Perception of Women on Gender-Based Violence in Guinea: A Qualitative Study

Background: Gender-based violence exists and is increasing worldwide, with higher rates in African regions where gender inequality persists. It affects adolescent girls and adult women. In Guinea, violence against women is a widespread phenomenon. Indeed, 9 out of 10 women aged from 15 to 64 have been victim of at least one act of violence. The objective of this study is to explore the perceptions of women in the community about the violence that they have undergone. Methods: It is a qualitative study using focus group discussions (FGD) with women aged 15-49 in three health districts. Results: Of the 18 FGD conducted, young women aged 20 to 24 were the most represented (33%). The main types of Gender-based violence include physical violence, sexual violence (rape) and verbal violence. These types of violence are committed by husbands and boyfriends as well as parents of young girls in a context of forced marriage. The consequences of this violence are injuries, unwanted pregnancies, induced abortions, woman humiliation, depression, divorce and abandonment of the children by the husbands. Women’s attitudes to this violence are essentially to remain silent for fear to be stigmatized, health care seeking and filing complaints to the gendarmerie/police or to the leaders of district and notables. Conclusion: GBV is recurrent in Guinea in all its forms. The perpetrators are intimate partners, family members and unknown aggressors. This phenomenon requires sustained attention of the authorities and a commitment of all the stakeholders in order to highlight the problem and make advocation for women so that these acts of violence can be reduced.


Background
The GBV phenomenon is universal. According to the WHO global estimates, 35% (approximately one third) of women, report to have been exposed to physical or sexual violence in their life, by an intimate partner or someone else. The WHO regions of Africa and the Eastern Mediterranean are most affected by this phenomenon, with a prevalence of 33% [1]. In fact, intimate partner violence refers to any behavior within an intimate relationship (partner or ex-partner) that causes physical, sexual or psychological harm, including physical aggression, coercive sex, psychological violence and other forms of domination [1].
The GBV is a problem that reflects the unequal power dynamics created in the gender binary system and is often perpetrated by those with more physical, cultural or social power and inflicted on those without [2]. It is prevalent among adolescent girls and young social positions to men and women. This perception of male-female relations establishes a real supremacy of the first over the second. Under the leadership of the Ministry of Social Action, Promotion of Women and Children, true progress has been made with the support of technical and financial partners, to fight against all forms of GBV. Legislative and regulatory texts have been adopted, and new institutions have been created or strengthened, such as the Office for the Protection of Gender, Childhood and Morals [5].

Methods
This is a cross-sectional qualitative study of women aged from 15 to 49 years in the community.

Study sites
To guarantee national representativeness on this issue, which is strongly customs-based, the prefectures of Mamou, Dabola and Lola, located in the different natural regions of Guinea, were targeted for this study.

Sampling
A random draw was carried out to select one urban and rural area per prefecture. The selection of FGD participants was done with the help of a local community guide and with the support of local women's association leaders.

Data collection techniques
Eighteen FGDs were equally conducted between urban and rural areas from September to October 2014. To conduct FGDs, Interviewers and supervisors received training on the use of the FGD guide for this study (magnitude, types, health consequences, women's attitudes).

Data analysis
The strategic assessment technique developed by the WHO/HRP with the use of similarity and difference tables was used to analyze the data collected in the field [8].

Ethical considerations
The National Health Research Ethics Committee of Guinea validated the study protocol. The procedure for obtaining informed consent from participants was followed throughout the data collection. Confidentiality of the information collected was ensured during and after the study. Table 1 shows that adolescent girls aged from 15 to 19 years constitute more than a quarter (26%) of the study population and young women in the age group of 20-24 years represent 33% of it. Among them, 64.9% were married; 29.2% were housewives and almost half (49.4%) had no schooling. adult women of low-and middle-income countries. Indeed, 28% of adolescent girls and 29% of young adult women reported to have experienced physical or sexual violence in their life, with the highest prevalence in the Eastern and Southern African region according to a quantitative study derived from the Demographic Health Survey (DHS) [3].

Results
Violence against women is a widespread phenomenon in Guinea. Indeed, the results of a survey conducted in 2009 revealed a prevalence of 91.9% of GBV, at least 9/10 women aged from15 to 64 have been victims of an act of violence since the age of 15. Among these, 36.5% were victims during the last 12 months preceding the survey [4]. Furthermore, at the age of 15 years, 24% of the girls live in a couple, this early marriage is a factor contributing to GBV in Guinea.
Another national survey conducted in 2016 on GBV reported that 55.7% of women reported to be victims of physical violence and 29.3% of sexual violence [5]. Guinean legislation stipulates laws against all forms of gender-based violence, but due to the ignorance of these laws, the economic vulnerability including sociocultural factors (religion, customs), victims' recourse is restricted. A training program for providers on the management of GBV has been developed, but it has not been widely distributed [5]. This is why it is important to understand this topic in order to get the opinions of women in the community on the violence perpetrated against them. It was noted that female genital mutilation (FGM), another form of GBV which is deeply rooted in Guinea (95% of women aged 15-49 have undergone FGM/Cutting), will not be included in this study due to its scope, associated factors and specific characteristics [6,7].

Objective of the Study
To explore perceptions and attitudes of women in the community towards GBV.

Specific objectives
• Determine the magnitude of GBV

Study setting
The Republic of Guinea is a coastal country in the West African region, covering an area of 245,857 km 2 , with a population estimated at 12,877,894 in 2021. It is comprised of four natural regions, and eight administrative regions including the capital Conakry. The majority of the Guinean population is strongly influenced by gender biases and stereotypes that assign Insults are also very frequent, especially in households. "In our community, women are victim of all kinds of violence. We are insulted by our husbands. We are marginalized in decisions that concern our children. We are wronged in the sharing of inheritances. We are also beaten and hurt by our husbands and their brothers. It is really pitiful to be a woman in this context." Concerning sexual violence perpetrated by husbands or sometimes by some young men in the neighborhood. A young woman living in a rural area report: "Last time

Types/Forms of GBV
As illustrated by the following statements, physical (beatings), sexual and verbal violence as well as forced marriages were reported as the main types of GBV experienced by women in their community. For example, a young participant from an urban area confirmed: "I have a cousin who is unhappy at home. Her husband always beats her for; he does not like her very much. He sometimes beats or insults her in front of the neighborhoods. It's a situation that worries the whole family". "There are corners in the city here where you don't dare to go alone there at late hours otherwise the young people gather to smoke, as soon as a girl goes there alone, they go and rape her." The parents can perpetrate physical and psychological violence against girls in a context of early and forced marriage. A woman from urban center reports: "I am not saying that violence against women does not exist here, but it is not too widespread. The cases I have seen are that, the parents of a young girl who was only 12-years-old decided to give her to marriage but the girl didn't want at all. I saw her father who tied her up and beat her badly until her whole body became a mess. Under the pretext that she wants to dishonor him."

Consequences of GBV
There are many consequences. For example, rape can lead to unwanted pregnancies. This can lead to induced abortions. A young student from a school explains: "The consequences of violence are numerous. There are pregnant women who commit abortions or give birth prematurely when they are beaten and they are too stressed. We also have cases of induced abortions because of shame. Because if a girl who is victim of rape is unlucky enough to get pregnant, she will try to abort the pregnancy. This puts her life at risk. Afterwards, she may not be able to have a child anymore." Furthermore, in the case of a pregnancy resulting from rape, the perpetrators often refuse to acknowledge paternity; this leads to the humiliation of the woman and her family. A young woman from a rural area report: "Girls who are raped by their boyfriends end up with unwanted pregnancies that the boyfriends refuse to recognize. So you will see that she is shunned in her own family and even in her surroundings." A young woman living in an urban area also insists on this shaming of women: "Talking about the consequences of rape, there are many unwanted pregnancies here that lead to abortions with all the problems. There are girls who are not married that get pregnant. They will no longer have any respect in their family and even in their surroundings." Pregnancies resulting from rape are sometimes accompanied by depression of the victim. A young woman in an urban area report: "Women who are victim of violence or rape are often depressed. Others are so ashamed that they find it difficult to go out in the community. Some of them prefer to move to another neighborhood because of the stigma." Participants in the FGDs also reported that physical violence sometimes leads to injuries and even fractured limbs in female victims, as this 25-year-old girl reports: "We women are forced to follow what our parents tell us. I have got an older sister who ran away from her a girl was raped at home by her cousin in our district. The young man took advantage on the long absence of the mother, who was on a trip to Dabola. And the girl's brothers were at school." Sexual and intimate violence is common in households with the previous of forced and often early marriage. A young woman in a rural area explains that: "When a girl is married by force, most often there is fight in the home. Her husband often beats her because she has no love for him and he wants to force her to have sex." Concerning forced marriages, a participant from an urban area insists on the full responsibility of parents in the GBV: "Yes, we have cases of forced marriages. A 15-year-old girl was forced to marry an adult man that she did not want. The man with whom she wanted to get married was the father of one her friends, you see? She was obliged to get married to a man that she didn't love. This act can traumatize her during all her lifetime. This girl's parents deprived her of everything. We can say that she was a victim of violence by her own parents."

GBV perpetrators
Most of the participants said that husbands are the main perpetrators of GBV. Husbands are very violent and use every argument to hurt their wives, as reported by a 28-year-old woman in an urban area: "We are much mistreated by our husbands. I  According to a participant from an urban area, it is very risky to walk around at night in some neighborhoods because the possibility of being assaulted by young people under drugs. of the families of victims of physical and sexual violence (including rape) are mainly addressed to the gendarmerie and the police: "In cases of rape of young girls on the first day, we often start with the hospital to treat the girl. Then the family of the perpetrator is summoned to the gendarmerie".
Complaints are also filed with the neighborhood leaders and the family of the perpetrator of the rape or physical violence (assault and battery). The following quotes speak for themselves: In cases of domestic violence, mediation within the family or with community leaders is prioritized.

"When there is a problem between a husband and his wife, the woman goes first to her in-laws to talk about it and if they do not manage to resolve it, she goes to her parents' house".
"The women victim of violence also turns to the local notables and imams in the hope that they will be able to sensitize their husbands and bring them to quit violence".

Discussions
Gender-based violence is a widespread phenomenon in Guinea. It is observed in many countries around the world, to various extents. Indeed, women are constantly exposed to threats of violence, especially domestic violence [9][10][11].
The main forms of violence against women observed in our study are physical violence in the form of beatings, sexual violence (including rape) and verbal violence as well. The same observation has been made by several authors. In Ghana and Brazil, sexual violence was also accompanied by physical and psychological violence [12,13]. Also in Nigeria, physical violence was the most common type experienced by women (58.1%) [14]. In another school-based study in Ethiopia, sexual violence and physical violence were 37.2% and 56.3% respectively [15]. In addition, other authors have reported harassment [16,17]. A systematic review in sub-Saharan Africa also reveals other forms including emotional violence (29.40%) [18]. A study in Pakistan also reports other types of violence against women in the community besides physical and verbal violence, including controlling behavior of the husband, conflicts with in-laws, overload of domestic work and the threat to leave or remarry [19].
husband who almost killed her. She says that he requires sex every day, morning and night. Then, the day she refuses, he beats her. One day he broke her arm and then apologized. My sister has decided never love him anymore even if we have to kill her. She said that she won't go back to her husband." Divorce is another consequence of domestic violence cited in several FGDs. For example, a young married girl in a rural area explains: "I left my first husband because of this. Every time he used to insult and beat me, especially on the day he was drunk. And that day, I would not have peace of mind. I did everything I could but I realized that I would always have problem him. I went one day to tell my parents that I could no longer stay with him. Fortunately, I did not have a child with him." These separations as a result of domestic violence can lead to the husband abandoning his children. A 25-year-old woman from an urban area explains: "Violence has more consequences. Especially if it leads to divorce. I am telling you this because I divorced my first husband. But I know that it caused difficulties in the education of my children. You know that men, when they abandon a woman, do the same thing to the children and this has a direct impact on their education."

Attitudes towards GBV
As for the attitude of women and their families towards GBV, the first one is silence, followed by the care and the steps to take after the violence. Because of the fear of parents' reactions or stigmatization in the community, girls who have been raped are sometimes forced to remain silent, as these urban adolescents explain: "The problem is that some girls, when they are raped, do not dare to talk to their family members or friends because they are ashamed or they fear discrimination. The pregnancy is discovered when they start to get sick and the family sends them to the hospital." This silence is also observed among married women in domestic violence cases for discretionary reasons: "We try to talk about it as a family, but sometimes we keep quiet. Otherwise, everyone will say that you filed a complaint against your husband with the authorities. You won't be welcome in the community. If you divorce, you won't find a husband because people will label you as a woman who doesn't respect men" In addition, women victim of physical violence go to local health facilities (hospitals, health centers) for treatment, especially in case of injuries or fractures.
"We go to the hospital for treatment of violence, and the injuries are treated. But you know that scars and after-effects can remain on the victim…." In the case of legal proceedings, the complaints of their "acceptance" of domestic violence. Indeed, the 2018 Guinea DHS reported that 48% of women think it is justified for a man to beat his wife if she refuses to have sexual intercourse with him and 54% when the woman goes out without her spouse's permission [6]. The prevalence of acceptance of intimate partner violence (IPV) is lower in Benin with 15.7% [29].
Studies conducted in Ethiopia also show that intimate partner violence is accepted in the community in case of infidelity [11,30]. For some women, GBV should be tolerated rather than condemned [11]. According to some authors, most women remain silent and very few defend themselves against violent husbands/partners [11,30]. The reason for women's silence is that they fear that the violence will intensify if they report it, and they fear the social stigma as well as the impact of the violence on the children [2,19].

Strengths and limitations
This study explored women's perceptions of violence against them, focusing on the forms and consequences of GBV and the attitudes they adopt when they are victims. However, the lack of data on the causes and associated factors is a limiting factor of this study. Furthermore, the collection of men's opinions on GBV would have allowed us to better grasp the issue.

Implications for practice and future research
The results of this study could be used to develop programs to fight and prevent GBV. In order to strengthen the prevention and fight against GBV in Guinea, it would be important to conduct studies in the future, including a quantitative component that would analyze the causes and factors that contribute to the occurrence of violence against women. This research should also reach out to men in the community and other stakeholders (health care providers, security and judicial services workers).

Conclusion
The GBV in all its forms is significant in Guinea. It is perpetrated by intimate partners, family members or unknown aggressors. Women often choose to remain silent in order to avoid other harmful consequences. This phenomenon should call for sustained community commitment through actions that will make everyone aware of their rights and duties. It also requires special attention from the authorities with the collaboration of all stakeholders through awareness and the adoption and enforcement of laws to fight against the phenomenon until its eradication.

Source of Funding
This article is a secondary analysis of data from a research study on "Women's Health in Guinea. Situational analysis" which is funded by WHO with MUSKOKA funds in 2014.
The Perpetrators of GBV in Guinea is often perpetrated in households by women's husbands, in neighborhoods by girls' boyfriends and also at family level, by the parents of young girls in cases of forced marriage. The perpetrators of violence against women are described differently in other studies on GBV, depending on the circumstances in which they occur. For example, women's intimate partners are often cited in cases of sexual violence [10,[20][21][22]. Perpetrators can also be unknown aggressors [10,13], as in our study, or known aggressors in the community [10]. Alcohol abuse has been cited in our study and by other authors as a factor contributing to the occurrence of physical and sexual violence [15,16,[22][23][24][25][26]. In Northern Macedonia, other major risk factors have been identified, such as the perpetrator's poor economic status, low level of education, unemployment, male privilege and the woman's subordinate status [23].
Consequences of GBV are multiples. According to our data, rape can lead to unwanted pregnancies, resulting in a high rate of induced abortions and the humiliation of women and their families. In addition, there are cases of depression of the victim woman. Our study also revealed that physical violence often leads to injuries, including broken limbs. Divorce and abandonment of children by the husband are others consequences of domestic violence. These different effects have also been reported by other authors, such the risk of induced abortion [27]. As in our study, female victims of GBV are also stigmatized in the Caribbean and in Pakistan [2,19]. The same applies to feelings of shame and guilt, which often prevent victims from seeking help from health professionals [2,19]. In Ghana, women have suffered physical injuries, psychological problems, sexual and reproductive health problems and suicidal thoughts as a result of violence [12]. These health problems have significantly affected their economic activities and impoverished their income. Sexual violence thus clearly interferes with women's empowerment [12].

Women's attitudes towards GBV
This study reveals that girls who have been raped often remain silent for fear of their parents or of stigmatization in the community. This phenomenon was also highlighted among women who married to save their homes. Physical violence is treated in health facilities. Families of victims of physical and sexual violence (including rape) file complaints with the security services, but also with neighborhood leaders and the family of the perpetrator of the rape or other physical violence. In the case of domestic violence, mediation within the family or with community leaders is the preferred option. In terms of GBV management, other authors highlight the limited availability of health services for GBV and the low use of these services like in Tanzania [28]. Many studies have noted, as in our results, the silence of married women, which is the result