Intimate partner violence against Palestinian women in Gaza strip: Prevalence and correlates.

CONTEXT: Intimate partner violence (IPV) affects gravely the victims and is resulting in negative physical and psychological consequences. AIMS: This paper aimed to determine the prevalence of IPV against women in Gaza strip and associated factors. Moreover, to explore women's seeking behaviors to help. SETTINGS AND
DESIGN: Cross-sectional study. METHODS AND MATERIALS: Community internet-based survey was conducted using the Heart Insult Threat Scout questionnaire and the reporting behavior of respondent to violence act. STATISTICAL ANALYSIS USED: A number of 517 ever married women responded and data were entered and analyzed using SPSS software version 23.
RESULTS: About 517 women participated. Of which, 23% (119/517) reported exposure to any types of IPV. Multivariate logistic regression showed factors associated with IPV were as follows: husbands who are drug user (OR = 27.577, CI95%: 5.153-147.591; P < 0.001), husband exposure to violence in childhood (OR = 9.174, CI95%: 4.753-7.727; P > 0.001), and family with a special needs child (OR = 2.956, CI95%: 1.131-8.607; P < 0.05). Approximately, two-thirds of the victims tended to keep silent toward violence and dealt with it as a private and family issue; hence, they hesitated to communicate with others or seek any help to protect themselves.
CONCLUSIONS: About 23% from the study participants experience violence in their life time. Factors associated with IPV are husband's drug abuse, having a child with special needs, and husband's childhood experience of violence. Qualitative researches are needed to understand the women experience to violence and sociocultural barrier for disclosure. Copyright:

Introduction

Intimate partner violence (IPV) is a major social and public health issue,[1] which occurs in various cultures and communities.[2] IPV is a serious human right violation because reports from the World Health Organization (WHO) revealed that more than one-third of women worldwide have experienced either physical and/or sexual IPV or nonpartner sexual violence in their lifetime.[3] IPV involves different types of physical and emotional abuse. IPV affects the health, safety, and quality of life for women, men, and children as well.[4] Moreover, a range of various physical and mental adverse outcomes, including death as an extreme result, are associated with IPV.[4] Such violence is associated with different factors including but not limited to low socioeconomic status, presence of conflict, low levels of education, alcohol and/or drug use, having multiple partners, and life stressors.[3567] Women who exposed to IPV reported high level of anxiety and depression,[8] in addition to negative delivery consequences when victims are pregnant.[9] Many cases require healthcare interventions and some are prevented from seeking health care.[1011] Women in low and middle income countries rarely disclose their conditions and violence to the widely available healthcare services, unless they are directly asked about it.[12] Therefore, empowering women, socially, economically, and educationally, has a significant role in lowering IPV.[8] Wars and conflicts in Palestine were significantly associated with IPV.[13] According to the Palestinian Central Bureau of Statistics, 30% of ever-married women in the West Bank and 51% in the Gaza strip have been subjected to any forms of violence within the household.[14] About 28 women were killed in the name of so-called “honour killing” in 2013.[15] In order to improve women's wellbeing, it is necessary to know to what extent women are exposed to IPV and what factors are associated with. Researches about women reaction to IPV and associated factors are lacking in Gaza strip. This study aimed to assess the prevalence of IPV among married women in the Gaza strip, to determine factors associated with such experience, and to explore women's seeking behaviors to help.

Subjects and Methods

This was an internet-based survey conducted on Palestinian women using an anonymous questionnaire from March to May, 2017. The data were collected through using an adopted questionnaire from a study conducted previously in Saudi Arabia and comprised of three parts.[16] First part contained sociodemographic questions for woman and her spouse. Second part was the hurt, insulted, threatened with harm and screamed (HITS) scale. The HITS scale is promising as a domestic violence screening tool to report prevalence of IPV.[17] The validity and reliability of this instrument was confirmed in our study (Cronbach alpha was 0.892). Responses to HITS questions were on a five-point Likert scale (1: never to 5: frequently). The scores range from a minimum of 4 to a maximum of 20 and 10.5 was a cut of point to consider a woman with experience of violence by her intimate partner.[17] The third part was to measure IPV reporting behavior of violence victim's.[1618] The questionnaire link was developed using Google forum. The link was given to participated women through women community health institutes. These institutes operate in Gaza and focus on women health, social, and legal issues. Databases, including lists of women, members, or attending, were obtained from the institutes and were contacted via their social media contact. The study link enclosed a brief description and objectives of the study, eligibility requirements, and statement of informed consent. Participants had the option to decline or stop participation at any time. Their participation was completely anonymous. The study population comprised of currently married Palestinian wives living in Gaza strip. IPV is the dependent variable and is measured by adding the scores of four items related to different types of violence from verbal to physical and psychological. The range of score is 4–20 and women with a score <10.5 were classified as having no violence and >10.5 were scored as having experienced IPV.[17] In this study, we considered the wife age, wife education, wife employment status, family's income, living place condition, witness to violence in childhood, exposure to violence in childhood, husband's exposure to violence in childhood, husband's drug abuse, husband's age, husband's educational status, husband's job, number of children, gender of children, and finally, having children with special needs as independent variables. Analyses were performed using the Statistical Package for Social Sciences version 23. Data were checked for errors and outliers. Descriptive analysis including means (standard deviations) for continuous variables and frequencies (percentages) for categorical variables was used.

Bivariate analysis and multivariate analysis were conducted to identify independent factors associated with IPV. In Bivariate analysis, Chi-square and Fisher's exact tests were used for comparisons among independent variables and compared between wife with experience of violence and wife who do not experience violence. Findings were presented as COR and 95%CI. In multivariate analysis, all independent variables with P value < 0.05 were chosen for binary logistic regression analysis. In logistic regression, independent variables with P < 0.05 were stated as predictors for IPV. All tests were two sided, with a P < 0.05 considered statistically significant. Ethical approval from Helsinki Committee for ethicka approval number PHR/CH/221/17.

Results

Five hundred and seventeen eligible women participated. Mean age ± SD was 29.197 ± 9.5819 years. Nearly 51.3% (265/517) were between 18- and 29-year-old and 46.8% (242/517) were from Gaza city. Approximately 70.8% (366/517) and 66.2% (342/517) had a university degree and were housekeepers, respectively [Table 1]. From among 517 participants, 23% suffered from one type of IPV [Table 2]. The score of 10.5 was a cut-off point to discriminate between women experienced violence and no violence. In examining the association between IPV and other independent factors, IPV was significantly associated with such husband's related factors (P < 0.05). These factors were husband's job status, drug abuse, previously exposed to violence in childhood, income level, having child with special need and place of living status. In return, partner violence was also found to be associated with wife's characteristics including education level, witness of and exposure to violence in childhood, and exposure to violence in childhood (P < 0.05) [Tables 3 and 4]. All of the independent variable < 0.05 were selected for logistic regression. Multivariate logistic regression showed factors associated with IPV were as follows: husbands who are drug user (OR = 27.577, CI95%: 5.153–147.591; P < 0.001), husband exposure to violence in childhood (OR = 9.174, CI95%: 4.753–7.727; P > 0.001), and family with a special needs child (OR = 2.956, CI95%: 1.131–8.607; P < 0.05) [Table 5]. Regarding our participants response to violence, nearly 68.8% (82/119) of participated women kept silent and did not inform anyone about their aggressive events. Around 10% (11/119) disclosed the violence when they seek medical consultation or care, whereas 7.1% (9/119) reported the violence to husband's family as it shown in Table 6.

Table 1

Demographic characteristic of the participant (n=517)

Variable		n	Percentage
Living place	North of strip	109	21.1
	Gaza city	242	46.8
	Middle zone	89	17.2
	South of strip	77	14.9
Age (year)	18-29	265	51.3
	30-39	179	34.6
	40-49	45	8.7
	50-59	21	4.1
	≥60	7	1.4
Martial duration (year)	<5	190	36.8
	From 5 to 10	169	32.7
	From 11 to 15	71	13.7
	>15	87	16.8
Education status	Illiterate	12	2.3
	High school	82	15.9
	University	366	70.8
	Postgraduate	57	11
Working status	Working	164	31.7
	Not working	342	66.2
	Retired	11	2.1

Table 2

Prevalence of intimate partner violence in Gaza strip

Ever experienced intimate partner violence	Frequency	Percent
No	398	77
Yes	119	23
Total	517	100

Table 3

Women’s factors associated with violence

Women’s risk factors	No violence	Violence	P	OR	CI
Age (year)
≤40	341	103	0.88‡†	0.929	0.512-1.68
≥40	57	16
Educational level
high school or less	63	31	0.01*‡†	0.534	0.327-0.871
University or postgraduate	355	88
Working status
Not working	262	80	0.82‡†	0.939	0.608-1.451
Working or ever worked	136	39
Martial duration (year)
≤10	276	83	0.55‡†	0.981	0.629-1.532
>10	122	36
Witness of violence in childhood
Yes	90	44	0.003*‡†	0.498	0.321-0.773
No	308	75
Exposed to violence in childhood
Yes	85	52	0.000*‡†	0.35	0.22-0.54
No	313	67
No of female children
Three or less	375	110	0.51‡†
More than three	23	9
No of male children
Three or less	375	108	0.13‡†	1.81	0.85-3.89
More than three	21	11

P-value<0.05*, ‡Pearson Chi-square, †Fisher’s exact test, OR=odds ratio, CI=confidence interval

Table 4

Husband demographic characteristic associated with violence

Husband risk factor	No violence	Violence	P	OR	CI
Husband Education
Higher school or less	115	46	0.05‡†	0.64	0.42-0.98
University or postgraduate	283	73
Husband age (year)
< 40	299	96	0.22‡†	0.72	0.43-1.20
≥40	99	23
Husband job
Not working	36	23	0.003*‡†	0.41	0.23-0.73
Working or ever worked	362	96
Drug or alcohol abuse
Yes	2	13	0.000‡†	0.04	0.009-0.18
No	396	116
Husband exposed to violence in childhood
Yes	173	105	0.000*‡†	103	0.057-0.185
No	225	14
Income
≤2,000	269	93	0.03*‡†	0.58	0.36-0.945
>2,000	129	26
Living place type
Separate home	311	80	0.02*‡†	1.74	1.11-2.73
Living with extended family	87	39
Having child with special need
Yes	10	16	0.000*‡†	0.16	0.07-0.37
No	388	103

P-value<0.05*, ‡Pearson Chi-square, †Fisher’s exact test, OR=odds ratio, CI=confidence interval

Table 5

Multivariate logistic regression of intimate partner violence with associated risk factors

Variable	Categories	B	SE	Wald	Sig	AOR	CI
							Lower	Upper
Wife undergoes to violence at your childhood	†Yes	0.395	0.292	1.828	0.176	1.484	0.837	2.632
	No	-	-	-	-	1	-	-
Witness of family member undergo to violence	†Yes	-0.027	0.297	0.008	0.928	0.974	0.544	1.742
	No	-	-	-	-	1	-	-
Husband undergoes to violence at his childhood	†Yes	2.216	0.336	43.641	0.000*ǂ	9.174	4.753	17.708
	No	-	-	-	-	1	-	-
Husband job status	Jobless	0.462	0.375	1.520	0.218	1.588	0.761	3.311
	Have a job	-	-	-	-	1	-	-
Family income	†Less than 2000 NIS	0.224	0.295	0.579	0.477	1.251	0.702	2.230
	More than 2000 NIS	-	-	-	-	1	-	-
Residency type	†Living with extended family	-0.363	0.277	1.722	0.189	0.696	0.404	1.196
	Living separately	-	-	-	-	1	-	-
Having child with special need	†Yes	1.084	0.490	4.888	0.027*	2.956	1.131	7.727
	No	-	-	-	-	1	-	-
Husband is drug addict	†Yes	3.317	0.856	15.020	0.000ǂ*	27.577	5.153	147.591
	No	-	-	-	-	1	-	-
Wife education	†Not educated	0.202	0.317	0.405	0.525	1.223	0.658	2.276
	Educated	-	-	-	-	1	-	-

AOR=adjusted odds ratio, CI=confidence interval. *P<0.05, ǂP<0.001, †reference category

Table 6

Women communication respond related to violence

Women’s communication on violence	Frequency	Percent
I did not tell any body	82	68.8
I Told my husband family	9	7.4
I told the doctor	11	9.7
I told the Shekh	8	6.4
I told the Doctor and family	5	3.5
I told the Doctor and sheikh	2	1.9
I told the Family and sheikh	2	2.3
Total	119	100.0

Discussion

IPV is a public health problem, which is quite prevalent; in many societies, it is negatively the general health and mental wellbeing.[19] Screening of violence among women who seeking health services is very important to identify women at risk and help them to find the survivor pathway from being trapped in violence cycle.[20]

This is the first cross-sectional Internet-based survey to investigate the prevalence of IPV in Palestinian community and its correlate. In this study, we observed the lifetime prevalence of IPV and was 23% and this prevalence is lower than previous reports from nearby countries (77% in Egypt and 43% in Saudi Arabia).[21] Differences could be attributed to various instruments used in data collection. Moreover, lower rate of violence in this study could be a result of the some interventional community programs against domestic violence to support Palestinian women in Gaza.

We analyzed the sociodemographic factors that predict IPV in Palestinian community. After adjusting for possible confounding factors, IPV was significantly associated with husband exposure to violence in childhood, having a child with special needs and husband drug or alcohol abuse. Our study showed a strong association between drug abuse and practice of IPV.[22] Women who live with drug abuser partner reported higher incidence of exposure to violence, which is consistent with ex-reports worldwide.[23] The association between substance use and IPV was studied in many researches world widely[23]; men who batter and men who abuse substances share experience of poor self-control, poor conflict resolution skills, and poor endurance of frustration, which increase their violating behavior[24] and drinks alcohol. Overall, substance abuse disorders were consistently related to IPV after controlling for important covariates. These results provide further evidence for the important link between substance abuse disorders and IPV.[25]

We also found correlation between IPV and families who have special needs. Women who have a child with special needs suffer from a lot of life stressors and IVP could be triggered with low socioeconomic status in terms of low income or bad housing conditions. Therefore, increasing financial and social demands that are sometimes above community capabilities increase the probability of IPV events.[26]

Husbands exposed to violence in childhood are more likely to engage and practice violence against their partners. The violent behaviors are often learned within the family of origin, and then these behaviors reoccur as individuals become adults and enter intimate relationships. Another possible explanation could be attributed to negative consequences on personality development, which affects individual's social and psychological status.[16]

The study showed that 68.8% of the participants had not disclosed the violence to anyone and they preferred to keep silent. Social and cultural constrains could be a hinder and women usually consider IPV as a private and familiar issue that must not be reported. Moreover, mistrust to medical and social care to provide appropriate care and help should not be ignored as well.[2728]

Using of HITS tool does not show the different forms of violence. Families and women with low socioeconomic status and who are poor have limit access to internet. Therefore, selection bias could not be ignored.

The study reports 23% of Gazan women exposed to IVP. This lower prevalence compares with previous reports on violence statistics could be resulted from “End violence against women” program initiated by the Ministry of Women and women rights and health institutes. Predictors for IVP are husband's drug user, husband's exposure to violence in childhood, and family with special needs children. Women are hesitant to report violence due to social and/or personal constrains.

The findings have research and policy implications. Further qualitative researches are needed to explore process and types of violence and their effects on the psychological status, personality development, and motherhood role in family. Future studies are also necessary to understand wives’ reporting behavior and reasons for not reporting the violence, for the purpose of interventions. Policies should be revised and reformed and “End of violence” program has to be re-evaluated. Legislations are also in need to focus on woman protection against IPV. Further research on clinical setting should be done to assess the primary care response to the victims of violence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.