Assessing Intimate Partner Abuse: Associated Factors and Health ...

Issues in Mental Health Nursing

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Assessing Intimate Partner Abuse: Associated Factors and Health Consequences among Jordanian Women Reema R. Safadi, Mayada A. Daibes, Waheda H. Haidar, Ahmad H. AlNawafleh & Rose E. Constantino To cite this article: Reema R. Safadi, Mayada A. Daibes, Waheda H. Haidar, Ahmad H. AlNawafleh & Rose E. Constantino (2018): Assessing Intimate Partner Abuse: Associated Factors and Health Consequences among Jordanian Women, Issues in Mental Health Nursing, DOI: 10.1080/01612840.2017.1401187 To link to this article: https://doi.org/10.1080/01612840.2017.1401187

Published online: 25 Jan 2018.

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ISSUES IN MENTAL HEALTH NURSING https://doi.org/./..

Assessing Intimate Partner Abuse: Associated Factors and Health Consequences among Jordanian Women Reema R. Safadi, PhD, RNa , Mayada A. Daibes, PhD, CNS, RN MPA, CI, RNd , and Rose E. Constantino, PhD, JD, RNe

b

, Waheda H. Haidar, PhDc , Ahmad H. Al-Nawafleh, PhD,

a Maternal and Child Health Nursing, University of Jordan, Jordan; b Faculty of Nursing, Philadelphia University, Jordan; c Women Studies Center, University of Jordan, Jordan; d Adult Health Nursing, Mutah University, Jordan; e Health and Community Systems, University of Pittsburgh, Pittsburgh, PA, USA

ABSTRACT

In this cross-sectional study, we assessed levels and types of psychological and physical intimate partner abuse (IPA), and the association of IPA with socio-demographic factors and health consequences. The Abusive Behavior Inventory was completed by 471 Jordanian women. IPA was higher among older women who were: of older age, of younger age at marriage, married to unemployed spouses, living in urban residence, and of lower educational level. IPA was associated with most of the health problems except dental injuries and burns. We recommend educational programs that raise women’s awareness to their rights to education, free choices in marital age, and policies that mitigate IPA in Jordan and similar patriarchal societies.

Background

Literature review

Intimate partner abuse (IPA) is pervasive Jordan across the globe and is generally more accepted in patriarchal societies (Al-Atrushi, Al-Tawil, Shabila, & Al-Hadithi, 2013; Boy & Kulczyki, 2008; Haj-Yahia, 2005). According to Ellsberg, Jansen, Heise, Watts, and Garcia-Moreno (2008), one in three women worldwide have experienced either physical and/or sexual intimate partner abuse or non-partner sexual abuse in their lifetime. In a systemic review of 134 studies from North America, Europe, Asia, Africa, and the Middle East, Alhabib, Nur, and Jones (2010) demonstrate that IPA has reached epidemic levels worldwide. Jordan is a Middle Eastern country with a population of 9.5 million (Jordan Department of Statistics (JDoS), 2016). The Jordanian population is conservative and patriarchal; and the male is often the head of the household (Haj-Yahia, 2002, 2005). In central Jordan, where the capital Amman is located, the society features more tolerance for a liberal lifestyle. In contrast, northern and southern Jordan are rural and feature traditional villagers and Bedouins holding on to conservative rules and traditions (Abuidhail, 2014). The family is the basic unit of the social system in the Jordanian society (Ibrahim & Howe, 2011). The family is not only at the center of social and economic activities, but also considered relatively cohesive, with its patriarchal, pyramidal hierarchal (in respect to sex and age), and extended characteristics (Barakat, 1993). The hierarchy of status is more obvious among villagers and Bedouins characterized by men and fathers controlling gender relations and social and economic decisions in their families (Rabo, 1996).

The huge body of literature concerning IPA provides evidence of not only the importance of this worldwide phenomenon, but also its complexity and variations across cultures, ethnicities, and socioeconomic and demographic backgrounds. In this paper, we focus on the regional studies encompassing countries in the Middle East, Arabs, and Islamic populations; nonetheless, including a worldwide literature is inevitable in recognition of the wider and various relevant studies conducted elsewhere; and to contextualize our results within the global reference and evidence of IPA. This approach of focusing on the regional studies is warranted because of the commonalities of cultural groups such as shared language, religion, and sociocultural beliefs and traditions. In this study, we use the terms abuse and violence interchangeably.

CONTACT Reema R. Safadi, Associate Professor ©  Taylor & Francis Group, LLC

[email protected],

Context for IPA: prevalence and rates of abuse In Jordan, a nationally-representative survey of urban and rural areas (JDoS, 2012) report that one-third of married women, aged 15–49 years, have experienced physical abuse at some point of their lives. This burden is echoed in Al-Badayneh (2012), who found that 45% of Jordanian women had personally experienced violence, and 55% were witnesses of violence during childhood. Studies about IPA in Jordan reveal variations among the three main regions of the country (north, center [Amman and its surroundings], and south). In a study in Balqa, central Jordan, AlNsour, Khawaja, and Al-Kayyali (2009) found that 47.5% of the women were emotionally The University of Jordan Research Deanship abused, and 19.6% had been physically abused. On

University of Jordan, School of Nursing, Queen Rania Street, Amman , Jordan.

2

R. R. SAFADI ET AL.

the other hand, in a Bedouin community in northeastern Jordan, Okour and Badarneh (2011) reported a lower rate of psychological abuse (i.e., 28.1%) and a higher rate of physical abuse (38.7%).

Factors associated with abuse Although factors related to IPA have been studied worldwide, the literature presents little concerning the Arab and Islamic region. Among the most commonly agreed upon factors associated with IPA globally are the age of a woman, age at marriage, education of men and women, employment, and urban–rural living. In a systematic review of the literature on the risk factors for partner violence by Capaldi, Knoble, Shortt, and Kim (2012) and by Semahegn and Mengistie (2015) in Ethiopia, it was found that those of younger age were at higher risk for violence. In contrast, Al-Nsour et al. (2009) and Clark, Silverman, Shahrouri, Everson-Rose, and Groce (2010) have provided evidence that Jordanian women of older age were more accepting of abuse. Nevertheless, in a review of IPA in the Middle East and North Africa, Boy and Kulczycki (2008) found that women of all ages were at risk of violence. As for age of marriage, studies in Jordan (Al-Nsour et al., 2009; Clark et al., 2010) and Turkey (Marshall & Furr, 2010) have consistently found that women of younger age at marriage are at a greater risk for abuse. This result resonates with more studies from non-western societies such as Ethiopia (Erulkar, 2013) and Bangladesh (Ahmed, 2005; UNICEF, 2005). The phenomenon of early marriage in traditional societies is comparable to teen dating violence (TDV) in the West. This phenomenon was examined by Chan, Straus, Brownridge, Tiwari, and Leung (2008), who reported increased likelihood of IPA among teenage dating and younger women in intimate relationship. Recent studies have revealed that women with higher education were at a lower risk for IPA (Vakili, Nadrian, Fathipoo, Boniadi, & Morowatisharifabad, 2010). In addition, the higher a spouse’s level of education, the lower is the risk for abuse (AboElfetoh, 2015; Vakili et al., 2010). Interestingly, Heise and Kotsadam (2015) found that not only education was associated with reduced risk of partner violence, but also the association was strongest in cultures where abuse is the norm. Employment and the ability to earn an income are considered factors of female empowerment and necessary for gender equity across all societies (Elborgh-Woytek et al., 2013). A study in Iran, (Vakili et al., 2010) found that unemployed women with less than $200 monthly income were at a higher risk of violence, which is consistent with Capaldi et al. (2012)) and Semahegn and Mengistie (2015). In this study, we examined more factors that we believe are considered cultural norms influencing IPA. For example, a consanguineous marriage, defined as “a union between two individuals who are related as second cousins or closer” (Hamamy, 2012, p. 185), has been examined for association with IPA in societies such as Jordan and other Middle Eastern countries. Marriage to a cousin has been a tradition for many generations out of a belief that it provides stability and maintenance of family structure and property (Hamamy & Bittles, 2008). Hamamy and Bittles (2008) report that first-cousin marriages actually protect against IPA. In a study in Africa, the Middle East, and India,

Usta, Khawaja, Dandachi, and Tewtel (2015) reported a significant association between consanguinity and the experience of IPA. Conversely, Shaikh, Kayani, and Shaikh (2013) found that Pakistani women married to their relatives reported more emotional and physical violence, albeit, a weak relationship. Both the gender and the number of children in a family have also been examined as possible associated factors with IPA. For example, Al-Tawil (2012) and Marshall and Furr (2010) have all found that a larger number of children in a family is associated with increased incidence of IPA in Iraq and Jordan, respectively. In addition, in Jordan, Okour and Badarneh (2011) have shown that a greater number of female children and the pressure to have male children are associated with increased IPA. Finally, in terms of the rural–urban residential dichotomy, most studies (Al-Nsour et al., 2009; Marshall & Furr, 2010; Semahegn & Mengistie, 2015; Vakili et al., 2010) indicate that rural women, regardless of country, were more likely to be victimized. Conversely, one study reported more acts of physical violence against urban women compared to women living in rural areas in Pakistan (Abdullah, Shahzad, Abbasi, Riaz, & Fatima, 2015). In one study, DeKeseredy, Dragiewicz, and Rennison (2012) indicated that there were no differences in the rates of IPA among urban, suburban, or rural racial/ethnic minority females in Canada. IPA and health outcomes In 2008, a multi-country study on domestic violence by Ellsberg et al. confirmed a statistically significant association between lifetime experiences of partner violence and self-reported poor health. Hamdan-Mansour, Constantino, Shishani, Safadi, and Banimustafa (2012) reported that Jordanian women experienced psychological abuse that resulted in depression and increased level of stress. Women in IPA are more likely to experience depression, anxiety, chronic pain, trauma, and psychotic disorders (Hamdan-Mansour et al., 2012), and more physical injuries related to IPA such as scratches, bruises, broken bones, broken teeth, burns, and lacerations (Al-Atrushi et al., 2013; Haddadin, 2012). Moreover, abused women are subject to longterm effects of IPA such as gynecological problems i.e., dyspareunia and sexually transmitted diseases (Kaur & Garg, 2008) and daily dysfunctional complaints (migraines, low energy, and sleep problems (Chrisler & Ferguson, 2006; Ellsberg et al., 2008)). Furthermore, the literature demonstrates that women who have been beaten are more likely to smoke (Chrisler & Ferguson, 2006). Considering (1) the worldwide phenomenon of IPA, (2) the inconsistencies of factors contributing to IPA, and (3) the association of IPA with women’s health, this study is guided by the following research questions: 1. What are the levels and types of IPA to which a convenience sample of Jordanian women are exposed? 2. What socio-demographic and cultural factors (age of a couple, age at marriage, income of a couple, and number and gender of children) are associated with IPA among Jordanian women? 3. Is there a statistically significant difference in psychological and physical IPA among Jordanian women that can be attributed to (1) consanguineous marriage, (2) the educational level of a woman and her spouse, (3) income

ISSUES IN MENTAL HEALTH NURSING

and employment status of a woman and her spouse, and (4) area of residence (northern, central, and southern Jordan), and (5) urban vs. rural living? 4. What is the relationship between levels of psychological and physical abuse and health problems and abuserelated injuries among Jordanian women?

Methods Design The study described in the paper was cross-sectional and correlational in nature. Sample, sample size, and sampling methods A sample of (n = 471) women, aged 15 years or older, and able to read and write Arabic were selected to represent the three geographical (northern, central, and southern) regions of Jordan. Power analysis for the ANOVA test was conducted in GPOWER (Buchner, Erdfelder, & Faul, 1997). The following criteria were considered in sample size calculation for the groups in the three regions in Jordan: an alpha of .05, a power of .80, and a relatively small effect size (p = .15). The minimum required sample size was 432 participants. A convenience/quota sampling technique was used to recruit women from the northern (n = 151), central, (n = 169), and southern (n = 151) regions of Jordan between November 2014 and March 2015. Unlike most Jordanian studies that were conducted in healthcare settings, representing women seeking healthcare services (Al-Nsour et al., 2009; Oweis, Gharaibeh, AlNatour, & Froelicher, 2009), or studies conducted in women’s centers representing women experiencing abuse (HamdanMansour et al., 2012), we targeted women in the community and general public service settings such as schools, public service institutions, public and private healthcare clinics, and women’s union centers. We did not limit selection to a certain assemblage of women to represent women from the general public. The administrative staff of the selected institutions facilitated our recruitment by conveying our research purpose and contact information to potential participants. For example, once we determine to visit a location (e.g., schools, factories, private, and public health clinics) for recruiting, we visit the key person(s) in administration, give them our information sheet regarding the research purpose, “Assessing for IPA,” procedures involved, questionnaire, and our interest in inviting female staff to complete a questionnaire and share information about their marital relationship. The administration posted our contact information for possible inquires, and for interested participants to reach the researchers. Having our research information disseminated, we waited for interested women to contact the researcher or the trained research assistant (TRA) to express their interest in participation. Over the phone, if a potential participant decided to participate, an appointment was scheduled. Ethical considerations The University of Jordan, Research and Ethics Committee approved our study. We also obtained a recruitment approval

3

from the managerial and administrative bodies of the institutions we visited. Upon receiving a call/contact from potential participants, the researchers or the research assistants approached women, explained not only the purpose, procedures, risks, and benefits of the project, but also the voluntary nature of the participation and their right to withdraw at any time. Accordingly, the researcher/TRA invited a willing participant to a private room to complete informed consent and the study questionnaire. The researcher/TRA was available while the participant completed the questionnaire in the event she needed clarification of the questions, or in case there were apparent distressful feelings during completing the questionnaire. To ensure anonymity, confidentiality, and privacy, no names or identifying information were collected. Moreover, data were entered into SPSS, with password protection, and all questionnaires were kept in a locked cabinet by the principal investigator. Instruments and measures Our questionnaire comprised two parts. The first part featured (1) socio-demographic and cultural items (e.g., age, employment, and consanguinity) that gathered information about the participant and her spouse and (2) eleven yes/no questions eliciting responses about health complaints (six items) and abuserelated injuries (six items). The second part featured a measure of abuse, the Abusive Behavior Inventory (ABI) (Shepard & Campbell, 1992). We chose the ABI after reviewing several tools that measure abuse. We concluded that the ABI would be a culturally appropriate and comprehensive measure of abuse in the patriarchal system typical of Jordan. The ABI items are derived from the “Power and Control wheel” (Zink, Klesges, Levin, & Putnam, 2007) and is built on the assumptions of a feminist theory of coercive control and patriarchal terrorism (Johnson, 1995). Since its development, the ABI has been used in several contexts that include medical settings (Ali et al., 2000), the community (Postmus & Severson, 2006), interventional studies (Burch & Gallup, 2000), and the Jordanian population (Haj-Yahia, 2000). In addition to its cultural appropriateness, the ABI includes both physical and psychological abuse items and subscales for measuring sexual and economic abuse. Moreover, the ABI not only is easy to administer among women and men (Dwyer, 1999), but also has demonstrated good reliability and psychometric measures ranging from .70 to .92 when tested with four groups of men (n = 100) and women (n = 78), divided into abusers/abused and non-abusers/non-abused (Shepard & Campbell, 1992). For our study, Cronbach’s alpha indicated .97 for the entire scale, .95 for the psychological subscale, and .94 for the physical subscale. In this study, we used the new, revised ABI, which consists of 29 items that comprise psychological abuse (17 items) and physical abuse (12 items). The 17 psychological abuse items measure the following six parameters: (1) emotional abuse humiliation and degradation (5 items); (2) isolation from friends and family (2 items); (3) intimidation (2 items); (4) threats; (3 items); (5) use of male privilege (3 items); (6) economic abuse (2 items). Meanwhile, the 12 physical abuse items measure three parameters: (1) using physical force (7 items), (2) sexual abuse (3 items), and (3)

4

R. R. SAFADI ET AL.

threat with weapons and sharp objects (2 items). In this study, we used the total, psychological, and physical abuse scores to (1) examine the association between abuse and socio-demographic factors as well as health consequences and to (2) identify differences in abuse level related to these variables. Responses to ABI items comprise a five-point Likert scale (i.e., 1 = never; 2 = rarely; 3 = occasionally; 4 = frequently; 5 = very frequently). Potential score ranges from least to maximum are the following: psychological abuse (17–85), physical abuse (12–60), and total score (29–145). Two professional translators translated the ABI from English to Arabic, and two other professional translators back-translated the resultant Arabic ABI to English to check for consistency. When translating the ABI from English into Arabic, we assumed conceptual equivalence, which means that the concept and its indicators under translation are existent, relevant, and acceptable across cultures (Sidani, Guruge, Miranda, Ford-Gilboe, & Varcoe, 2010). We examined the equivalence of ABI items of the final Arabic questionnaire by asking three consultants (one for tool measurement, and two for IPA) to give their opinion about the relevance and cultural sensitivity of all ABI items. The consultants approved the entire questionnaire. A pilot test of the questionnaire among 30 women demonstrated their clear understanding of all items of the ABI scale. Data collection procedures Upon obtaining consent and recruitment, participants were invited to complete the questionnaires in a private room. Time for questionnaire completion ranged between 30 and 40 minutes. Seventeen questionnaires (3.5%) were discarded because of missing demographic or ABI scale data. Some of the participants (i.e., 31 employed women) chose to answer the questions privately and then return the completed questionnaire in a sealed envelope for pick-up by the TRA from an assigned office. The TRAs were nurses or social workers who were (1) living in the region of data collection and (2) trained by the researchers for how to answer questions for clarification, and to observe for symptoms of distress if appeared. The first few self-report completion encounters were completed with the help of the researchers to confirm that the TRAs could conduct data collection independently. Data analysis Descriptive and inferential statistical analyses were conducted using SPSS (IBM, 2012, Version 21) to describe and identify factors and health outcomes associated with IPA.

Table . Demographic and socioeconomic characteristics of women (N = ). Variable Region of living Northern Central Southern Geographic location Urban Rural Woman’s age Spouse’s age Woman’s age at marriage Marital status Married Widowed Divorced Separated Consanguineous marriage Woman’s education Less than high school High school/Diploma University graduate Spouse’s education Less than high school High school/Diploma University graduate Woman’s employment status Employed Retired Not employed Woman’s income Spouse’s employment status Employed Unemployed Spouse’s income Number of children (total) Number of male children Number of female children

n

%

  

. . .

    

. .

    

. .  . .

  

. . .

  

.  .

   

  

  

. .

M

SD

. . .

. . .

.

.

. . . .

. . . .

our sample in relation to age, age of marriage, educational and employment status of a couple, consanguinity, number and gender of children, and residence location after marriage. The mean age of marriage for females in Jordan is 21.2 years (JDoS, 2016). IPA: rates and types About one quarter (22.7%) of participants reported moderate to severe psychological and physical abuse. Participants reported instances of psychological abuse twice as much as that of physical abuse. Furthermore, participants reported higher rates on all psychological subscales of IPA, with intimidation and use of male privilege as the top two subscales of the total abuse. Use of physical force was the highest among the three subscales of physical abuse. Table 2 demonstrates rates of all types of abuse. Factors associated with IPA

Results Demographics A roughly equal distribution of Jordanian women was sampled from the three regions (northern, central, and southern) of Jordan. As shown in Table 1, urban dwellers (62.2%) outnumbered rural citizens (29.7%). The Jordanian Department of Statistics (JDoS, 2016) reported that 90.3% of the Jordanian population is urban. Table 1 shows the socio-demographic characteristics of

The Pearson Correlation Coefficient was used to test the association of IPA (total, psychological, and physical abuse) with eight socio-demographic factors (i.e., age and income of a woman and her spouse, a woman’s age at marriage, having male or female children, and number of children). Of the eight sociodemographic variables, a woman’s age and age at marriage were the only two variables that showed a statistically significant correlation with the total (r = .102; −.12), psychological (r = .099; −.10), and physical (r = .097; −.13) IPA, respectively.


Table . Percentage of women experiencing psychological and physical abuse and their subscales. Psychological abuse Intimidation Use of male privilege Humiliation and degradation (Emotional) Economic Isolation Used threats Physical abuse Use of physical force Sexual abuse Threats with weapons

†

No of Items

%

  

. . .

  

. . .

  

. . .

Note. † Indicates percentage with moderate to severe level of abuse.

A spouse’s age was also significantly associated with total abuse (r = .098) and physical abuse (r = .107), but not with psychological abuse (r = .87). All other five variables were not significantly associated with IPA. An independent samples t-test was used to determine whether there were differences in the level of psychological and physical abuse related to (1) consanguineous marriage, (2) employment status of a woman, (3) employment status of a spouse, and (4) urban/rural residence. Of these variables, women of unemployed spouses were more physically abused, vis-à-vis women of employed spouses (t = 2.4; p = .019); however, psychological abuse was not associated with a spouse’s employment status. Additionally, women living in urban areas reported more psychological abuse (t = 3.5; p = .001) and physical abuse (t = 2.5; p = .008); compared with women living in rural areas. Marriage consanguinity and a woman’s employment status did not show a statistically significant difference between the groups. One-way analysis of variance was also conducted to examine whether, or not, there was a statistically significant difference in the level of psychological and physical abuse that can be attributed to a woman and her spouse’s educational status and the region of living (Table 3). Results showed that women with higher education and married to educated spouses were less likely to be psychologically and physically abused than lower educated women. Moreover, those living in the central Table . Diﬀerences in psychological and physical abuse in relation to selected variables (ANOVA). Psychological abuse Variable Psychological abuse Women’s education Illiterate School/diploma Bachelor and more Spouses’ education Illiterate School/diploma Bachelor and more Region of living North Center South ∗ p < .

N

M

SD

  

. . .

. . .

  

. . .

. . .

  

. . .

. . .

F

Physical abuse M

SD

. . .

. . .

. . .

. . .

. . .

. . .

.∗

.∗

.∗

F .∗

.∗

.∗

5

region (the capital and its surroundings) —more urbanized, had a greater level of psychological and physical abuse than those living in northern and southern Jordan—more rural and of Bedouin origin. To examine the relationship of total, psychological, and physical abuse with each health problem and each abuse-related injury, we used a Pearson Correlation Coefficient test. Women subjected to IPA reported several health problems. The most frequent were fatigue, headaches, and feeling depressed. Bruises were the most common abuse-related injuries. Our results demonstrate a statistically significant relationship between the total, psychological, and physical abuse and all examined health problems—and almost all abuse-related injuries (Table 4).

Discussion The salient findings of this study are discussed under three foci of IPA: (1) the level and types of IPA experienced by women in Jordan, (2) socio-demographic factors associated with IPA, and (3) health problems and abuse-related injuries. In this discussion, we reflect on local and regional literature, and the social and cultural background of IPA in Jordan. We found that nearly one in four (22.7%) women of this convenience sample of participants had experienced combined psychological and physical abuse during the previous 12 months. This rate (22.7%) is commensurate with the rate (33%) reported by the Jordanian Department of Statistics survey that was conducted in the three regions in Jordan (JDoS, 2007a, 2007b). Moreover, this result is consistent with a more recent study (AlBadayneh, 2012) that demonstrates a much higher rate of IPA (45%) among Jordanian women experiencing IPA. Our participants reported psychological abuse as occurring more frequently than physical abuse, and this is congruent with previous studies of IPA—both in Jordan and elsewhere (Clark et al., 2010; Vakili et al., 2010). Slightly less than one-half of our participants reported having had experienced intimidation and use of male privilege, and over one-third experienced humiliation and economic abuse. Such findings are common in patriarchal societies, such as those in Bangladesh, Jordan, and India, that feature traditional beliefs of male supremacy (Bates, Schuler, Islam, & Khairul-Islam, 2004; Haj-Yahia, 2005; Krishnan et al., 2010). Our study, as with many other studies (Bint-AlHussein et al., 2005; Haj-Yahia, 2002; Khawaja, Linos, & El-Roueiheb, 2008), not only reveals a patriarchal predominance, but also indicates that beatings and disciplinary actions against women are justified by both men and women in Jordan. Of the psychological abuse subscales, classified by Shepard and Campbell (1992), the concept “use of male privilege” is pertinent to this cultural context. In the Arab context, men use their privileges based on their interpretation of religious verses. With this cultural explanation of supremacy, men are given the right to watch over women, have them as their protégées, and thus under their control. In the second focus of this study and in terms of factors contributing to IPA, our study assessed 15 socio-demographic factors that may influence the occurrence of abuse. The resultant association of IPA with age of marriage, educational level,

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R. R. SAFADI ET AL.

Table . Intimate partner abuse and health consequences (Percentages and Correlations).

Health problems complaints Do you have fatigue? Do you feel depressed? Do you have headache? Do you have sleep problems? Do you smoke? Do you have other health problems? Abuse-related injuries History of bruises History of fractures/joint problems History of abortion History of eye injuries History of dental injuries History of burns ∗

Total

Psychological

Physical

r

r

n

%

r

   

. . . .

. ∗∗ . ∗∗ . ∗∗ .

 

 .

. ∗ .

 

. .

. ∗∗ .

   

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rural/urban living, and regional residence, suggests a sociocultural determinant for the occurrence of IPA that warrants considerable attention for detraction. As a matter of fact, literature about abuse shows a strong significance between IPA and the educational level of women (Abo-Elfetoh, 2015; Heise & Kotsadam, 2015; Vakili et al., 2010), and women’s age of marriage (Al-Nsour et al., 2009; Marshall & Furr, 2010). Indeed, Jordan has achieved some progress on these two dimensions, but more effort is still needed on both areas to establish change for future generations. In education, UNICEF (2011) reports that Jordan has achieved not only gender parity in primary and secondary education, with a literacy rate at 99% for both males and females, but also a higher enrollment ratio for females at the tertiary level (43% compared to 39% for men). Moreover, Jordan exhibits one of the lowest numbers of young people without a primary school education in the region (UNESCO, 2012). Given this significant impact of education on IPA, and the improvement in the educational level of women in Jordan, it becomes imperative to consider additional factors that may be influencing the rate of abuse. Factors such as the employment status of women, income, and other sociocultural beliefs and their interacting effect are only a few suggested factors that are worth considering in future studies. On the other dimension, age of marriage, we found that women who were married at a younger age, between 16 and 24 years, were at a higher risk for IPA than women who were married at an older age (25–40 years). This result is congruent with contemporary literature concerning traditional societies and the association between abuse and younger age at marriage, especially when it is an arranged marriage (Erulkar, 2013; Jensen & Thornton, 2003). In this regard, it must be noted that marriages in Jordan are performed according to the Personal Status Laws under Sharia’a (Islamic) law. This law pertaining to age of marriage of 1976 under Article 5 have undergone two modifications, in 2001 and 2010. It states that the legal age for marriage in Jordan is 18 years, with one exception that can be granted by the Sharia’s court judge to wed 15–17-year-old girls

under specific circumstances (UNICEF, 2014). A study by the United Nations Population Fund (UNFPA) revealed that even though the rates of early marriage is declining in Jordan, however, figures released by the Department of Statistics for the years 2009–2011 remained unchanged. It was concluded that about 26% of the total number of registered marriages were for girls between 15 and 19 years (Al-Khozahe, 2009; UNICEF, 2014). With this figure of 26% of women being married before the age of 18, it becomes imperative to address this social/legal problem by enforcing the law and elimination of all exceptions for the implementation of the legal age of marriage. Our results demonstrate that the advanced age of a woman and her spouse was a contributing factor in IPA. In other words, the more recently married young couples had experienced less IPA than older couples. This association of abuse with age can be explained in relation to several factors, including— but not limited to—the socio-legal development, the level of abuse awareness, and the growing emphasis on women’s education that are present in contemporary Jordan. In addition, the increasing influence of women’s movements (Alatiyat & Barari, 2010; Dababneh, 2005), revisions of laws pertaining to women’s rights, and women’s involvement in governmental positions and decision-making forces (Al Maaitah, Oweis, Gharaibeh, Olimat, & al-Maaitah, 2012), and their enrollment in higher education, as revealed in national figures (UNICEF, 2011) suggest an increased awareness of rights and independence among younger Jordanian women. Our results that showed higher level of IPA in the urban and central regions of Jordan (capital) were congruent with the Jordan Department of Statistics report (JDoS, 2012; JDoS & ICF international, 2012). The Jordanian report (JDoS, 2012; JDoS & ICF international, 2012) indicated that women living in urban areas experience more physical abuse than those living in the rural north and south of Jordan (i.e., 35.3% in urban areas; 29% in rural areas). Rates of IPA in northern, central, and southern Jordan could be due to demographic variations. For example, the people of central Jordan, Amman, the capital, is more urbanized, cosmopolitan, and densely populated; in contrast,


the population of the rural north and rural south is more bound to family clans, and tribal Bedouin ancestry traditions. Against these regional differences, the lower rates of IPA in the north and south compared to those in central Jordan may be understood vis-à-vis extended family ties and sociocultural codes of behavior. Rapidly changing population demographics in Jordan—due to the influx of refugees from Iraq and Syria, migration from rural to urban areas, unemployment, educational opportunities, and exposure to awareness-raising campaigns—underlie the differences in IPA among the regions. Unemployment of a spouse was a statistically significant predictor of IPA. We maintain that the economic consequence of a spouse’s unemployment is a major underlying cause of IPA in Jordan, and elsewhere, because men often are the sole breadwinners, especially in the more traditional regions of the country, and women are typically financially dependent on their spouses. This result is congruent with a study from Iran (Vakili et al., 2010) in which a husband’s unemployment, and family income were significantly associated with increased levels of physical, psychological, and sexual abuse. In the third focus of this study, and in terms of consequences of IPA, we included several health problems and abuse-related injuries that would compromise a woman’s everyday quality of life and result in poor health status. Fatigue, lack of sleep, headache, and depression are daily problems that may turn a functional woman into a dysfunctional member of the community. Additionally, some commonly abuse-related injuries, and one gynecologic problem were included. Similar to previous studies (Dillon, Hussain, Loxton, & Rahman, 2013; Pallitto et al., 2013; Sugg, 2015), our results provided further evidence of the association of IPA with all assessed health problems and almost all abuse-related injuries. Sugg (2015) pointed out that IPA affects the health, safety, and quality of life for women, men, and children worldwide, and it includes a range of mental and physical health consequences. Similarly, it is congruent with Dillon et al. (2013)) review of 75 national and international studies which reports physical and mental health problems including poor functionality, depression, PTSD, gynecologic problems, chronic disorders, and chronic pain. Regarding abuse-related injuries, our results indicated an association of abuse with all injuries except for burns and dental injuries. Indeed, Haddadin (2012) has demonstrated that burning assaults are rare in Jordan. Dental injuries and burns are less tolerated in Jordanian society because they are highly visible injuries, which, if they occur, would quickly come under the scrutiny of the omnipresent extended family, and this scrutiny is best avoided. We believe, that although spousal abuse may escalate tremendously within the small family system, however, the extended family and neighborhood systems are always nearby and would rush before greater damage takes place. When a spousal dispute gets severe, a savior (family, friend, neighbor) would be called upon to calm things down and settle disputes by temporarily separating the couple or taking further actions depending on the severity of the situation. All studies have limitations and ours relate to self-reporting methods of data collection. Recall error is a threat to the validity and accuracy of data when compared to other more objective measures. This is crucial, especially when answers reveal embarrassing information (Polit & Beck, 2012). Moreover,

7

a non-probability, convenience, and self-selection sampling is another limitation, making our findings not generalizable to other populations. Our results are more congruent with communities with similar sociocultural backgrounds.

Conclusions Our results demonstrate that Jordanian women are subject to psychological and physical abuse, and that abuse is associated with almost all health problems. Factors contributing to IPA such as early marriage, low educational level, unemployment, urban residence suggest the importance of engaging healthcare professionals, women activist groups, and policy makers for working together on these potentially modifiable variables, (i.e., education, age of marriage, and cultural beliefs of male dominance) to avert IPA in Jordan and in societies with similar patriarchal societal modes of male privilege. Results also provide evidence of the detrimental impact of abuse on women’s health and well-being. This strong association of IPA with all health problems opens a space for nurses to be engaged in assessing and helping women experiencing IPA in Jordan. It is pertinent that healthcare professionals adopt tools that gauge abuse in the practice settings, and include learning material that impart screening and management skills of IPA in nursing schools’ curricula in Jordan. This recommendation would be a first step in shifting the long established cultural tradition of IPA in this part of the world. Policies and programs that enforce women’s rights and enhance services for women experiencing IPA in Jordan should be developed, particularly those informed by, for example, the WHO clinical and policy guidelines (WHO, 2013) for training nurses and healthcare professionals in supporting women experiencing IPA.

Acknowledgments The authors would like to acknowledge the contributions of Professor Valerie Swigart, PhD and Brian Greene, EdD(c) (from the University of Pittsburgh, School of Nursing) and Dr. Faris Doghmi (from the Arab Medical Center) for their valuable review of this manuscript. We would also like to thank our participants for completing the questionnaire, without whom this work would not have been produced.

Funding Academic Research Deanship, The University of Jordan, Amman, Jordan.

Declaration of interest The authors declare No Conflict of Interest.

ORCID Mayada A. Daibes

http://orcid.org/0000-0003-0499-0876

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