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Year : 2018  |  Volume : 23  |  Issue : 3  |  Page : 205-210

Performance of healthcare providers regarding iranian women experiencing physical domestic violence in Isfahan

1 Students Research Centre, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Nursing and Midwifery Care Research Center, Midwifery and Reproductive Health Department, Isfahan University of Medical Sciences, Isfahan, Iran
3 Community Medicine Department, Isfahan University of Medical Sciences, Isfahan, Iran
4 Epidemiology and Biostatistics Department and Heart Failure Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication2-May-2018

Correspondence Address:
Nafisehsadat Nekuei
Nursing and Midwifery Care Research Center, Midwifery and Reproductive Health Department, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Hezarjarib Avenue, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnmr.IJNMR_35_17

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Background: Domestic violence (DV) can threaten women's health. Healthcare providers (HCPs) may be the first to come into contact with a victim of DV. Their appropriate performance regarding a DV victim can decrease its complications. The aim of the present study was to investigate HCPs' performance regarding women experiencing DV in emergency and maternity wards of hospitals in Isfahan, Iran. Materials and Methods: The present descriptive, cross-sectional study was conducted among 300 HCPs working in emergency and maternity wards in hospitals in Isfahan. The participants were selected using quota random sampling from February to May 2016. A researcher-made questionnaire containing the five items of HCPs performance regarding DV (assessment, intervention, documentation, reference, and follow-up) was used to collect data. The reliability and validity of the questionnaire were confirmed, and the collected data were analyzed using SPSS software. Cronbach's alpha was used to assess the reliability of the questionnaires. To present a general description of the data (variables, mean, and standard deviation), the table of frequencies was designed. Results: The performance of the participants regarding DV in the assessment (mean = 64.22), intervention (mean = 68.55), and reference stages (mean = 68.32) were average. However, in the documentation (mean = 72.55) and follow-up stages (mean = 23.10), their performance was good and weak respectively (criterion from 100). Conclusions: Based on the results, because of defects in providing services for women experiencing DV, a practical indigenous guideline should be provided to treat and support these women.

Keywords: Domestic violence, healthcare providers, Iran, women

How to cite this article:
Yousefnia N, Nekuei N, Farajzadegan Z, Yadegarfar G. Performance of healthcare providers regarding iranian women experiencing physical domestic violence in Isfahan. Iranian J Nursing Midwifery Res 2018;23:205-10

How to cite this URL:
Yousefnia N, Nekuei N, Farajzadegan Z, Yadegarfar G. Performance of healthcare providers regarding iranian women experiencing physical domestic violence in Isfahan. Iranian J Nursing Midwifery Res [serial online] 2018 [cited 2023 Mar 25];23:205-10. Available from: https://www.ijnmrjournal.net/text.asp?2018/23/3/205/231490

  Introduction Top

Physical domestic violence (DV) is any intentional use of physical force by a family member which may lead to death, disability, and injury of the victim. DV is an important and widespread public health problem. The financial impact of DV on communities is estimated to be more than $8.50 billion annually with the majority of costs going to healthcare services.[1] DV can have physical, mental, sexual, and reproductive health consequences.[2] Women experiencing DV are in danger of prenatal and neonatal mortality more than other women during pregnancy.[3] The World Health Organization (WHO) has reported that 35% of women worldwide have experienced physical and sexual violence. Regrettably, because of lack of supportive actions for DV victims in several countries, many cases of violence go unreported.[2] Previous studies have reported a prevalence of 24.30% and 60% exposure to DV among women in the United States [4] and Bangladesh,[5] respectively. In India, 31% women experienced severe physical DV in 2012.[6] It is estimated that 36% of women over the age of 18 years in Tehran, Iran, have experienced physical DV. The prevalence of physical abuse in Isfahan, Iran, was reported to be 27.20% in 2005.[7] Moreover, the prevalence of physical DV among pregnant women in Tehran was approximately 10.70% in 2014.[8] Therefore, due to the high incidence of DV (66%) in Iran [9] and other countries,[10] it is necessary to identify the problem and provide adequate treatment and support to reduce and prevent its complications. Healthcare providers (HCPs), especially those working in emergency and maternity wards, have an important role in identifying and intervening in DV [11] because they may be the first to come into contact with a DV victim. Therefore, their appropriate measures can reduce the mental and physical consequences of DV in women. According to standard protocols, HCPs should identify and manage DV efficiently. Moreover, they should refer the victims to available services and centres if needed. Finally, to prevent and reduce DV, HCPs should investigate and explore the cases of DV.[11] With regard to DV and the performance of HCPs, a few studies have been carried out based on standard protocols. Considering the knowledge, attitude, and performance of HCPs with regard to DV, two studies have examined the quality of DV screening.[12],[13] Similarly, in another study, the relationship between attitude and performance of HCPs and other health-risk factors was investigated.[8] The aforementioned studies examined only some areas of the protocol. Screening for DV is currently performed at the level of the primary healthcare (PHC) in Iran. However, it is still under the assessment of the health system.[8] Accordingly, considering DV protocols, the present study aimed at investigating the performance of HCPs regarding women experiencing DV.

  Materials and Methods Top

The present descriptive, cross-sectional study was conducted among HCPs working in the emergency and maternity wards of 10 general hospitals of Isfahan from February to May 2016. All hospitals affiliated to the Isfahan University of Medical Sciences, Isfahan, which are referral centres for DV cases, were selected according to the census. To calculate the sample size, assuming normal distribution of scores, Cochran's formula (Z = 1.96, d = 0.05, p= q = 0.50) was used, and the scores were converted on a scale of 1–100. Among 796 HCPs, 300 were selected using random sampling. The participants of the study consisted of 42 physicians, 46 midwives, and 212 nurses. The inclusion criteria included one year or more of professional experience and at least one encounter with a woman experiencing DV. The data for the present study were collected through a self-administrated questionnaire developed by the researcher. It was based on DV international guidelines and consisted of two sections. The first section of the questionnaire included demographic information. The second section consisted of 35 items evaluating treatment and supportive measures. The questionnaire consisted of the subscales of assessment (performances regarding physical and mental assessment) (12 items), intervention (performances regarding physical and mental treatment) (7 items), documentation (recording all information on the victim and the services provided for her) (8 items), reference (performances regarding referral of victims to appropriate services) (4 items), and follow-up (following the victim by phone calls or revisits) (4 items). The items were scored based on a five-point Likert scale (1–5 scores).

The DV questionnaire was prepared based on international guidelines. The developed questionnaire was examined in terms of its psychometric characteristics (i.e., reliability and validity). The content validity of the questionnaire was delineated through expert judgment. To determine quantitative face validity, impact score was used and important items were kept. To determine quantitative content validity, content validity ratio (CVR) (≥0.99) and content validity index (CVI) (≥0.79) were used. Finalizing the final questionnaire with 35 questions was the next step. To assess the reliability of the questionnaire, a pilot test was performed on 20 participants selected from the same study population. The reliability of the questionnaire was confirmed with Cronbach's alpha of at least 0.75. The purpose for implementing such a phase was to discover any existing problems and eliminate them, as well as to assess the time allotted for administering the questionnaire, the quality of the instructions, and the quality of the individual items. Finally, the questionnaires were distributed among the participants to be completed in the presence of the researcher.

To analyze the data obtained through the administration of the questionnaire, data were entered into SPSS software (version 20, IBM Corporation, Armonk, NY, USA). To have a general description of the data, descriptive statistics (i.e., the means and standard deviations) were calculated for each subcategory of the questionnaire used in this study. Scores of less than 50, 50–75, and over 75 in different sections of HCPs' performance regarding DV were, respectively, considered as poor, average, and good (criterion from 100).

Ethical considerations

The ethics committee of Isfahan University of Medical Sciences approved this research (Ethic code: 394461). Ethical considerations in this study included obtaining written or oral consent from participants, assuring them of confidentiality, and allowing them to freely participate in this research.

  Results Top

The response rate was 100%, and 300 questionnaires were analyzed. The age of the participants ranged from 24 to 50 years with the mean (SD) age of 34.34 years (5.98). The majority of the participants were women (75.33%) and married (74%) with a mean professional experience of 9.10 (6.12) years [Table 1]. The mean (SD) scores in the assessment, intervention, documentation, reference, and follow-up stages were 64.22 (17.24), 68.55 (15.42), 72.66 (17.38), 68.32 (20.05), and 23.10 (26.17), respectively. The mean score of measures was 58.19 (14.48) (criterion from 100). The frequency of performance stages is presented in [Table 2]. Only 12% of the participants evaluated the victim's decision after leaving the hospital whereas 86% assessed the physical and mental effects of DV on the victim. Moreover, 84% of the participants performed the right measures to repair the physical damages. It was demonstrated that 94% of the participants recorded all the measures taken for the victim. Marking trauma on the body map was the measure least taken. Furthermore, 80.6% of the victims were referred to a psychologist or psychiatrist, but almost 85% of the participants did not follow the victim's condition after leaving the hospital.
Table 1: Demographic characteristics of participants (n=300)

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Table 2: Frequency of assessment, healthcare providers' intervention, documentation, healthcare providers' reference, and follow-up regarding domestic violence (n=300)

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  Discussion Top

The present study is the first in Iran to evaluate HCPs' performance regarding DV according to standard protocols. No research could be found reporting HCPs' performance according to the DV protocol details as in the present study. The average quality of HCPs' performance regarding DV was the main finding of the present study. The response rate was 100%. This response rate may indicate the interest of the participants in DV. The age range of the participants was 24–50, that is, the participants of the present study were younger in comparison to other similar studies.[8],[14] The mean number of participants who came into contact with victims of DV was 25.29. However, a study carried out in Hamburg (Germany) showed that the rate of encountering women who had experienced DV ranged from 1 case every 2 years to 10 cases per year.[14] Another study conducted in Lebanon found that physicians encountered DV cases with a prevalence of 0.50–70% during their professional career.[15]

Due to the high prevalence of DV in Iran [9] and some other countries [10] and the mean encounter with DV victims in the present study, it seems necessary that more attention be paid to DV. The mean score of general performance of the participants in the present study was average. The highest and lowest scores were related to documentation and follow-up, respectively. Likewise, a study carried out in the UK showed that the most important measures taken regarding DV were related to documentation,[16] which was similar to the results of the present study. Due to the legal consequences, documentation may be a sensitive topic in medical practices. It can be concluded that the health system should pay more attention to other components of performance related to DV and improve HCPs motivation to take appropriate measures. Based on the results related to the assessment, only a small number of the participants always took the injured woman to a private room. The WHO prioritizes the privacy and confidentiality of patients.[17] In many cases, because of shame or to prevent more quarrels among family members, the victims avoid talking about DV in the presence of HCPs. Thus, it is necessary to preserve patients' privacy. As can be seen a small number of the participants took this subject into consideration. Therefore, the causes of this issue must be identified and the staff must receive suitable training related to professional and ethical issues.

More than half of the participants never evaluated victim's decisions after leaving the hospital. According to a study carried out in Virginia, America, one of the decisions which a DV victim may take is to leave the house and become homeless, which leads to adverse effects and social damages.[18] Their bad decisions may even result in suicide or homicide.[19] Based on the San Francisco practical protocol for clinicians, before patients leave the clinic, they should be asked the following questions to determine their decisions: (1) If you return home now, will you be in danger?; (2) What type of help would you like?; (3) What action are you ready to take?; (4) How might we help?; and (5) Have you had any thoughts of harming or killing yourself)?[20] Nevertheless, the results of the study showed that the least attention was paid to the victim's decisions after their leaving the hospital. This could be due to a lack of knowledge and skills of the staff for effective communication with DV victims, lack of sufficient time for more evaluations, cultural community conditions, and lack of practical instruction for HCPs which can be the most important cause. Overall, the performance of the participants in the present study in the area of assessment was average. However, in a study conducted in the UK, performance was weak; only 40% of the participants asked the victims if they were abused.[16] The results of the study showed that this was due to lack of confidence and poor knowledge of participants in identifying and managing women experiencing DV. Thus, through increasing their knowledge, HCPs can improve their assessment of DV victims. In addition, requesting assistance from other medical teams and ensuring patients' confidentiality was the most reported intervention. Expressing sympathy with the victim was ignored by the participants. In addition, the ability to continue supporting the victim is an important component of care. Sympathizing with DV victims causes the victim to confide in HCPs and cooperate in treatment.[21] One reason for not offering sympathy to DV victims may be the lack of effective communication skills that could mostly be solved by training sessions. To inform the police is one of the interventions that may be controversial; however, a national instruction would solve this issue. The findings revealed that 69% of the participants informed the police when they came into contact with a victim of DV. Similar outcomes were found in a study carried out in Malaysia.[12] It is worth mentioning that any intervention should be guided by the principle of “do no harm” and prioritization of the safety of women and their children as the utmost concern.[17] An effective consultation with the victim and her family can lead to the right intervention.

In the documentation, the measure least taken was the marking of trauma on the “Body Map.” It is important to document injuries because the injured may later wish to use it in law enforcement.[22] The participants reported that documenting the demographic characteristics of the injured, date and time of the visit, and the actions taken are the most important measures they had taken for the victim regarding documentation. It seems that the consideration of documentation by HCPs results from the control and supervision of the Ministry of Health. The outcomes of a similar study showed that documentation was conducted completely, and HCPs had taken photos of injuries when permitted by the victim.[14] In Iran, it is not common to photograph injuries except in special cases which have led to fatal injuries. Although our participants' documentation was good, another study in Iran reported poor documentation.[8] The difference between the findings of the present study and the above mentioned study may be due to the lack of a practical national DV protocol in Iran or differences between the studied populations. However, it appears that a national protocol is necessary to create harmony in the health system.

The results revealed that over 70% of the participants had referred victims to social workers, psychiatrists, psychologists, and at times legal authorities. Contrary to the findings of the current study, reference was weak in two similar studies.[8],[16] When assessment is combined with appropriate referral to services and training, the incidence of DV may reduce and women's health can improve. Thus, HCPs can help victims by providing them with pamphlets and a list of centres. Nonetheless, only few participants reported giving information to the victims of DV. This may be due to unavailability of pamphlets or lack of HCPs' knowledge about service resources. Preparing a DV pamphlet and training HCPs can ease this shortage, and thus, increase victims' knowledge.

Furthermore, the results of the present study are in line with the results of a study carried out in Tehran. It was shown that participants had a weak performance regarding follow-up through phone calls or revisits.[8] It may be suggested that more attention be paid to follow-up in Iran. According to the protocol of the WHO, the victim should be followed up by phone or follow-up appointments at least once after the last act of violence. The next follow-up can prevent DV and create confidence in the victim.[23] The participants of another study stated that they were not trained regarding DV and that a large group of them were unaware of service resources.[16] Therefore, adequate training would improve performance. The lack of a national protocol in Iran, time constraints, and differences in attitude and culture result in conflicting performance regarding DV victims. Accordingly, employing a specialized group (physicians, nurses, and midwives) and codifying a national protocol to treat DV can improve the performance of HCPs and the health of women and society. Because of observational bias and other problems, we could not assess HCP performance directly.

  Conclusion Top

Based on the findings of the study, it can be stated that the performance of HCPs regarding DV is not satisfactory. Because emergency and maternity wards as the first line of treatment and support can manage and control DV, their strategies and supports can reduce both the incidence of DV as well as its medical, social, and public health effects. Therefore, to improve women's health and reduce DV in the society, a national standardized protocol should be codified and HCPs should receive training on this protocol.


We appreciate Clinical Research Development of Isfahan hospitals for cooperation and Isfahan University of Medical Sciences for supplying research funding. The authors are grateful to all who provided their time to carry out this study (Project number 394461).

Financial support and sponsorship

Isfahan University of Medical Sciences.

Conflicts of interest

Nothing to declare.

  References Top

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Sarkar N. The cause and consequence of domestic violence on pregnant women in India. J Obstet Gynaecol 2013;33:250-3.  Back to cited text no. 3
National Center for Injury Prevention and Control Centers for Disease Control and Prevention, The National Intimate Partner and Sexual Violence Survey: 2010 Summary Report, Atlanta, Georgia, 2011. p. 1-113.  Back to cited text no. 4
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  [Table 1], [Table 2]


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