Abstract
Objectives: To estimate the prevalence of intimate partner violence (IPV) among female patients, age 18-60 years, attending primary health care centers (PHCCs) and to measure its determinants, and reporting behavior.
Methods: A cross-sectional study design using validated, translated, and self-administered questionnaire among 497 Saudi female patients attending PHCCs in Taif, Kingdom of Saudi Arabia (KSA) from January to February 2015 was employed. A 2-stage probability sampling was adopted for selection of PHCCs in the first stage, and then participants in the second stage.
Results: The estimated prevalence of IPV during the last year was 11.9%. Predictors of IPV related to abused women included divorced status and divorced parents; while those related to abusers (husbands) included widowed parents, exposure to violence in childhood, and alcohol or drugs addiction. Most of the abused wives (56%) talked regarding their IPV to their families, their husbands’ families (15.2%), or their friends (11.8%); while only a minority (3.3%) complained to the police or to a judge, and no one reported this to a family physician, or to women protection agency.
Conclusion: One out of 10 women is a victim of IPV in Taif, KSA. Intimate partner violence is significantly associated with a number of victim and abuser-related psychosocial factors, the detection of which might help screening for individuals at risk.
Intimate partner violence (IPV) is defined as any behavior within an intimate relationship that causes physical, sexual, or psychological harm. The present study examines IPV within the context of marriage,1 and focuses only on physical and psychological violence. Sexual violence, which is an important type of IPV was not assessed due to the sensitivity of the issue, and the expectation that there would be few instances to be reported. Intimate partner violence has major short- and long-term social, mental, and physical wellness effects.2 Nationwide surveys in Canada and the United Kingdom found that approximately 25% of women experienced IPV.3 In some Arab countries, IPV is still not properly investigated despite its relatively high prevalence.4 It is difficult to calculate the financial burden of IPV on the health system,5 but some studies estimate the cost to be from 1.7 - 10 billion US$ per year in the US,6 and approximately 400 million Swiss Francs in Switzerland.7 Many risk factors are associated with IPV, such as young age, low socioeconomic status, marital conflicts, a past history of violence in childhood, alcohol and drug addictions,1,6 disempowerment of women, stress, and jealousy.1 Intimate partner violence is a significant public health issue that is associated with serious health outcomes, including depression, suicide attempts, and death.1 Eldoseri8 conducted a cross-sectional study in Jeddah, Kingdom of Saudi Arabia (KSA) and interviewed women attending the primary health care centers (PHCCs), found that the prevalence of physical IPV was 45.5% that was significantly associated with husbands having alcohol or drug addictions, exposure to violence during childhood, and unemployment status. Al-Faris et al9 conducted a study in Riyadh, KSA on 222 women at a teaching hospital and found that 12.2% of them experienced lifetime physical abuse, which was significantly associated with unemployment, past exposure to violence, and living in rented houses. In Iraq, Al-Atrushi et al10 conducted a cross-sectional study at 2 community hospitals and found 58% of visiting women experienced lifetime IPV with physical violence accounting for 38.9%, and sexual violence accounting for 21.1% of the IPV. Due to the discrepancy in the prevalence rate of IPV across the country, a common simple measure is needed to assess and compare IPV in future studies. Therefore, the current study was conducted to measure IPV and its associated risk factors among female patients attending PHCCs in Taif, KSA, and to assess wives’ reporting behavior.
Methods
Design and setting
A cross-sectional study was conducted from January until February 2015 among Saudi female patients attending PHHCs in Taif, KSA, who were 18-60 years-old, currently married, divorced or widowed, and able to read and write. Ethical approval was obtained from the research ethical committee at King Abdulaziz University and the Directorate of Health Affairs in Taif, KSA. Confidentiality and the right to withdraw from the study were explained, and all women were provided referral cards that contained contact numbers of social services and the women’s protection agency in Taif.
Instruments
The survey instrument consisted of 3 parts. Part I contained questions regarding the basic characteristics of participants and their husbands. Part II contained the HITS, a structured, self-administered questionnaire, which is a valid, reliable, and simple measure,11 that is comprised of 4 questions: “How often does your partner: physically hurt you, insult you or talk down to you, threaten you with harm, and scream or curse at you?” Patients responded to each of these items on a 5-point Likert scale: 1 - never; 2 - rarely; 3 - sometimes; 4 - fairly often; and 5 - frequently. The scores range from a minimum of 4 to a maximum of 20, with a score of 11 or more considered a case of IPV.11,12 The HITS questionnaire was originally developed in English and designed to be used in outpatient clinical settings. The investigator translated the questionnaire into Arabic, through forward and backward translation, using professional translators and following published guidelines.13,14 Part III, which measured IPV reporting behaviors was adopted from a World Health Organization report.1
Sample size and sampling
A sample size of 340, based on a 33% IPV prevalence, was calculated,8,9,12 and then increased to 500 to account for anticipated missing data and refusal to participate. Two-stage probability sampling was conducted. First stage, 5 PHCCs was selected by simple random selection, and the second stage, 100 subjects were selected from each of the chosen 5 centers using systematic random sampling.
Data analysis
Analyses were carried out using Stata software version 13.1 (StataCorp LP., College Station, TX, USA).13 Descriptive analyses were presented using frequencies with percentages for qualitative variables, and means with standard deviations for quantitative variables. The chi-square and Fisher’s exact tests were used for comparisons between 2 qualitative variables, while Student’s t-test and the Mann-Whitney test were used to test the differences between means. Stepwise logistic regression using 95% confidence interval (CI) was used to identify predictors of IPV. Statistical significance was set at α=0.05 with 2-tail probability.
Results
The study sample’s age ranged from 18-60 years with a mean of 33.9 ± 8.4 years. Most of the women were married. Marriage duration ranged from one month to 40 years with a mean of 11.4 ± 8.9 years. Nearly half of them were categorized as having secondary school, or lower level of education. The prevalence of IPV in the past 12 months was 11.9% (Table 1). The IPV was significantly associated with being older, divorced, working or ever worked, higher income, divorced parents, and witnessing violence in the family during childhood. The husbands’ ages ranged from 20-85 years with a mean of 39.9 ± 10.2 years. Husbands with a low educational level, non-working status, lower income, a history of alcohol or drug abuse, divorced parents, and exposure to violence during childhood were significantly more likely to abuse their wives (Table 2).
Demographic characteristics of women by intimate partner violence (IPV) status.
Demographic characteristics of husbands by wives’ intimate partner violence (IPV) status.
Table 3 shows the results of the multiple logistic regression analysis of factors predicting IPV. The predictors were: being a divorced woman; wives’ parents being divorced; husband with a widowed parent; husband’s exposure to violence in childhood; and husband’s addiction to either alcohol or drugs. Goodness of fit was p=0.1628. Most of the abused wives (56%) talked with their families regarding IPV, 15.2% talked to their husbands’ families, and 11.8% talked to their friends. Only 3.3% told the police or a judge, while no one told a physician or a women’s protection agency.
Multivariable logistic regression of intimate partner violence‡ with associated risk factors.
Discussion
Women in the present study tended to be unemployed housewives with low income and financially dependent on their husbands. This is consistent with other studies.4,8,15 The current study did not measure IPV perpetrated by the women, although bidirectional IPV results in more serious injuries to women. The reported IPV in the present study was only 11.9%, contrary to higher prevalence rates reported elsewhere.10 This could be attributed to variation in instruments used, type of intimate violence investigated, study designs, sample size, and selecting only educated women. A true decrease in prevalence could have occurred due to the establishment of first family protection program in KSA in 2004, and national registry for abused cases in 2009,15 resulting in identifying abused wives at older age in our study. Divorced compared with married or widowed women showed a significantly higher prevalence of IPV. The current study did not find a relationship between level of education and IPV, which is in agreement with previous studies.11
Working women with higher income experienced significantly more IPV than non-working ones, which is inconsistent with other research8 and explained by husband’s feelings of inferiority and dependence. A divorced wives’ parents was significantly associated with being a victim of IPV showing the loss of parental support resulting from marital conflict.1 Women married to a partner with a low educational level experienced significantly more IPV, similar to what was reported in Fageeh’s study.15 Working husbands practiced significantly less violence against their wives.15 Alcohol addiction and drug abuse were associated with IPV in our study.1 Polygamy, number and order of wives were not significantly associated with IPV, which was supported by a previous study.8 Similarly, a divorced husbands’ parents was significantly associated with IPV showing the effect of parental family conflicts on offspring’s future life. The IPV was significantly associated with wives’ witnessing violence, exposing to violence themselves, or their husbands within the family during childhood leading to psychological maladaptation of both victims’ and abusers’ attitudes and behaviors.8,9
The present study has limitations, such as, the potential of information bias/under-reporting resulting from sensitivity of the topic being investigated, as well as selection bias due to inclusion only of literate women, which was a necessary criteria for including women in the study to ensure self-administering of the study instrument.
In conclusion, one out of 10 women is a victim of IPV in Taif, KSA. The IPV is significantly associated with many victim and abuser-related psychosocial factors, the detection of which might help in screening for individuals at risk. Governmental and non-governmental sectors should collaborate to tackle IPV. Studies are needed to explore its geographic variations in KSA using a common measure that allows for comparison across studies. The injuries occurring from bidirectional IPV deserve to be investigated. Future studies are needed as well to analyze the wives’ reporting behavior for the purpose of control and prevention.
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Algwaiz WM, Alghanim SA. Violence exposure among health care professionals in Saudi public hospitals. A preliminary investigation. Saudi Med J 2012; 33: 76-82.
Afifi ZE, Al-Muhaideb NS, Hadish NF, Ismail FI, Al-Qeamy FM. Domestic violence and its impact on married women’s health in Eastern Saudi Arabia. Saudi Med J 2011; 32: 612-620.
- Received August 3, 2015.
- Accepted November 19, 2015.
- Copyright: © Saudi Medical Journal
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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