011) argued factoring in the additional problem of IPV. For instance, that once diagnosed with HIV, women often face new situ- because persons living with HIV/AIDS have a compromised ations involving violence; male partners’ notification may or suppressed immune system, they may be exposed to oppor- create conditions for blame, with high risks of emotional and tunistic infections that affect physical health outcomes; they physical violence (Chappell, 2015; Colombini et al., 2016; are also more likely to live with cardiovascular diseases, Mulrenan et al., 2015). including diabetes, hypertension, and stroke (Alonso et al., Studies around the world have found IPV has deleterious 2019; Stone et al., 2017; Yang et al., 2019). Similarly, women health consequences for victims. Women with experiences living with HIV are more likely to suffer depression, anxi- of IPV are significantly more likely to report negative physi- ety, and other mental health problems due to the stigma and cal, sexual, and psychosocial health outcomes (Campbell discrimination associated with the virus (Hoare et al., 2021; et al., 2008; Silverman et al., 2008; Silverman & Raj, 2014; Mekonen et al., 2021; Waldron et al., 2021). Tenkorang, 2019). For women living with HIV/AIDS who Experiencing IPV adds a layer of vulnerability, given the are already vulnerable, the health impact of experiencing long-term negative health consequences. IPV can manifest IPV may be particularly severe. Some evidence shows higher as different types, including physical, sexual, psychological/ prevalence of mental health disorders among HIV-positive emotional, and economic. Campbell (2002) argued women women with a history of intimate partner abuse than among who experience physical abuse are more likely than others those with no such history (Mitchell et al., 2016; Rose et al., to report physical injuries, bruises, and cuts that can lead to 2010). Woollett and Hatcher (2016) identified IPV, HIV, and physical deformities and mobility problems. For women liv- poor mental health as intersecting epidemics, with depression ing with HIV, the risk of physical abuse is high and occurs and post-traumatic stress disorder the most pervasive mental mostly after they have disclosed their HIV status to their part- health consequences of IPV and HIV. ners (Aloyce et al., 2021; Maman et al., 2000; Mulrenan et al., However, there is a paucity of research on the health con- 2015). Status disclosure, while important, may lead to nega- sequences of IPV on HIV-positive women. Researchers have tive emotional responses from the partner and withdrawal that examined HIV-positive women’s psychosocial/mental health, if not checked can degenerate into physical violence. Gielen but paid limited attention to their physical and sexual repro- et al. (2000) noted that physical abuse following HIV diag- ductive health outcomes (see Mitchell et al., 2016; Woollett nosis appears to occur frequently and tends to be severe. In & Hatcher, 2016). Moreover, most studies have focused on addition to causing immediate physical injury, this type of pregnant women (see Lin et al., 2022; Yonga et al., 2022) and abuse can negatively affect the health of HIV-positive persons HIV-related health outcomes, including medication adherence by altering the red blood cells and reducing the T-cell function and CD4 count (Schafer et al., 2012). This study is one of very (Brokaw et al., 2002). few to comprehensively investigate the health consequences Like physical abuse, sexual abuse can have significant of IPV on HIV-positive women by focusing on their physical, health consequences for women who experience it. Sexual sexual, and psychosocial health outcomes. To the best of our abuse is a known risk factor for HIV infection (Jewkes et al., knowledge, it is the first in Ghana to examine these outcomes 2006), but the abuse does not end post-infection and can con- in a demographic group that remains vulnerable and highly tinue for a long time. This means women with such experi- marginalized. ences, including those living with HIV, may suffer severe sexual and reproductive health problems, such as reduced Health Consequences of IPV Among sexual desire, genital irritation, and other known gyneco- HIV-Positive Women logical problems (Campbell, 2002). In his study on IPV and sexual and reproductive health outcomes in Ghana, Tenkorang Previous studies have established theoretical and empirical (2019) found women with experiences of sexual abuse were pathways between IPV and health outcomes among HIV- more likely to report unwanted pregnancies and pregnancy positive persons (Fiorentino et al., 2019; Schafer et al., loss. Some studies show unwanted pregnancy is high among 2012; Wetzel et al., 2021). However, in determining the women living with HIV due to limited contraceptive use health consequences of IPV, the majority of these studies (Alene & Atalell, 2018; Jarolimova et al., 2018). Others report have examined HIV infection as the outcome (Durevall that although anti-retroviral treatment (ART) reduces negative & Lindskog, 2014; Nyamayemombe et al., 2010; Rigby birth outcomes among women living with HIV, even when & Johnson, 2017), focused on HIV-related outcomes of ART is effective, the risks of miscarriage and stillbirth remain selected samples, mostly pregnant women (Hatcher et al., high (Schwartz et al., 2012). Sexual violence can undermine 2014; Lin et al., 2022; Wetzel et al., 2021; Yonga et al., HIV-positive women’s sexual agency and their ability to 2022), or explored the health-related consequences of IPV negotiate safer sex and related birth outcomes. Knowledge in the general population (Campbell, 2002; McKelvie et al., of a female partner’s HIV status, especially in serodiscordant 2021; Potter et al., 2021; Tenkorang, 2019). relationships, may be used by male partners to intimidate and Tenkorang et al. 3 establish dominance in ways that can undermine the sexual approximately 304.4 km2 of the total land area of 18,310 km2 expression and autonomy of female partners, with implica- in the Eastern Region of Ghana (Ghana Statistical Service, tions for their sexual health outcomes. Finally, the stigma and 2014). The administrative capital of the district is Odumase; trauma accompanying sexual abuse may be sufficient to sup- major towns include Atua, Agormanya, Nuaso, Akuse, and press the immune system of women whose bodies are already Kpong (Ghana Statistical Service, 2014). The district serves compromised by the AIDS virus. a population of approximately 90,000 residents in the catch- Non-physical types of abuse, including psychological/ ment area (Addo-Atuah et al., 2012). emotional and economic abuse, can also have serious health We chose this district as our study site for several reasons. consequences for women living with HIV. Following diagno- First, HIV prevalence in the district has remained the high- sis, HIV-positive women have to deal with the psychological est in Ghana since 1986, when the first case of the virus was trauma and mental health effects of living with a disease that found. HIV prevalence was estimated at 13% in 1999, 4 times is heavily stigmatized in Ghana and Africa. But disclosure higher than the national average of 3% at the time. Although to male partners eliciting a negative reaction has the greatest a recent national HIV sentinel survey indicates a reduction psychological impact on women. Research shows emotional/ in prevalence to 11%, the district continues to lead in AIDS psychological abuse often follows women’s disclosure of morbidity and mortality (see NACP, 2003; Owusu, 2020). their serostatus (Chilemba et al., 2014; Medley et al., 2009). The high HIV prevalence in the Lower Manya Krobo District Knowledge of the female partner’s HIV status may lead to has often been traced to high levels of poverty in the area and insults, guilt, intimidation, and blame, and the violence ensu- the migration of local women to neighboring countries, such ing from these behaviors can exacerbate the negative psy- as Cote D’Ivoire (known to have one of the highest rates of chosocial and mental health effects associated with diagnosis infection in West Africa), where they engage in commercial and disclosure. Previous studies have found that HIV-positive sexual activities. After becoming infected, they return to con- women who experience emotional abuse frequently devel- tinue the sex trade in Ghana (Fobil & Soyiri, 2006). Second, oped anxiety disorders, post-traumatic stress disorder, and our own IPV studies in the area indicate high prevalence and depression (Merrill et al., 2022; Zunner et al., 2015). severe forms of violence compared to other parts of Ghana. Another type of non-physical abuse is economic abuse. We attribute this to patrilineal norms and entrenched patriar- Economic abuse refers to behaviors that threaten an individu- chal values among the indigenes in the area. al’s economic security and financial self-sufficiency (Fawole, 2008; Sedziafa et al., 2017). While women can be perpetra- Data Collection and Sampling tors, they are mostly victims because of their socio-economic marginalization, especially in patriarchal cultures (Sedziafa Data were collected from a cross-section of 538 HIV-positive et al., 2017; Tenkorang & Owusu, 2018). For women living women aged 18 years and older in the Lower Manya Krobo with HIV who are too sick to work or discriminated against District. A sample of respondents was drawn from two hos- in the labor market due to their HIV status, dependence on pitals serving the District (Atua Government Hospital and St. male partners is inevitable, making economic abuse almost Martins de Porres Catholic Hospital located in Agormanya). inescapable. Male partners can abuse female HIV-positive The hospitals were selected because they treat almost all women by neglecting or abandoning household economic HIV-positive persons in the District. Both hospitals were needs. They may extort, steal, and prevent female partners chosen by the Ghana Ministry of Health and the Family from engaging in productive economic activities, thus sabo- Health International as pilot “learning centres” for the pro- taging their financial independence. At the moment, few stud- vision of comprehensive HIV/AIDS-related services (Addo- ies (if any) have explored the effects of economic abuse on the Atuah et al., 2012; Ritzenthaler, 2005). HIV/AIDS services health outcomes of women living with HIV/AIDS. While the provided by the hospitals include voluntary counseling and health impact of economic abuse on Ghanaian women more testing (VCT), prevention of mother-to-child transmission, generally has been demonstrated in a study by Tenkorang and clinical care, and home-based care (Addo-Atuah et al., 2012; Owusu (2018), to the best of our knowledge, this is the first Ritzenthaler, 2005). study to examine the impact of IPV and economic abuse on Study participants were selected from those who came for the health outcomes of women in Ghana. check-ups at Antiretroviral Treatment Centres of the Atua government hospital and the St. Martin de Porres hospital. An average of about 25 HIV-positive women show up for Data and Methods such services daily at each hospital. Each arrival is handed a Study Context unique code number. This method ensured a random selec- tion of 16 participants for our study (eight for each hospital a This study was conducted in the Lower Manya Krobo District day). The assignment of unique code numbers meant we were in Ghana. This district constitutes one of the 26 administra- able to track all participants, so they were not included in the tive districts in the Eastern Region of Ghana. Its major eco- same process the next day and not used twice in the study. nomic activities are farming and fishing. The district covers Data were collected in face-to-face interviews, and research 4 Health Education & Behavior 00(0) assistants (RAs) conducting the interviews confirmed all par- various sources: WHO’s survey for the Study of Women’s ticipants were HIV positive. All RAs had received COVID Health and Violence against Women, domestic violence vaccinations, wore face masks, and observed social distancing modules from Demographic and Health Survey and Multiple protocols. All participants wore face masks and observed all Indicator Cluster Survey (MICS), and the 2007 Ghana COVID-19 protocols during interviews. Domestic Violence Act (Institute of Development Studies, Recruitment of participants began in August 2021 and ended Ghana Statistical Services and Associates, 2016). in December 2021 after receiving ethics clearance from the A series of control variables measured the socio-eco- Interdisciplinary Committee on Ethics in Human Research nomic and demographic characteristics of participants: edu- (ICEHR) at Memorial University of Newfoundland (where the cational background (no education = 0, primary education first author is affiliated) and the Ghana Health Service (GHS) = 1, secondary education = 2, postsecondary education = operating under the Ministry of Health (MOH). The first two 3); employment status (not employed = 0, employed = 1); authors and six RAs participated in data collection. Training monthly income (no income = 0, less than 1,000 Ghana sessions were held for all RAs at the Institute of Statistical, Cedis = 1, more than 1,000 Ghana Cedis = 1); ethnicity Social and Economic Research (ISSER), University of Ghana (Ga Adangbe = 0, Ewe = 1, Akan = 2); currently married (no (where the second author is affiliated). Given the sensitive = 0, yes = 1, cohabiting = 2); and age measured in complete nature of the topic, they were trained to ensure the safety and years and as a continuous variable. confidentiality of participants. Counseling services in-person and over the phone were provided for participants who needed Data Analysis these services before and after the interview process. RAs were native Krobos who had excellent knowledge of other Ghanaian The dependent variables had different measurement schemes, languages and could speak and interact fluently. Data were col- so we employed statistical techniques specific to those lected in Krobo and English. Before data collection, question- schemes. We used binary logistic regression for all the dichot- naires were pretested with some participants (constituting about omous/binary outcomes (cardiovascular and sexual health) 5% of the sample) and modified as needed. Individuals used and ordinary least squares (OLS) regression for the continu- in the pre-testing phase did not participate in the final study. ous outcome (psychosocial health). For the binary outcomes, we used different link functions, given the skewness of the Measures distributions. For instance, a glance at Table 2 shows our sex- ual health outcomes were not evenly distributed, with cases We used three measures of health, given our interest in exam- heavily concentrated in a specific category. In such cases, ining the impact of IPV on health outcomes: cardiovascular using a logit link function, which is mostly suitable for sym- health, sexual health, and psychosocial health. Cardiovascular metrically distributed cases, may be problematic and can lead health was measured with four variables; participants were to biased standard errors and statistical inferences. Thus, for asked if they had been diagnosed with non-gestational hyper- our sexual health outcomes, we employed the log-log link tension, heart attack, high blood cholesterol, and non-gesta- function suitable for asymmetrical distributions and available tional diabetes. Those who answered in the affirmative to at in STATA 16 in the generalized linear model (GLM). The least one variable had a cardiovascular health problem; oth- GLM is an umbrella of statistical techniques that allows flex- erwise, they did not. Thus, the derived cardiovascular health ibility in choosing different link functions appropriate for how variable was dichotomous. Sexual health was measured with outcomes are distributed. We estimated univariate, bivariate, two binary variables; participants were asked if they had and multivariate statistics to describe our data. We used bivar- experienced an unwanted pregnancy or a pregnancy loss. iate and multivariate models for all three health outcomes Psychosocial health was measured with 11 variables for emo- (cardiovascular, sexual, and psychosocial health). Odds ratios tional/psychological health (see Table 1). A weighted sum- and regression coefficients were used to describe the relation- mative index was extracted (Anderson-Rubin factor scores) ship between IPV and health outcomes. Odds ratios greater after principal component analysis (PCA). Cronbach’s alpha than one means participants are more likely to experience the for this scale was .970. Positive values on the scale indicate outcome; less than one means they are less likely to do so. A poor psychosocial health, and negative values indicate better positive regression coefficient in this research context means psychosocial health. We used four main variables to measure poor health, and a negative coefficient means good health. respondents’ experiences with IPV: physical, sexual, psycho- logical/emotional, and economic abuse. These latent binary Results variables were derived from several indicators measuring the lifetime experiences of IPV (see Table 1). These lifetime Table 2 shows the univariate distribution of the selected measures of IPV were adapted from the 2015 Ghana Family dependent and independent variables. The average age of Life and Health Survey (GFLHS; Institute of Development the sample was about 45 years; unsurprisingly, the majority Studies, Ghana Statistical Services and Associates, 2016). (79%) were Ga Adangbes. Very few women (9.2%) had post- GFLHS uses locally adapted measures of violence from secondary education, although the majority were employed. Tenkorang et al. 5 Table 1. Description and Operationalization of Variables. Intimate partner violence Description and operationalization Physical violence A summative index derived from six questions that asked women whether their husbands/partners: pushed, shook, or threw something at them; slapped them; twisted their arm or pulled their hair; punched them with their fist; tried to choke and burn on purpose; and kicked, dragged, or beat them. All variables were coded “yes = 1” and “no = 0.” All variables loaded on the same construct using PCA. Respondents experienced physical violence if they answered in the affirmative to at least one of the questions; otherwise, they did not experience physical violence. Sexual violence A summative index derived from four questions that asked women whether their husbands/partners: physically forced to have sex with them even when they did not want to; forced them to perform sexual acts they did not want to; made inappropriate sexual acts that made them feel uncomfortable; and penetrated them with an object against their will. All variables were coded “yes = 1” and “no = 0.” All variables loaded on the same construct using PCA. Respondents experienced sexual violence if they answered in the affirmative to at least one of the questions; otherwise, they did not experience physical violence. Psychological/emotional A summative index derived from four questions that asked women whether their husbands/partners: violence said or did something to humiliate them in front of others; threatened to harm them or someone close to them; insulted them or made them feel bad about themselves; and threatened them with a knife, gun, or any other weapon. All variables were coded “yes = 1” and “no = 0.” All variables loaded on the same construct using PCA. Respondents experienced psychological violence if they answered in the affirmative to at least one of the questions; otherwise, they did not experience psychological violence. Economic violence A summative index derived from eight questions that asked women whether their husbands/partners: refused to give enough housekeeping money even though he had enough money to spend on other things; taken cash or withdrawn money from their bank account or other savings without permission; controlled their belongings and/or their spending decisions; destroyed or damaged property they had material interest in; prohibited them from working or forced them to quit work; forced them to work against their will; prevented them from working in a paid job; and refused to give them or denied them food or other basic needs. All variables were coded “yes = 1” and “no = 0.” All variables loaded on the same construct using PCA. Respondents experienced economic violence if they answered in the affirmative to at least one of the questions; otherwise, they did not experience psychological violence. Health outcomes Cardiovascular health A summative index derived from four questions that asked women whether they had been told by physician/doctor they had any of these diseases: non-gestational hypertension; heart attack; high blood cholesterol; and non-gestational diabetes. All variables were coded “yes = 1” and “no = 0.” Respondents had a cardiovascular problem if they answered in the affirmative to at least one of the questions; otherwise, they did not have a cardiovascular health problem. Psychosocial health A weighted summative index derived from 11 questions that asked women to indicate how many times they felt the following in the last 30 days: hopeless; owned and controlled; had no control over their life and property; ashamed; like a prisoner; nervous; depressed that nothing could cheer them up; that everything was an effort; restless or fidgety; worthless; and thought of ending their lives. All variables were coded “none of the time = 0,” “a little of the time = 1,” “some of the time = 3,” “most of the time = 4,” “all the time = 5.” All variables loaded on the same construct using PCA. The Anderson– Rubin factor scores were extracted and used as a scalar variable. Positive values on the scale means poor psychosocial health and negative values better psychosocial health. Note. PCA = principal component analysis. Approximately 34.5% lived with at least a cardiovascular and the three measures of health. HIV-positive women with health condition. About 17% and 12% reported unwanted experiences of physical abuse were 54% and 2.57 times more pregnancies and pregnancy loss, respectively. On average, likely to report unwanted pregnancies and pregnancy loss, women reported poor psychosocial health. IPV was high respectively, than those with no such experiences. Women among this sample of HIV-positive women. About 61% had with experiences of physical violence also reported poor psy- experienced physical violence, 50.9% reported sexual vio- chosocial health. Similar to the findings for physical abuse, lence, 79.6% mentioned emotional/psychological violence, HIV-positive women with experiences of sexual violence had and 66.8% reported economic violence. a greater likelihood to report unwanted pregnancy, pregnancy Table 3 estimates the bivariate effects of IPV on health out- loss, and poor psychosocial health. Surprisingly, those who comes. Results indicate significant relationships between IPV reported sexual abuse were less likely to report cardiovascular 6 Health Education & Behavior 00(0) Table 2. Distribution of Selected Dependent and Independent unwanted pregnancies, pregnancy loss, and poor psychosocial Variables. health. Dependent variables n = 538 %/mean Although the bivariate findings are important, they only indicate the gross effects of our focal predictors on the out- Cardiovascular health comes. Table 4 shows multivariate results and the net effect No 352 65.5 of IPV on the three health outcomes after controlling for the Yes 186 34.5 socio-economic characteristics of the sample. The multivari- Sexual health ate results are largely consistent with our bivariate findings. Unwanted pregnancy HIV-positive women who had experienced physical abuse No 448 83.2 were 42% more likely to report unwanted pregnancies than Yes 90 16.8 those who had not and about 2.5 times more likely to report Pregnancy loss pregnancy loss. We had similar findings for women who were No 472 87.7 Yes 66 12.3 sexually abused; they were more likely to report unwanted Psychosocial health (mean score) — .179 pregnancies (66%), pregnancy loss (59%), and poor psycho- Focal predictor social health. As in the bivariate results, HIV-positive women Physical violence who experienced emotional abuse were about 2 times more No 211 39.2 likely to report living with a cardiovascular health problem; Yes 327 60.8 they also had poor psychosocial health. Finally, economically Sexual violence abused women reported unwanted pregnancy, pregnancy loss, No 264 49.1 and poor psychosocial health. Yes 274 50.9 Emotional violence Discussion No 110 20.4 Yes 428 79.6 IPV is an important global health and development concern that Economic violence requires immediate attention from policy makers, especially No 179 33.2 in sub-Saharan Africa where patriarchy is rife, and this type of Yes 359 66.8 violence is commonplace. The literature is replete with stud- Socioeconomic/demographic variables ies that document its negative impact on women’s health out- Educational background comes (Silverman & Raj 2014; Tenkorang, 2019). The effects No education 139 25.8 are exacerbated for women living with HIV/AIDS, as they are Primary 96 17.9 already marginalized and their health may be compromised. Secondary 253 47.0 Yet studies on the health consequences of IPV on women living Postsecondary 50 9.2 with HIV are lacking. In Ghana and sub-Saharan Africa, we Employment status know little about the IPV experiences of HIV-positive women, Not employed 167 31.0 and the health consequences of such experiences are conspicu- Employed 371 69.0 ously missing. This study begins to fill the gap by examining Monthly income No income 252 46.8 the effect of several dimensions of IPV on the cardiovascular, Less than 1,000 Ghana Cedis 192 35.7 sexual, and psychosocial health of women living HIV/AIDS in More than 1,000 Ghana Cedis 94 17.5 the Lower Manya Krobo District of Ghana. Ethnicity Our findings show high levels of intimate partner abuse Ga Adangbe 426 79.2 against HIV-positive women in this District of Ghana. Ewe 76 14.2 Emotional/psychological abuse was the most reported, fol- Akans 36 6.6 lowed by economic, physical, and sexual abuse. The preva- Currently married? lence of IPV in this sample was higher than has been reported No 298 55.5 in the general female Ghanaian population (see Institute Yes 123 22.8 of Development Studies, Ghana Statistical Services and Cohabiting 117 21.7 Associates, 2016; Tenkorang, 2019; Tenkorang et al., 2013). Average age of respondents — 44.7 This finding of a significantly higher prevalence of IPV against HIV-positive women is consistent with other studies in sub- Saharan Africa (Burgos-soto et al., 2014; Maman et al., 2000; health problems. HIV-positive women with experiences of Olowookere et al., 2015) and elsewhere (Orza et al., 2015). emotional violence were about 2 times more likely to report In a study comparing the lifetime prevalence of IPV against living with at least a cardiovascular health problem; they also HIV-positive and HIV-negative women in Togo, Burgos-soto reported poor psychosocial health. Finally, those who experi- et al. (2014) estimated that about 63.1% and 69.7% of HIV- enced economic abuse were significantly more likely to report positive women had experienced physical and sexual violence, 7 Table 3. Bivariate Associations Between Intimate Partner Violence and Health Outcomes Among HIV+ Persons in Ghana, 2022. Sexual health Cardiovascular health Unwanted pregnancy Pregnancy loss Psychosocial health Focal predictors OR 95% CI OR 95% CI OR CI B 95% CI Physical violence No 1.00 1.00 1.00 0.000 Yes 0.800 [0.555, 1.15] 1.54 [1.23, 1.93]*** 2.57 [1.91, 3.46]*** 0.826 [0.664, 0.988]*** Sexual violence No 1.00 1.00 1.00 0.000 Yes 0.665 [0.463, 0.955]** 1.80 [1.44, 2.25]*** 1.63 [1.30, 2.04]*** 1.18 [1.04, 1.32]*** Emotional violence No 1.00 1.00 1.00 0.000 Yes 2.19 [1.32, 3.61]*** 1.21 [0.925, 1.59] 1.86 [1.33, 2.60]*** 0.937 [0.735, 1.14]*** Economic violence No 1.00 1.00 1.00 0.000 Yes 1.21 [0.823, 1.78] 1.36 [1.07, 1.71]*** 1.69 [1.31, 2.18]*** 0.485 [0.305, 0.665]*** Socioeconomic /demographic variables Educational background No education 1.00 1.00 1.00 0.000 Primary 0.656 [0.383, 1.13] 1.23 [0.880, 1.72] 0.848 [0.599, 1.20] –0.120 [–0.378, 0.138] Secondary 0.516 [0.335, 0.797]*** 1.64 [1.25, 2.15]*** 1.12 [0.854, 1.46] 0.518 [0.315, 0.721]*** Postsecondary 0.302 [0.139, 0.654]*** 0.843 [0.538, 1.32] 1.31 [0.867, 1.97] 0.543 [0.228, 0.858]*** Employment status Not employed 1.00 1.00 1.00 0.000 Employed 0.588 [0.401, 0.861]*** 0.853 [0.678, 1.07] 1.05 [0.827, 1.32] 0.019 [–0.169, 0.205] Monthly income No income 1.00 1.00 1.00 .000 Less than 1,000 Ghana Cedis 1.09 [0.714, 1.66] 0.357 [0.709, 1.15] 1.19 [0.930, 1.51] –0.963 [–1.13, –0.797]*** More than 1,000 Ghana Cedis 2.68 [1.63, 4.41]*** 0.457 [0.317, 0.658]*** 0.856 [0.619, 1.18] –1.25 [–1.46, –1.05]*** Ethnicity Ga Adangbe 1.00 1.00 1.00 0.000 Ewe 0.687 [0.395, 1.20] 0.927 [0.678, 1.27] 0.989 [0.720, 1.36] 0.569 [0.323, 0.816]*** Akans 0.670 [0.303, 1.48] 0.837 [0.529, 1.32] 0.734 [0.448, 1.20] 0.334 [–0.014, 0.682] Currently married? No 1.00 1.00 1.00 0.000 Yes 0.326 [0.199, 0.533]*** 0.578 [0.432, 0.773]*** 0.598 [0.440, 0.811]*** –0.010 [–0.220, 0.204] Cohabiting 0.269 [0.159, 0.456]*** 1.06 [0.772, 1.38] 0.968 [0.737, 1.27] 0.512 [0.298, 0.726] Average age of respondents 1.06 [1.04, 1.07]*** 0.973 [0.964, 0.982]*** 0.988 [0.979, 0.997]*** –0.036 [–0.042, –0.030]*** Note. Unadjusted odds ratios (ORs) and coefficients (B) are reported with confidence intervals (CIs) in brackets. **p < .05. ***p < .01. 8 Table 4. Multivariate Associations Between Intimate Partner Violence and Health Outcomes Among HIV+ Persons in Ghana, 2022. Sexual health Cardiovascular health Unwanted pregnancy Pregnancy loss Psychosocial health Focal predictors AOR 95% CI AOR 95% CI AOR 95% CI AB 95% CI Physical violence No 1.00 1.00 1.00 .000 Yes 0.878 [0.519, 1.48] 1.42 [0.988, 2.05]** 2.48 [1.57, 3.90]*** .030 [–0.168, 0.174] Sexual violence No 1.00 1.00 1.00 .000 Yes 0.903 [0.528, 1.54] 1.66 [1.19, 2.30 ]*** 1.59 [1.13, 2.23]*** .592 [0.421, 0.763]*** Emotional violence No 1.00 1.00 1.00 .000 Yes 2.31 [1.18, 4.51]*** 0.636 [0.401, 1.01] 0.793 [0.450, 1.39] .360 [0.152, 0.568]*** Economic violence No 1.00 1.00 1.00 .000 Yes 0.829 [0.506, 1.36] 1.43 [1.03, 1.99]** 1.66 [1.15, 2.41]*** .216 [0.060, 0.372]*** Socioeconomic/demographic variables Educational background No education 1.00 1.00 1.00 .000 Primary 1.21 [0.637, 2.31] 1.22 [0.815, 1.84] 0.761 [0.467, 1.24] –.137 [–0.346, 0.072] Secondary 1.08 [0.603, 1.94] 1.22 [0.840, 1.78] 0.891 [0.608, 1.31] –.025 [–0.210, 0.159] Postsecondary 0.822 [0.315, 2.14] 0.494 [0.249, 0.980]** 1.15 [0.639, 2.17] .061 [–0.219, 0.342] Employment status Not employed 1.00 1.00 1.00 .000 Employed 1.22 [0.679, 2.19] 0.667 [0.460, 0.968]** 0.748 [0.508, 1.10] .068 [–0.112, 0.248] Monthly income No income 1.00 1.00 1.00 .000 Less than 1,000 Ghana Cedis 0.751 [0.412, 1.37] 1.44 [0.989, 2.10] 1.84 [1.25, 2.70]*** –.539 [–0.723, –0.354]*** More than 1,000 Ghana 0.779 [0.621, 2.59] 0.829 [0.471, 1.46] 1.22 [0.693, 2.16] –.504 [–0.733, –0.275]*** Cedis Ethnicity Ga Adangbe 1.00 1.00 1.00 .000 Ewe 1.08 [0.564, 2.07] 0.697 [0.463, 1.05] 0.944 [0.636, 1.40] .097 [–0.097, 0.292] Akans 0.779 [0.325, 1.87] 0.755 [0.415, 1.37] 0.781 [0.421, 1.44] .160 [–0.099, 0.419] Currently married? No 1.00 1.00 1.00 .000 Yes 0.394 [0.223, 0.695]*** 0.538 [0.369, 0.782]*** 0.634 [0.422, 0.952]** .072 [0.246, 0.101] Cohabiting 0.403 [0.218, 0.744]*** 0.751 [0.532, 1.06] 0.823 [0.577, 1.17] .063 [–0.113, 0.238] Average age of respondents 1.04 [1.02, 1.07]*** 0.973 [0.958, 0.987]*** 0.987 [0.970, 1.00] –.016 [–0.023, –0.009]*** Note. Adjusted odds ratios (AORs) and coefficients (AB) are reported with confidence intervals (CIs) in brackets. **p < .05. ***p < .01. Tenkorang et al. 9 respectively. They did not measure emotional/psychological loss are high (Adeniyi et al., 2018), the effects of violence violence, but other studies have found emotional violence is can be severe, as demonstrated in our findings. the most common type of abuse among women living with IPV also affects the psychosocial health of women living HIV (Fiorentino et al., 2019; Meskele et al., 2021). It was not with HIV/AIDS. Living with HIV comes with its own psycho- particularly surprising that emotional abuse was common in social stressors. Cianelli et al. (2022) indicated, for instance, our sample, as disclosure of HIV serostatus is often met with that depression may be a natural consequence of living with shock by male partners. In their study on emotional abuse the virus given the common experience of social isolation, among women living with HIV/AIDS in Malawi, Chilemba stigma, discrimination, and anxiety. Other contextual factors, et al. (2014) narrated experiences of abandonment, blame, including social class, may intersect to compound existing humiliation, and lack of support following female partners’ vulnerabilities, with consequences for psychosocial health. disclosure of their HIV status—behaviors that are either emo- For example, IPV has been found to be negatively associated tionally abusive or create conditions for abuse. with the psychosocial health of those who are HIV positive Economic abuse was the second most prevalent type of (Filiatreau et al., 2020; Schwartz et al., 2014) and our find- abuse in our sample. This is worth mentioning because eco- ings corroborate this. Emotional/psychological abuse often nomic abuse has rarely been studied among women living manifests via insults, threats, and intimidation and can affect with HIV/AIDS. As HIV-positive women suffer emotional victims’ self-esteem and confidence, while casting a shadow abandonment following disclosure, it is quite possible they of fear over their lives. Meanwhile, sexual abuse has been will also experience economic abandonment, where male documented to generate both emotional harm and post-trau- partners refuse to provide financially or economically. matic stress disorder for HIV-positive women (Machtinger Our results demonstrate that the various types of IPV et al., 2012). Economic abuse may create financial pressures have an impact on women’s cardiovascular, sexual, and for Ghanaian HIV-positive women as well. Economic vulner- psychosocial health. For instance, emotional abuse was sig- abilities can be stressful and may pose significant psychoso- nificantly associated with women’s cardiovascular health cial health risks for victims. outcomes. Research linking abuse to women’s cardiovascu- Despite these findings, there are some limitations we should lar health is scant, but a few studies document links between mention. First, we used cross-sectional data and thus cannot the two (Alonso et al., 2019; Stone et al., 2017). Drawing on draw causal links between IPV and the health outcomes of stress theory, Scott-Storey et al. (2019) identified lifetime women in Ghana. Second, survey research on sensitive topics emotional/psychological abuse as capable of generating including IPV may be subject to recall bias, and our study is chronic stress, and this, in turn, can lead to immunologic no different. In particular, respondents may underreport their changes and increased blood pressure. Abuse can also trig- experiences with intimate partner abuse. Third, the questions ger depression and changes in mood, both of which increase on IPV capture lifetime experiences of violence not specific the risk of cardiovascular diseases. HIV-positive Ghanaian to a certain period. Nevertheless, to the best of our knowledge, women have a high risk of cardiovascular disease, given this study provides the first known documented evidence of the levels of stigma associated with HIV in Ghana and the the impact of IPV on the health of HIV-positive Ghanaian depression resulting from social isolation. For this group women. As this study only focused on HIV-positive women, of women, experiencing emotional abuse is triple jeopardy, future research can compare the health consequences of IPV and the consequences of chronic stress and cardiovascular for HIV-positive and HIV-negative women. diseases are severe. Our findings point to some policy suggestions. First, it is Physical, sexual, and economic abuse were all significantly important to consider screening for domestic and intimate associated with the sexual health outcomes of our participants. partner abuse as part of HIV care for HIV-positive women Women who experienced these types of violence were more at risk. Screening in health care settings may provide a likely to report unwanted pregnancies and pregnancy loss. unique opportunity to identify and intervene before domes- These findings have been corroborated by studies in Ghana tic and intimate partner violence escalates (Boinville, 2013). (Tenkorang, 2019) and elsewhere (see Acharya et al., 2019; Interventions should include providing immediate counseling Ismayilova, 2010), although these studies focused on the gen- services and subsequent referral to the Domestic Violence and eral population. Research on abuse and sexual health using Victim Support Unit (DOVVSU). This could become part of HIV-positive samples is scarce; however, such information a national strategy toward dealing with HIV/AIDS. We are is required to address the reproductive health needs of HIV- not aware of existing policies or programs that encourage or positive women. Physical and sexual violence undermine require the screening of IPV among HIV-positive persons in women’s ability to assert their reproductive rights and auton- Ghana. Our findings offer evidence in support of such pro- omy. Economic abuse may create power imbalances that can grams. Second, it is clear from our findings that a substan- enhance male power and dominance, while increasing sexual tial proportion of women living with HIV in Ghana live with submissiveness and reducing women’s ability to negotiate other co-morbid conditions as well. This makes screening safer sex (Tenkorang, 2021). For women living with HIV/ for co-morbid conditions in HIV-positive women extremely AIDS, whose risks of unplanned pregnancy and pregnancy important to enhance their quality of life. Third, our findings 10 Health Education & Behavior 00(0) point to the need for integrating psychosocial counseling and Bowman, C. G. (2003). Theories of domestic violence in the treatment in HIV care, especially given the impact of IPV on African context. Journal of Gender, Social Policy & the Law, the psychosocial health of women living with HIV/AIDS in 11(2, 847–863. the Lower Manya Krobo Municipality, Ghana. Laurenzi et al. Brokaw, J., Fullerton-Gleason, L., Olson, L., Crandall, C., (2022) argue that psychosocial interventions are an impor- McLaughlin, S., & Sklar, D. (2002). Health status and intimate partner violence: A cross-sectional study. Annals of Emergency tant pathway to improving the health and other behavioral Medicine, 39(1), 31–38. outcomes of HIV-positive persons. Comprehensive HIV care Burgos-Soto, J., Orne-Gliemann, J., Encrenaz, G., Patassi, A., in Ghana includes providing psychosocial support for and Woronowski, A, Kariyiare, B., Lawson-Evi, A. K., Leroy, V., follow-up visits for persons living with the virus (Tenkorang Dabis, F., Ekouevi, D. K., & Becquet, R. (2014). Intimate partner et al. 2017). However, these services need to be expanded to sexual and physical violence among women in Togo, West Africa: be sensitive to the needs of HIV-positive women who experi- Prevalence, associated factors, and the specific role of HIV infec- ence IPV. tion. Global Health Action, 7(1), 23456. https://doi.org/10.3402/ gha.v7.23456 Declaration of Conflicting Interests Campbell, J. C. (2002). Health consequences of intimate partner violence. The Lancet, 359, 1331–1336. The author(s) declared no potential conflicts of interest with respect Campbell, J. C., Baty, M. L., Ghandour, R. M., Stockman, J. 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