STUDY OF DOMESTIC VIOLENCE AGAINST WOMEN ATTENDING OUT PATIENT CLINICS IN ASSIUT UNIVERSITY HOSPITALS

Asmaa Ghareeb Mohamed*, Hammam Mohamed Hammam**, Mahasen Ahmed Abd El-Wahed***, Hoda Diab Fahmy Ibrahim*, and Shokria Adly Labib*

*Community Health Nursing Department, Faculty of Nursing, Assiut University

** Community Medicine Department, Faculty of Medicine, Assiut University

***Community Health Nursing Department, Faculty of Nursing, Alexandria University

INTRODUCTION:

Violence against women cuts across social and economic situations and is deeply embedded in cultures around the world, so much so that millions of women consider it a way of life (Johnson, 1997). Domestic violence is a global problem that occurs regardless of culture, ethnicity, orientation, or socioeconomic class. In 2001, the U.S. Department of Justice found that more than half a million American women (588,490 women) were victims of nonfatal violence committed by Intimate Partners (Bureau of Justice Statistics Crime Data Brief, 2003).

                In Egypt, an estimate of incidence of abuse is not widely available. However, the results of a survey conducted by the National Social and Criminal Research Center revealed that 50% of violent crimes were within families (Zayed & Nasr, 1996). The National Demographic Health Survey conducted in Egypt in 1996 found that 35% of ever- married women had been beaten at least once since marriage (El- Zanaty et al., 1996). Children who witnessed domestic violence are victims of abuse. Daughters who witnessed their mother abused often, accept abuse later when they grow up from their brothers and husbands, i.e. they will behave as her model (mother). (Gage, 1990). Battering also poses a significant danger to unborn children. Nursing research has found that as many as 15.9% of women and 21.7% of female adolescents report abuse during pregnancy (Parker, et al., 1993). In Arab and Islamic countries, domestic violence is also a major understudied social problem. Surveys in Egypt, Palestine, Israel and Tunisia show that at least one out of three women is beaten by her spouse (Douki et. Al., 2003). This is not to say that domestic violence is a muslim problem, since a fair reading of the Koran shows that domestic violence is entirely prohibited. It seems that the high rate of domestic violence in Islamic countries is a result of culture rather than religion. Women who are abused have poorer mental and physical health, more injuries, and a greater need for medical resources than non-abused women (Campbell, 2002). There are many different effects that are caused by domestic violence; health may be impaired, which includes any thing from minor injuries to chronic problems. Children and young women are also greatly affected through both experiencing and witnessing abuse. Intimate partner violence is associated with both short- and long- term problems, including physical injury and illness, psychological symptoms, economic costs and death (National Research Council 1996). Long term effects of domestic violence on women who have been abused may include: anxiety, chronic depression, chronic pain, death, dehydration, dissociative states, drug and alcohol dependence, eating disorders, emotional “over reactions” to stimuli, health problems, malnutrition, panic attacks, poor adherence to medical recommendations, poverty, repeated self- injury, self neglect, sexual dysfunction, sleep disorders, strained family relationships, suicide attempts and an inability to adequately respond to the needs of their children (Newton, 2001).

Nurses are often the first professionals to assess clients when they come to a health care facility; they are in position to identify women, children, and elders whose presenting problems are associated with abuse. Community health nursing is in a unique position to address the health needs related to violent behavior. Community nursing directs community health nurses toward establishing long-term relationships with individuals, families, and communities. They have the knowledge, perseverance, and sensitivity to assist clients in coping with the many concerns and health needs associated with violent behavior.

Aim of the Study:

The present study aims to:

1-Study the magnitude of domestic violence against women who attend the outpatient clinics in Assiut University Hospitals.

2-Investigate the underlying factors behind it.

SUBJECTS AND METHODS:

I-Setting: This study was conducted in four outpatient, clinics' namely antenatal, gynecological, family planning and sterility clinics affiliated to Assiut University Hospitals.

II-Subjects: women who attending the previously mentioned outpatient clinics. The total number of the interviewed women was 1000, selected by a quota sample. The magnitude of the problem (violence inflicted on the woman) was calculated as a percent from the total interviewees.

III-Tools of the study:

1-The quantitative part (structured interview):

This part consists from structured interview questionnaire which was designed to collect quantitative data about some items which includes:

Sociodemographic data such as wife and husband age, residence, educational level, wife age at marriage, occupation, family type and consanguinity, present and past history of wife abuse, history of obstetrical complications accompanied by spousal abuse, effect of spousal abuse upon the physical, psychological and social status of the women and the causes of wife's abuse.

2-The qualitative part (Focus group discussions):

                Focus group discussion (FGD) are a powerful information gathering technique that uses small group discussion to identify views of people in the group about certain subject (Leebov, et al., 1991). This approach was selected to gain insight by encouraging participants to speak in their own words, to introduce related issues and to voice their concern during the course of the discussion. An interview guide was designed in Arabic language to obtain rich in- depth description of the wives belief and experiences about domestic violence, Participants were provided with an explanation of the purpose of the study, assured that their participation was voluntary and any information shared would remain confidential. To facilitate the group discussion, physical environment was prepared prior to the interview to ensure that each group member was physically comfortable as much as possible.

Methods:

I-Preparatory phase: It included the following activities:

Permission was obtained through an official letter to the Director of Assiut University Hospitals to carry out the study, after explanation of the aim and methods for data collection the data. An oral consent was obtained from women to participate in the study after explaining the purpose of the study.

Pilot study was carried out on 10% of women attend the previously mentioned clinics to test the clarity and relevance of the tools according to results of pilot study necessary modifications in the sheet were done. A structured interview method was used for data collection. The researcher read every question to the participant and obtained the participant’s responses and their feedback.

II-Data collection:

• ·Data was collected during the period from October 2003 to September 2004, through the interview of the women individually on 2 days weekly with a range of 10 questionnaire sheets per day, every sheet took an average time for 10-15 minutes. Every woman was interviewed individually according to the circumstances of the previously mentioned clinics in order to obtain the necessary information. The purpose of the study was explained to each woman before starting the interview to gain her confidence, cooperation and to allay her fear and anxiety. Women were assured that the data is confidential and secret.   
• · Six focus group discussion were conducted over a three weeks period. Each group comprised an average from 5-6 women.

FGDs were conducted by the researcher as a moderator with the assistance of a note taker to write every thing during the interview, and a tape recorder was used. FGDs were approximately 30-40 minutes in length. The data yield from each of the focus group interviews were analyzed and categorized based on the recurrent themes that emerged.

III- Data analysis:

The obtained data were analyzed and tabulated. Descriptive statistics were calculated e.g. frequency, percentage, mean and standard deviation. Statistical analysis was applied and the relevant tests (Chi square tests) were done by SPSS version 11 statistical program. P value considered significant when its value ≤0.05% was adopted.

RESULTS:

Results of this study were presented according in the following sequence:

Section I- results of quantitative study.

Table(1): shows sociodemographic charact-eristics of the studied sample. The mean age of wives was 26.89±6.55, more than half of women were illiterate of (54.2%). Only 5.6% of them were working for cash; more than half (56.3%) of them married at age of (15-19). The mean age at marriage was 19.01±3.72. Regarding to their husbands characteristics, their mean age was 32.84±8.43, one third of them were illiterate and about one third completed the secondary school education. Husbands were employees (25.4%) followed by farmer (23.8%). More than three quarters 78.2% live in rural areas compared to only 21.8% in urban areas, also half of them live in nuclear family, and two third of them (66.3%) had children and more than half (57%) of them had consanguinity with their husbands.

Figure (1) revealed that more than one third 41.3% of the studied sample had experienced one or more type of abuse.

As for types of abuse,table (2) shows that more than three quarters of them 89.3% verbally abused, 82.8% of them were physically abused by hitting, while about half of them were pushed, 41.2% pushed on the floor and more than one third of them pulled from hair. Regarding the psychosocial abuse facing wives, the present study revealed that, 14.2% of abused wives their husbands frustrate and inferior look to his wife, 11.1% of them their husbands prevent them from visiting relatives or friends and about 9.9% of abused wives their husbands prevent them to seek job.

Regarding the causes of domestic violence, table (3) revealed that one third 33.1% of stated causes by women who faced violence were due to husbands relatives problems, while 21% of causes were due to financial problems and 20.8% due to household duties (e.g late preparing food, poor house hygiene). Moreover, 19.1% of abused women mentioned that they were abused when refusing sex with their husbands, while 10.6% of causes due to children problems and 10.1% of causes when wife's reply on her husband instructions by bad words.

As regard the causes that prevent the abused wife from leaving home, figure (2) shows that among the abused wives who thinking about leaving home; 28% of them don't leave the house for many causes mentioned by them. The most important causes are fear about children, love her family, keeping her house from destruction and for traditions and values in a percent of 52.5%, 38.3%, 31.3%, and 16.1% respectively.

As regard the physical problems of physically abused women, table (4) shows that 26.8% had cyanosis in different parts of the body, while 9.9% of them had injuries, and there are (0.9%) women had bone fracture. Moreover, among the abused women 35.3% of them faced physical abuse during pregnancy. On the other hand, 8.2% of them had abortion and 1.3% of them had bleeding. As for the psychosocial problems facing the abused wives,it was noticed that about half of women not tell any one about abuse even their mothers and keep it secret, while more than one quarter 26.4% of them had a sense that they can not talk or discuss her own feelings with their husbands. On the other hand, about one third 30.5% of abused wives had a feeling of loneliness, and 19.9% had a feeling of unhappiness.

Table (5) shows the distribution of wife and husbands education in relation to violence. It was observed that the higher education of wives and husbands the lesser episodes of abuse. Statistically significant difference was observed between education of wife and violence also education of husband and violence, where (p ≤0.05 and p≤0.001 respectively).

Figure (3) shows the relationship between wives' age and experiences of violence. It was noticed that about one third 32.4% of abused wives, their age ranged between (20-24), while 24.9% their age ranged between (25-29). Moreover, 14.8% were in age group (30-34), and 13.8% their age between (35-39). 

Table (6) shows the relationship between husbands' age and occurrence of violence. It was observed that one quarter (24.7%) of violent husband, their age ranged from (25-29), while 21.5% their age between (20-24). On the other hand, it was observed that 16.7% their age ranged from (30-34), and 14.3% their age ranged from (35-39). Statistically significant difference was observed between husband age and violence, where (P ≤ 0.05).

Table (7) shows the relationship between husbands' education and types of violence. It was noticed that verbal abuse was high (38.5%) among illiterate husbands and became lesser (3.5%) among university graduated husbands. Similarly, physical abuse by pushing, hitting, push on the floor and pulling hair was higher among illiterate husbands in a percent of (43%, 39.2%, 44.1% and 43.9%) respectively and it became lesser among husbands who achieve university education. Statistically significant difference was found between verbal abuse, physical abuse by pushing, push on the floor and pulling hair in their relation to husband education, where, (P ≤ 0.05).

Table (1): Demographic data of the studied subjects

Fig.(1): Distribution of wives and husbands according to presence of violence

Table (2): Distribution of abused wives according to their exposure to the different types of violence

# More than one answer was stated

Table (3): Distribution causes of domestic violence among wives who experienced it

^# More than one cause was stated

Fig. (2): Distribution of Causes that prevent the wives from leaving their homes

Table (4): The effect of violence on wives' health

^# More than one answer was stated

Table (5): Wives & husbands education in relation to violence

* Significant

Fig. (3): Relationship between wives' age and experiences of violence.

Table (6): Relationship between husbands' age and occurrence of violence

* Significant

Table (7): Relationship between husbands' education and types of violence

* Significant                                           NS = Not significant

II- Results of qualitative study (FGDs):

Wives in this part of the study had verbalized their knowledge, experiences regarding domestic violence. In this regard, three main categories were expressed:

A-Wives perception of domestic violence.

B- Factors that influence domestic violence.

C-Reaction of wives regarding domestic violence.

There were a total number of 33 participants who respond to share in focus group discussion.

A- Participants perception of domestic violence (D.V):

A-1- What the term domestic violence means?

- ما هو تعريف العنف الأسرى؟

Participants were asked to describe what to them constitutes D.V. Two thirds of the participants don't know anything about D.V, and the rest of them describe D.V in different ways. Cited below, are a few sample of how FGD participants described D.V:

-To me domestic violence means using physical force.

- بالنسبة لي العنف الأسرى يعنى لما الزوج يمد أيده على مراته

 - D.V. is any kind of abuse.

- العنف الأسرى يعنى الشتيمة- الضرب- الإهانة

- D.V. can define as misunderstanding between the woman and man.

-العنف هو سوء التفاهم بين الراجل والست

 - D.V. is any problems between spouses in the home.              

- المشاکل اللي بتحصل بين الزوجين في البيت

A-2- Is there any type of abuse occurred to any one of you?

-هل تعرض اى احد منکم إلى اى نوع من أنواع العنف الأسرى؟

Participants were asked to verbalize their experiences of abuse. After they gain a sense of confidentiality and the group became familiar to each other, they began to express their history of being abused by their husbands. About half of the participants had a past history of physical abuse and more than one third of them abused verbally.

A-Factors influence domestic violence:

What are the causes that can provoke domestic violence?

- ما هي الأسباب التي تساعد على حدوث العنف الأسرى؟

Participants were asked to describe the factors and causes that can emerge a marital conflict lead to abuse. The three most cited factors as having influence on D.V were home duties, financial pressure and children. Other factors mentioned as having negative influence on D.V were her mother in law; go out side home without husband permission and late pregnancy.

B-Reaction of wives towards domestic violence:

C-1What is your reactions when any one of you faced violence?

- ما هو رد فعلکم عندما يواجه اى احد منکم العنف؟

All Wives had a history of abuse stated that they cannot defend their selves or wife's reply on her husband instructions by bad words because it is not from their traditions and cultures they bringing up on it.

Most of participants stated that they thinking about leaving home but they don't do for bringing up their children and because there is a love between the two spouses.

C-2 what are the factors that can help domestic violence not occurring?

- ما هي العوامل التي تساعد على عدم حدوث العنف الأسرى؟

                Wives, who don't experience any kind of abuse since they married, stated that love and understanding between spouses is the key for their happy life.

Two thirds of participants stated that it is very useful if there is a clinic present a service for domestic violence management; they will come if it is found to seek help when a marital conflict occur and it must be for the two spouses not the wife only.

DISCUSSION:

Domestic violence or intimate partner violence, which typically occurs when a man beats his female partner, is the most prevalent form of gender- based violence (UNICEF, 2000). The results of the study are discussed within the frame of the references of the effect of domestic violence on women health. The present study revealed that 41.3% of the studied sample reported being abused at some point in their marriage. It is similar to that reported by El- Zanaty 1996, who reported that 35% of women reported being abused by their husbands. Concerning the physical pattern of violence, the present study showed that 82.8% of women being abused by hitting with hand or any other object, Further more, a little less than half of them abused by pushing. While Abou El- Naga, 2001 reported that out of 1326 study sample (women who ever married), 48.42% of them had experienced physical violence by a current or former partner at some point in their marriage. On the other hand, a finding seen in a population reports, 1999 which conducted a study among six population region based surveys from around the world, indicated that 10% to 50% of women report being hit or other wise physically harmed by an intimate male partner at some point in their lives. As regards to the effect of domestic violence on women health, the present results revealed that injuries were about 10% of all abused women. This result was on contrary with the study done by Nelson and Zimmerman, 1996 in Cambodia who found that 50% of all women reporting abuse had sustained injuries. Another study done by Rodgers, 1994 in Canada's national survey on violence against women revealed that 45% of wife assault incidents resulted in injuries and of the injured women, 40% subsequently visited a doctor or a nurse. Pregnancy doesn't necessarily protect women from being battered, the results of the present study revealed that slightly more than one third of wives faced violence were physically abused during pregnancy. This finding supported that reported by Abou El- Naga, 2001 that slightly less than one third of ever being battered and have had at least one birth or were currently pregnant, have been battered during pregnancy. Concerning the psychological pattern of violence, many forms of psychological violence were mentioned by the wives in the present study as their husbands prevent them visiting family/friends, prevent them to seek job. This study supports that of Kandeel et al., 2003. National Center on child abuse and neglect (NCCAN 1996c), reported that emotional abuse is almost always present when other types of abuse or neglect are found. This agreed with the result of the present study, where verbal abuse represented more than three quarters of all wives faced violence. Regarding the causes that provokes violence, the present study revealed that one third of the mentioned causes by wives were due to problems with their husband's relatives (especially problems with their mother in-law). Women justify this, as because they live in an extended families the conflicts with their husbands increased, and if they have a separate house these conflicts will be decrease. The second cause of violence, as revealed by the present study, was financial or economic problems. This result is similar to that reported by Kandeel et al., 2003. Also Tadros, 1998 concluded that a main reason for violence was expenses, either in terms of the women merely asking for house expenses or because husbands believe that the women over spend. Also UNICEF, 2000 emphasized that lack of economic resources underpins women's vulnerability to violence and their difficulty in extricating themselves from violent relationship. On the other hand, the other most mentioned causes for violence, as revealed by the present study, were failure to get house work adequately (e.g. late in preparing food and lack of house hygiene), failing to care for the children (e.g. children crying, lack of child hygiene and problems with neighbor children). This result similar to that reported by Armstrong1998, that among the events that trigger violent responses were failing to care for the children or home and not having food ready on time. In addition, the present study also showed that some of wives mentioned that their refusal to have sex with their husbands was the cause of marital conflict in many cases. This result coincides with those studies done by Kandeel et al. 2003, Abou El-Naga 2001, Armstrong 1998 and Tadros 1998. The present study shows that as the educational level of both wives and husbands increases, the episodes of violence decreased. This finding was supported by Kandeel et al., 2003, Abou El-Naga 2001, Smith & Maurer 2000 and Population reports in 1999. The present study shows that as the educational level of both wives and husbands increases, the episodes of violence decreased. This finding was supported by Kandeel et al., 2003, Abou El-Naga 2001, Smith & Maurer 2000 and Population reports in 1999. The results of thisstudy shows that wives who were married to a relative and faced violence represents 43.3% from the total wives who had consanguinity with their husbands. While Abou El-Naga 2001, reported that women who were married to a relative were significantly more encountered among battered wives (56.70%) than non battered group (41.30%). The present study revealed that wives who experienced violence and had children represents 74.8%. This means that violence increases in families with children.

Wives' age play an important role in the occurrence of violence, the present study revealed that wives faced violence were significantly younger. It means that as the age of wife increase, the lesser that she experience violence. This result was consistent to that reported by Kandeel et al., 2003, Abou El-Naga 2001, Hassan 1997, and Goldberg & Tomlanovich 1984. The present study highlighted how wives perceived domestic violence and how they react with it. A qualitative study [FGDs] was carried out to explore the nature of domestic violence as perceived by wives. The following questions guided the analysis of the data: what the term domestic violence means? What are the types of domestic violence faced participants? What are the factors influence domestic violence? What is the reaction of wives towards domestic violence?. El Rafei and Mekheimar, 2004 stated that, interventional studies are lacking, especially in developing countries. Egypt is no exception- only limited studies can be found on what is acknowledged to be a pressing topic. Wife beating is very much under- reported and under- documented; due to the social conventions and pressures that lead individuals to keep silent about this issue. The human cost in grief and pain is difficult to calculate. Its prevalence is also under estimated around the world as it can be defined only against a backdrop of local cultures, traditions and customs. The result of the present qualitative study supports that of the quantitative study. It shows that, several factors were mentioned by the participants to be the most causes that can emerge a marital conflict on the home; it included the household duties, financial causes and concern for children.

CONCLUSION:

Based on the findings of the present study, it can be concluded that, the main causes of domestic violence against women were mothers in law problems due to living in a shared house with extended families, household duties problems, children problems, sexual and financial causes. Demographic factors contributing to a predisposition for violence were pinpointed. These include a wife and husband age and education, wife age at marriage, family type and having children. Societal factors included cultural norms and attitudes play an important role in the wife decision to don't leave the home although experiencing domestic violence.

RECOMMENDATIONS:

From the results of the present study the following could be recommended:

1-Reaching out the men to change their behaviors is an important part of the solution of the problem.

2-The primary goal is to make men accept personal responsibility for their violent behavior and to teach them non- violent way to manage their anger and inter-personal conflict.

3-Health education programs should be directed toward increasing awareness of people about the problem of domestic violence.

4-More studies should be conducted about the magnitude and prevalence of domestic violence and how to manage it.

5-Focus discussion sessions in this field of
study was lack, so it should be increased as it helped women to overcome their structural isolation and realize that their individual sufferings have social causes and are, in some ways, shared by other women.

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