Violence against women is a major public health issue, with 30% of women in the world having experienced violence in some form (World Health Organization [WHO], 2013). Domestic violence consists of physical, sexual, psychological, and economic abuse exerted by one person over another in an intimate and close relationship (Sen & Bolsoy, 2017). Men's violence against women includes two dimensions: physical violence (i.e., physical injury to the body by beating using one's hands or tools) and non-physical violence (e.g., threats, humiliation, verbal abuse, using obscenities, exerting control, forcing social isolation, prohibiting communication with others) (Hajnasiri et al., 2016). Domestic violence is a major problem in most societies, especially third world countries, and has many consequences for women (Anderson & Leigh, 2010; Kalra & Bhugra, 2013).
Non-lethal physical consequences of violence include acute trauma; unintended pregnancy; sexually transmitted diseases; unintentional abortion; pelvic inflammatory disease; chronic pelvic pain; headache; asthma; irritable bowel syndrome; behaviors such as smoking, drug addiction, and alcoholism; and lethal consequences, such as suicide, homicide, traumatic brain injury, and maternal mortality (Garcia-Moreno et al., 2006). Psychological consequences of violence include depression, fear, anxiety, sexual disorders, obsessive-compulsive disorder, and posttraumatic stress disorder (Hall et al., 2014; Jamali & Javadpour, 2016). Factors influencing violence against women include societal attitudes about violence, lack of commitment in the family, and couple's dissatisfaction (Patrikar et al., 2017). Reasons for domestic violence include moral disagreement, disinterest, selfishness, poverty, addiction, lack of religious beliefs, and sexual impotence (Guruge et al., 2012). Many criminologists, sociologists, and anthropologists have attributed various cultural factors to violence (Kurt et al., 2018). In addition, patriarchal attitudes have provided context for the control of women through the use of force and violence (Boroumandfar et al., 2010). A culture's view of family, women, and violence affects people living in that community. The social structure of a community, the laws governing it, its economic status, and public beliefs are factors that help explain domestic violence at a macro level (Gennari et al., 2017). In a study by the WHO (2014) on domestic violence in several countries, prevalence ranged from 13% to 71%.
Studies show that women need empowerment, and one of the concepts of empowerment is self-efficacy. Self-efficacy is the capacity perceived by an individual to perform a successful behavior (Zarei et al., 2012). High self-efficacy leads to more effort, work, resistance, and flexibility. People with high self-efficacy are generally positively affected by life events and expect more success than those with lower self-efficacy (Fitzgerald, 1991). Perceived self-efficacy and screening are important components of preventing domestic violence (Tower, 2003). In a study by Allen et al. (2012), higher self-efficacy was found to play a role in preventing domestic violence.
Self-esteem is another factor affecting the prevention of violence against women. Self-esteem encompasses a range of beliefs about one's abilities, values, approval or disapproval, and effectiveness (Eyo, 2006). When a person has a negative evaluation of their performance, it reduces their self-esteem (Lawrence et al., 2006). According to Sullivan et al. (2010), feelings of inferiority resulting from violence in women lead to stress, anxiety, fear, and severe depression. Increased self-esteem can help prevent violent and negative behaviors; thus, it is crucial to empower women because of their vulnerability to violence (Lee et al., 2007).
Given the prevalence of violence and the effects it can have on women, the current study aimed to investigate the prevalence of domestic violence and its relationship to self-esteem and self-efficacy in women.
Method
The current cross-sectional study was conducted in 496 women referred to Jahrom Women's Clinic from April to October 2017. The study was approved by the Ethics Committee of Jahrom University of Medical Sciences. Sampling was performed by observing all ethical issues and obtaining written consent from participants and assuring them of confidentiality. Inclusion criteria were women who reside in Jahrom, are Iranian, and have been married for at least 1 year. Exclusion criteria were having a psychological disorder (e.g., major depression, history of postpartum depression, bipolar disorder, obsessive-compulsive disorder, generalized anxiety disorder, schizophrenia, mania, bulimia), temporary marriage (i.e., couple is together for a limited time and then separate per a prior agreement), and incomplete questionnaires. Data were collected using questionnaires comprising four sections with items regarding (a) demographic information, (b) physical violence (11 questions), (c) non-physical violence (12 questions), and (d) attitude toward spousal abuse (eight questions).
The Violence Against Women Survey Questionnaire includes items related to physical violence, including objects being thrown; being slapped in the face, pushed, or beaten; hair or wrists being twisted; throat being squeezed; hands and feet being bound; burned with hot objects; injured with a gun or knife; and beaten during pregnancy. Items related to emotions include mocking and derision; humiliation; shouting; prevention of visiting family or friends; insults; threats to leave, use weapons against, or kill; forcing abortion; and coercion of unwanted or humiliating sex. This questionnaire was designed and validated by Ahmadzad-Asl et al. (2013). The reliability of the questionnaire was 0.76 for the knowledge section and 0.64 for the attitude section.
The 10-item Rosenberg Self-Esteem Scale (RSE) is scored on a 4-point Likert scale from strongly agree to strongly disagree, with higher scores indicating higher self-esteem. The RSE meets the criteria for validity and reliability of a quality instrument to measure self-esteem (Rojas-Barahona et al., 2009). The Persian version of this questionnaire was used in the current study (Alizadeh et al., 2005), with Cronbach's alpha of 0.72 and reliability of 0.74.
The Sherer General Self-Efficacy Scale comprises 17 items scored on a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree), with a total possible score range of 17 to 85. Cronbach's alpha was 0.85, and stability in terms of test–retest reliability was calculated in a separate sample of 138 students, with r = 0.60 (Luszczynska et al., 2005; Sherer et al., 1982). The Persian version of the questionnaire was used in the current study (Arabian et al., 2005), with Cronbach's alpha of 0.87 and validity of 0.61.
Statistical Analysis
Data were analyzed with SPSS version 21 using t test and Pearson and Spearman correlation coefficients. The t test was used to determine the correlation of self-efficacy and self-esteem scores between abused and non-abused women. Spearman correlation test was used to determine the correlation between participants' characteristics. Statistical significance was set at p < 0.05.
Results
Mean age of participants was 33.78 years (SD = 9.1, range = 18 to 64 years). Most participants had attended college or university (76.2%) and were housewives (71.6%) and city residents (87.9%). Approximately 76% of the sample owned real estate, and the majority (77.2%) lived separately from their spouse's family. Most women (99%) were not addicted to drugs or alcohol (Table 1).
Approximately 47.4% of participants mentioned that they had been abused by their spouse, 20.6% had experienced physical violence (i.e., bodily injury by beating with hands or tools), and 44.2% had experienced non-physical violence (e.g., threats, humiliation, verbal reproach, obscenity, prohibition of communication with others) (Table 2). Only 5.6% of participants had consulted a physician after violence, and 3.4% had only informed their family. Some women (11.9%) said that they do things against their will so that their spouse does not mistreat them.
Table 3 shows that the mean scores of self-efficacy and self-esteem in women subjected to violence are lower than those of women who are not subjected to violence (p < 0.05). Approximately 74.6% of women had a negative attitude and 26.4% had a positive attitude toward violence, with 78.6% believing that beating a woman is a crime, 76.9% stating that the law should support women, and 85.1% stating that a man has no right to beat his wife for any reason (Table 4).
Attitude toward violence had a significant relationship with self-efficacy, and self-efficacy had a significant relationship with self-esteem (p < 0.05). Violence also had a significant relationship with self-esteem and self-efficacy (Table 5).
Discussion
The prevalence of domestic violence against women in the current study was 47.4%. Of women who experienced violence, 20.6% were subjected to physical violence and 44.2% to non-physical violence. The prevalence of domestic violence against women in this study is comparable with results of similar studies in Bolivia (47%; Meekers et al., 2013) and Portugal (43.4%; Coutinho et al., 2015). In a study by Hajnaseri et al. (2018), the prevalence of violence against Iranian women was 66%. The prevalence of violence against women outside Iran ranges from 40% to 80% (Basar & Demirci, 2018; Yaman & Ayaz, 2010). A study in Pakistan reported a prevalence of violence against women of 69.5% (Haqqi et al., 2010). The prevalence of domestic violence also varies widely, with approximately 15% to 71% of women worldwide experiencing some form of violence at the hands of their husbands (Garcia-Moreno et al., 2006). Vakili et al. (2010) reported a prevalence of physical violence of 43.7% in Iran, whereas Fidan and Bui (2016) reported a prevalence of 32.7% in Zimbabwe. Other studies reported a prevalence of physical violence against women between 16% and 36% (Babu & Kar, 2009; Yang et al., 2006), and the WHO (2014) reported prevalences of 6% in Japan, 42% in Bangladesh, 30% in India, and 34% in Egypt.
The prevalence of violence varies from country to country. In the current study, the prevalence of violence against women was lower than other studies, which may be due to the fact that 68% of participants had a university education, and this high level of education is a protective factor against violence (Zarei et al., 2012). Differences across studies are due to population size, the culture of each region, laws in different countries, study location, socioeconomic differences, and sample collection method.
The prevalence of non-physical violence was 44% in the current study, which is comparable to previously reported prevalences of 42% (Zarei et al., 2017), 48.8% (Nikbakht Nasrabadi et al., 2014), and 46.4% (Shuman et al., 2016). A study in Turkey reported a prevalence of non-physical violence of 54.5% (Güleç Öyekçin et al., 2012). Fekadu et al. (2018) showed that non-physical violence is the most common type of violence in pregnant women, with a prevalence of 57.8%. Vakili et al. (2010) reported a high prevalence of psychological violence against women of 82.7%.
In agreement with our results showing that 74.6% of women had a negative attitude toward violence, and the majority believed that violence against women is a crime and the law should protect women, a study by Sepidkar et al. (2018) showed that 69% of women had negative attitudes toward violence. Emanifard and Fariba (2010) reported a relationship between dysfunctional attitudes and domestic violence. According to Mohtashami et al. (2014) on factors related to domestic violence against women, there is a significant correlation between women's negative attitudes and their educational level. Previous violence experience has also been shown to be the strongest and most important predictor of attitudes toward violence against women (Jamali & Javadpour, 2016). Therefore, identifying the thoughts, beliefs, and opinions that form attitudes about violence is important in any society.
Women's positive attitude toward violence was found to have a significant relationship with their self-efficacy, and low self-esteem and self-efficacy were observed in women subjected to violence. In a study evaluating empowerment and violence, Afkari et al. (2013) concluded that women should be aware of skills to control anger and violence and empower themselves against violence; thus, educational intervention may be required to promote self-esteem and self-efficacy. Ottu and Inwang (2013) showed that violence reduces women's self-efficacy, which in turn significantly decreases their empowerment. Shi et al. (2010) indicated that self-efficacy and knowledge training reduce domestic violence. Allen and Solomon (2012) found that high self-efficacy most likely prevents domestic violence. All of these studies refer to the relationship between violence and self-efficacy, which is consistent with our findings.
Other studies have also demonstrated the relationship between violence and women's self-esteem. Strategies such as life skills training and anger control can enhance women's self-esteem. According to Kim and Kim (2001) and McFarlane et al. (1998), the self-esteem of women subjected to violence should be increased through educational interventions to reduce violence.
Limitations
A limitation of the current study is the lack of standardized and universal tools to investigate violence. Data were obtained using a national questionnaire that is used in Iranian studies. In addition, due to the private nature of the questionnaire and the culture of the community, it is possible that participants were dishonest in their responses. Further, as only women referred to government centers were examined, the findings may not be representative of all women.
Implications for Practice
Physicians, medical students, nurses, and psychologists must become familiar with the signs and symptoms of domestic violence; the importance of screening for violence against women of all ages, especially young women of reproductive age; premarital education; and public awareness to control and eradicate this issue. In addition, counseling services and treatment centers for women should be expanded to help prevent the occurrence of domestic violence and its physical and psychological complications. Women who experience violence in Iran tend not to go to legal authorities for many reasons, such as feelings of guilt or fear of economic hardship, loss of social position, being deserted by their families, rumors, or separation from their children. Therefore, nurses and women's health professionals worldwide should perform routine screening of women, especially high-risk women, during midwifery and gynecology visits to detect cases of violence, discover the cause, and develop interventions. Epidemiological studies should be performed in different countries with different cultures to identify the causes of violence against women in different societies to eradicate this worldwide social problem.
Conclusion
Domestic violence is a major problem in Iran. In the current study, one half of women were abused by their husbands. Violence can reduce women's self-efficacy and self-esteem, which in turn reduces their empowerment. Therefore, violence screening should be a top priority for women's health promotion programs.
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Participant Demographics
| Characteristic | Women Who Have Been Abused (n = 235) | Woman Who Have Not Been Abused (n = 261) | Total (N = 496) |
|---|
| Age (years) | | | |
| <20 | 3 (1.3) | 1 (0.4) | 4 (0.8) |
| 20 to 30 | 93 (39.6) | 127 (48.7) | 220 (44.4) |
| 30 to 40 | 78 (33.2) | 78 (29.9) | 156 (31.5) |
| >40 | 61 (26) | 55 (21.1) | 116 (23.4) |
| Educational level | | | |
| Uneducated | 1 (0.4) | 5 (1.9) | 6 (1.2) |
| Primary school | 21 (8.9) | 8 (3.1) | 29 (5.8) |
| Secondary school | 51 (21.7) | 32 (12.3) | 83 (16.7) |
| College or university | 162 (68.9) | 216 (82.8) | 378 (76.2) |
| Employment status | | | |
| Housewife | 171 (72.8) | 187 (70.5) | 355 (71.6) |
| Employed | 84 (27.2) | 77 (29.5) | 141 (28.4) |
| Place of residence | | | |
| City | 208 (88.5) | 228 (87.4) | 436 (87.9) |
| Rural | 27 (11.5) | 33 (12.6) | 60 (12.1) |
| Living with spouse's family | | | |
| No | 177 (75.3) | 206 (78.9) | 383 (77.2) |
| Yes | 58 (24.7) | 55 (21.1) | 113 (22.8) |
| Addiction | | | |
| No | 235 (100) | 257 (98.5) | 492 (99.2) |
| Yes | 0 (0) | 4 (1.5) | 4 (0.8) |
Prevalence of Domestic Violence According to Type (N = 496)
| Type of Violence | n (%) |
|---|
| Yes | No |
|---|
| Non-physical | 219 (44.2) | 277 (55.8) |
| Physical | 102 (20.6) | 394 (79.4) |
| Non-physical and physical | 235 (47.4) | 261 (52.6) |
Participants' Self-Esteem and Self-Efficacy
| Variable | Mean (SD) | p Value |
|---|
| Women Who Have Been Abused (n = 235) | Women Who Have Not Been Abused (n = 261) |
|---|
| Self-esteema | 2.09 (2.87) | 4.44 (3.80) | <0.001 |
| Self-efficacyb | 61.74 (8.58) | 64.67 (9.87) | <0.001 |
Attitudes of Participants Toward Spousal Violence/Abuse
| Question: In my opinion... | % |
|---|
| Disagree | Uncertain | Agree |
|---|
| A woman who repeatedly refuses to make love with her husband deserves to be beaten. | 64.9 | 18.5 | 16.5 |
| If a woman is beaten by her husband, she is to blame. | 71.6 | 13.7 | 14.7 |
| Beating of the wife by the husband is a private matter and the wife should not talk about it with anyone (even a counselor or a friend). | 75.8 | 8.3 | 15.9 |
| Beating a woman occasionally by the husband helps preserve their lives. | 82.9 | 8.1 | 9.1 |
| A woman who calls her husband's masculinity and zeal in question deserves to be beaten. | 61.9 | 21.2 | 16.9 |
| The law should protect women who are beaten by their husbands. | 10.9 | 12.3 | 76.9 |
| Beating a human being for any reason is a crime. | 11.1 | 10.3 | 78.6 |
| A man has no right to beat his wife for any reason. | 10.5 | 4.4 | 85.1 |
Correlation Among Study Variables
| Violence | Self-Esteem | Self-Efficacy | Negative Attitude |
|---|
| Violence | 1 | | | |
| Self-esteem | 0.27** | 1 | | |
| Self-efficacy | 0.14* | 0.09* | 1 | |
| Negative attitude | 0.5 | −0.058 | −0.19** | 1 |