In this case-control study, we described injury patterns and identified risk factors for injuries from physical violence among women in the Gambia who sought care at urban ERs/OPDs. Our results revealed that being a Fula woman, living in a compound with multiple households, having more than five female siblings, being brought up in childhood by grandparents and being verbally or physically abused in the past 12 months were independently associated with injury from physical violence among women in the Gambia.

As with previous studies in the US Ranney et al., 2009; Jacovides et al., 2013, a large proportion of injuries from physical violence were assaulted by friends, in the daytime, in the home and were caused by hitting with objects or punched with fist / kicked with legs. The head, neck, and face were the most common injured body parts. These findings highlight the extent to which injury from physical violence may be associated with frequent social interaction with friends, colleagues and family members during the daytime.

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Our finding of the Fula ethnic group having an increased risk for injury from physical violence could be associated with early marriage. In the Gambia,  Fula women marry at an early age GBoS/UNICEF, 2010 which has been found to be associated with violence victimization Hong Le et al., 2014; Rahman et al., 2014; Peterman et al., 2015. More than 60% of the Fula women in the Gambia are married before age 18 years GBoS/UNICEF, 2010 which is more than 50% as found in our study.

The association between living in a compound with multiple households and injuries from physical may reflect the structural and sociocultural characteristics of the Gambian society where families live in communes, and often times consisting of two or more generations GBoS/ICF, 2014. This situation could be challenging, particularly where women from different backgrounds are married to male siblings and live together in one extended family compound. Consequently, misunderstandings and rivalry due to cooking turns, shared facilities, gossiping, teasing, as well as other issues relating to quarrels between children may have resulted in physical confrontation among women causing injury. In addition, physical violence against women may also be precipitated by male partners through jealousy regarding infidelity since it has been reported that physical violence against women is associated with a recent breakup in relationships Hirschinger et al., 2003. As for the association between having more than five female siblings and the risk of injury from physical violence; possible reasons for this is that having numerous children is synonymous with polygamous marriages Ali et al., 2014 where contentious rivalry among co-wives may be extended to their children. This pattern of violence could also be related to outgrown younger siblings trying to physically challenge older siblings. It is also possible that cultural norms for older sibling physically assaulting younger siblings as a means for protection or social control Tucker et al., 2010 may have resulted in physical assault causing injury. Additionally, spending time with a violent-prone female sibling has been found to increase the risk of later victimization Taylor et al., 2015.

Contrary to previous findings Hayslip Jr and Kaminski, 2005; Sandberg, 2016, we found women who had been brought up by grandparents to have had an increased risk for injuries from physical violence. Prior studies have indicated that children who are cared for by grandparents are deprived of parental love and can often exhibit violent behavior Hameed-ur-Rehman and Sadruddin, 2012; Laeheem, 2013. One possible explanation of our finding may be related to old age and chronic health problems associated with grandparents Keles et al., 2007 which may make them less likely to have full supervisory control over the grandchildren. As a result, children may be engaged in peer-motivated delinquent behaviors exposing them to the risk of victimization outside of the home Jackson et al., 2013. Another possible explanation may be due to the pampering of grandchildren by their grandparents which might have influenced their behaviors negatively. As found in Thai study children pampered by parents were more likely than their counterparts to be violent Laeheem, 2013.

Consistent with studies in the  US and Sweden, Kaufman et al., 2016; Pratt-Eriksson et al., 2016, the previous victimization in the past 12 months was a risk factor of injury from physical violence among women in the Gambian. This finding is in line with the violence cycle theory Walker, 2009, which suggests that women tolerate violence perpetrated against them and would not seek help even after repeated episodes of violent events. Several other reasons, including prejudice against female victims, fear of embarrassment and retaliation, family privacy, concern for children and cultural norms Gracia, 2004; Peerzada and De Sousa, 2016; Sapkota et al., 2016 might have also contributed to the recurrence of injury from physical violence in this group of women. Therefore, support from family, community and institutional levels, as well as knowledge of when and where to seek care or support if they had suffered from violence, may be important factors to consider when designing violence interventions for women.

This study has several limitations. First, the small sample size may have limited our ability to observe the effects of other important variables in female victimization such as marital status, educational level, employment status, alcohol consumption and illicit drug use. The lack of information on lifestyle and behavioral factors on the perpetrator for adjustment purposes is also a possible limitation. Second, the results of this study might not be generalizable to all women who sought treatment at the ER/OPD due to injuries from physical violence. The study focused only on patients from government-managed health facilities in urban areas and those treated in private health facilities or live in rural areas might have different characteristics from our study population. Third, misclassifying the cause of injury for control patients as non-violent could not be completely eliminated, which might have underestimated the effects of risk factors on injuries from physical violence. Finally, we cannot exclude the possibility of recall and social desirability bias from both the participants and interviewers. Therefore, findings of this analysis should be interpreted with caution.

5. Conclusions

Factors such as being a Fula woman, having more than five female siblings, living in a compound with multiple households, being brought up by grandparents, being verbally or physically abused in the past 12 months were independently associated with injuries from physical violence among women in the Gambia. These risk factors could serve as useful targets in physical violence preventive interventions among women in the Gambia, as well as to identify women at risk of revictimization, particularly in the home environment.