1. Background
Family is a place to be considered as warm, safe, personal and peaceful, but domestic violence (DV) is one of the problems in today’s societies (1). Domestic violence is defined as the violent physical, sexual or psychological behavior taking place by the current partner (1, 2). The world health organization (WHO) stated that domestic violence is a health-related priority and all countries should be alerted to come up with plans to identify and address this disaster. Approximately, one in five females report being physically assaulted by an intimate partner at some point in their lifetime (2). Estimates from the national violence against Females survey shows that 22.1% of the studied females reported that they were physically assaulted by a current or former spouse, cohabiting partner or boyfriend in their life time (3). Domestic violence may lead to premature deaths and can include not only victim death per case but multiple victims (4). Not only females, but also children are the victims of domestic violence. A basic assumption of the united nation convention on the rights of the child (CRC) is that the family is the natural environment for the growth and well-being of all its members, particularly for children (1). Unfortunately, the family is also the most common place where children experience or are exposed to different forms of violence. There is clear evidence indicating that both severe and moderate violence occur frequently in homes among family members and that children are exposed to this violence. It is likely that children who live in homes where domestic violence occurs are more likely to be abused and neglected (5) and children’s exposure to domestic violence (CEDV) predicts poorer health and development (6, 7).
DV has enormous unpleasant consequences on victims such as depression, PTSD, committing suicide, poverty, running away from home, social isolation, family’s disintegration, substance abuse and dependency (2, 8, 9). It has also, negative impact on children such as academic failure, skipping school, psychiatric disorders, low self-esteem, aggression and even delinquency. Furthermore, intra-parental violence has a tremendous negative effect on children. Children’s exposure to domestic violence (CEDV) predicts poorer health and development.
Studies on the incidence of domestic violence in Iran estimated the rate of abuse and mistreatment of females 30% to 90% (10-12). In another study, author reported that the rate of DV towards females including psychological, verbal, physical, sexual, financial, etc. was 66.3%, which 10.5% was severe. The rate of violence throughout last year was 53% and 28.05% of the participants had experienced physical aggression throughout marriage life (13). Similarly, an investigation in urban and rural areas on 600 females showed that physical aggression, emotional aggression, verbal violence and financial violence were experienced by 18.6%, 63.7%, 43.3% and 72% of the females, respectively (14).
According to the high prevalence of DV in Iran, it is valuable to investigate the prevalence and risk factors of domestic violence in a large sample.
2. Objectives
The current study aimed to assess DV in five provinces in Iran to identify the pattern of DV, the socio-demographic characteristics of victims and perpetrators of DV, and its risk factors among patients who referred to health care centers for irrelevant reasons.
3. Materials and Methods
In this cross-sectional study, according to the study by Ghazi Tabatabai et al. (13) four provinces with the highest rate of the violence and one province with the least rate of violence in Iran were selected.
The selected areas were as follows:
- From the West of Iran : Kurdistan province, Saqez city
- From the South of Iran: Hormozgan province, Minab city
- From the almost Center of Iran: Yazd province, Yazd city
- A rural area from the North-East of Iran (Khorasan Razavi province)
- Khuzestan province, Ahwaz city (with the lowest rate of violence)
The list of health centers, hospitals and rural health care centers in selected urban and rural areas were obtained. Using multistage randomized sampling, two to five health care centers from each area were selected as a cluster (five centers from Yazd, three centers from Saqez, two centers from Minab, three rural centers from Khorasan-Razavi province and three centers from Ahwaz).
3.1. Sample Size Calculation
With an estimation of a 50% frequency for violence, considering α = 0.05 and a precision of 0.05, at least 384 samples were required in each selected area .This sample size was distributed equally among centers in each city and rural area.
Therefore, about 200 females and 200 males who attend the selected centers and hospitals were assigned to the study in each area. Therefore, 2056 participants were assessed.
3.2. Inclusion Criteria
Any females or males with the history of marriage at least once, minimum 15 years old and signing the informed consent form to participate in the study. For illiterate subjects the researchers read the questionnaires and the form of informed consent.
3.3. Instrument
Authors designed a self-rated questionnaire, which evaluated the beginning violence experiences with such questions: “Has your spouse had violent behaviors towards you since the beginning of your marriage?”, “Has your spouse had violent behaviors towards you during the past year of marriage?” or “Has there ever been any case of domestic violence in your family?”
In addition to the mentioned questions, the questionnaire had 27 items assessing lifelong experience of different types of domestic violence including psychological-verbal, psychological-threat, psychological- restriction, mild physical, severe physical and sexual.
Face validity was evaluated by using the comments, revisions, judgments and consensus of eight experts in domestic violence who were faculty members of Iran University of Medical Sciences by Delphi method. The questionnaire had a reliability of 0.893, which was measured based on Chronbach’s alpha.
Demographic questionnaire included demographic characteristics and some social and economic variables.
3.4. Statistical Analysis
Independent samples T-test and Chi-square test were used. Significant level was considered at 0.05.
4. Results
In the current research, 2056 males and females from five provinces were screened. The provinces were classified into two groups according to the rate of violence. Group 1 included Khuzestan and Hormozgan provinces with the lowest rate of DV and Group 2 included provinces of Yazd, Khorasan Razavi and Kurdistan that had the highest rates of DV (Kurdistan with the highest rate of violence of 81.1% and Hormozgan with the lowest rate of 31.7%). In general, 53.7% of females and 40.4% of males had experienced a kind of violence throughout their life. This rate included all kinds of abuse (mental, physical, economical and sexual). The rate of outpatient visits due to domestic violence was 4.5% in females and 2.9% in males. Only 3% of subjects had sought help for violence. In addition, 2% of females and 1.2% of males were admitted to hospital because of domestic violence physical consequences. Also, 5.2%of females and 2.7% of males had reported that one of their family members had committed suicide because of DV. In both groups, the frequency of violence towards the females was more than that of males (P = 0.001). The frequency of domestic violence in each group is presented in Table 1.
Table 1.The Comparison of Frequency of Violence Between the Study Groups
| Violence | Group 2, N (%) | Group 1, N (%) | Df | P Value |
|---|---|---|---|---|
| Domestic violence, last year | 723 (60.5) | 251 (30.4) | 1.77 | 0.001 |
| Domestic violence, lifetime | 789 (65.6) | 280 (33.9) | 1.98 | 0.001 |
| Violence against spouse, since the beginning of the marriage | 668 (61.4) | 190 (25.6) | 2.26 | 0.001 |
Illiteracy, low income, lower age at marriage, shorter duration of marriage, physical disease, mental disorder and substance use were significantly prevalent in Group 2 (Table 2).
Table 2.The Comparison of Variables Between the Study Groups
| Variables | Group 2, N (%) | Group 1, N (%) | Df | P Value |
|---|---|---|---|---|
| Educational level | 1.32 | 0.001 | ||
| Elementary school and illiterate | 522 (42.9) | 154 (18.5) | ||
| High school and higher educations | 576 (47.3) | 564 (67.9) | ||
| Bachelor of Art and higher | 119 (9.8) | 113 (13.6) | ||
| Income | 61.99 | 0.001 | ||
| Less than 2,850 USD | 995 (79.1) | 525 (64.5) | ||
| About 2,850 USD | 236 (19.5) | 246 (30.2) | ||
| More than 2,850 USD | 17 (1.4) | 43 (5.3) | ||
| Residential status | 84.59 | 0.001 | ||
| Temporary | 69 (6.2) | 145 (20.5) | ||
| Permanent | 1042 (93.8) | 564 (79.5) | ||
| Homeownership status | 0.489 | 0.484 | ||
| Tenant | 748 (67.7) | 522 (66.2) | ||
| Owner | 357 (32.3) | 267 (33.8) | ||
| Financial dependency | 4.74 | 0.19 | ||
| Financial independence | 793 (68) | 515 (64.9) | ||
| Age at marriage (year) | 32.72 | 0.001 | ||
| Under 15 | 108 (9.5) | 35 (4.9) | ||
| 15-20 | 432 (38.1) | 216 (30.2) | ||
| 20-30 | 567 (50) | 441 (61.6) | ||
| Over 30 | 26 (2.3) | 24 (3.4) | ||
| Duration of marriage | 47.13 | 0.001 | ||
| Up to 1 year | 66 (5.9) | 79 (10.5) | ||
| 1 to 5 years | 221 (19.8) | 209 (27.9) | ||
| 6 to 10 years | 262 (23.5) | 190 (25.4) | ||
| More than 10 years | 567 (50.8) | 271 (36.2) | ||
| Number of marriages | 0.831 | 0.362 | ||
| Once | 1144 (96) | 781 (95.1) | ||
| More than once | 48 (4) | 40 (4.9) | ||
| Physical diseases | 23.28 | P = 0.001 | ||
| Yes | 291 (24) | 127 (14.3) | ||
| Physical disabilities | 2.34 | 0.13 | ||
| Yes | 30 (2.5) | 12 (1.5) | ||
| Mental disorders | 20.04 | 0.001 | ||
| Yes | 434 (36) | 206 (25.3) | ||
| Substance use | 5.88 | 0.05 | ||
| No | 1091 (84.4) | 693 (88.1) | ||
| Smoking | 152 (12.6) | 72 (9.1) | ||
| Substance | 57 (3.1) | 22 (2.8) | ||
| Having disabled child | 57 (5) | 36 (4.6) | 0.139 | 0.71 |
5. Discussion
The rate of violence experienced by females and males were 53.7% and 40.4%, respectively. It was less than that of the study by Ghazi Tabatabai et al., which showed the rate of DV experienced by females 66.3% in 28 Iranian provinces (13). In the study by Ghahhari et al., 73.5%, 92.2% and 49.6% of females faced mild physical, emotional and sexual violence, respectively, during their life time; meanwhile, the frequency of severe violence was approximately 4% (12). In Tehran, Iran, a study conducted on 1186 married females reported that the rate of physical and emotional abuse were 83% and 70.4%, respectively (12).
According to the WHO report on 20th June 2013, 15% of females in Japan and 71% of females in Ethiopia reported violence by an intimate partner in their lifetime (15). According to the mentioned reports, the risk factors of exposure to domestic violence were as follows:
- Lower educational level and exposure to child abuse
- Exposure to family violence
- Having multiple partners
- Positive attitudes towards violence and gender inequality
- Previous history of violence
- Marital discord and dissatisfaction
In the current study, illiteracy, low income, lower age at marriage, shorter duration of marriage, physical diseases, mental disorders and substance use seemed to be the risk factors of domestic violence.
Consistent with the current study findings, in a cross-sectional study in South Africa domestic violence was associated with lower education and drinking alcohol in victims and perpetrators and not related to household possessions and migrant status (16). In addition, a study in Eastern India presented age, level of education, marital duration and alcoholism as significant predictors for all types of domestic violence (17). Low levels of education and low income were also the characteristics of couples who experienced domestic violence (14, 17-24). Furthermore, occupational status and economic empowerment of females is a protective factor for violence against females in industrialized countries (14, 21, 25-29).
Similar to the current study findings, in a study conducted in Tehran, Iran, illiteracy, high number of children, being pregnant, substance addiction, psychiatric problems and spouse unemployment were determined as the risk factors for experiencing spouse abuse (30).
As expected, the rate of psychiatric disorders was higher in Group 2. Domestic violence was a risk factor for mental disorders such as depression, chronic pain disorders, gastrointestinal and stress-related syndromes such as post-traumatic stress disorder in victims; on the other hand, psychiatric disorders such as personality disorders increase the risk of aggressive behavior towards partner (8, 22, 31-34).
Concordance to the current study findings, medical diseases were also associated with partner violence. Many studies showed that various physical conditions (allergies or breathing problems, pain or fatigue, bowel problems, vaginal discharge, eyesight and hearing problems, iron deficiency, asthma, bronchitis or emphysema and cervix cancer) were associated with domestic violence (9, 32, 35-38).
But according to Stewart, the relationship between substance use and domestic violence was complicated and although the use of some substances such as alcohol and cocaine was associated with significant increases in the likelihood of partner violence; cannabis and opiates were not significantly associated with occurrence of aggression.
Conversely in the current study and some other studies, incidence of domestic violence was significantly higher in substance abusers than others (18, 38-40).
The current study selected thirteen urban centers in four provinces and three rural centers from Khorasan Razavi province, and this would interfere with homogeneity of subjects.
Based on the results of the current study, it can be stated that domestic violence had a significant relationship with socioeconomic characteristics and psychiatric and medical problems. It seems that providing social, financial and health supports for at-risk families may help to decrease domestic violence, but it needs further investigations since the study only assessed socio-economic factors and it is recommended to evaluate cultural, psychological factors and attitude toward the incidence of domestic violence.
As mentioned before, only 3% of the subjects had sought help for violence. It is important to increase the information of the families about different kinds of domestic violence and their hazards and it is crucial to support the report of domestic violence. Furthermore, it is crucial to provide the helpful strategies and treatments both for perpetrators and victims.
