Prevalence of Domestic Violence against Women in Iran: A Systematic Review

Violence against women is universal health problem, which impose social, economic, and healthy cost on communities [1]. World Health Organization (WHO) defined the violence against women as any harsh behavior related to gender that led to physical, sexual, psychologic harms. Such behavior can be occurred as threat, obligouse, and divestment of authority in hidden or apparent situation [2]. In Iran, the prevalence of violence against maiden women has estimated high, about 61.8%; it means that the domestic violence troubling 15-45 years old women much more than breast cancer, cervical cancer, and accidents [3,4]. Although, there are different statistics about prevalence of violence in Iran and other countries but according to WHOs estimation, one of five females are faced to violence during their life time [3,5-8]. Another performed study in 24 countries by world health organization about frequency of violence against women revealed that 13 to 61% and 10 to 50% of women have inflicted in physical and sexual harshment, respectively [9]. Furthermore, based upon a study about 66% of Iranian women experienced at least one violent behavior during married life [10].

Depression and its signs, and suicide are more common in violentfaced women [1]. So it can adversely affect other health aspects such as healthy and immunity of women, family planning, and prevention of AIDS and other psychologic issues. In the other word, violent behaviors not only affect, directly, the body of women but also do affect psychological health. Violence against women may be related to some disorders such as headache, depression, alcolism, abusement, irritable bowel syndrome, and fatigue. However, these symptoms are invisible in most cases [11]. Various factors such as poverty, addiction, psychologic disorder, female,alcolism, drug and alcohol use have found as arousing factors in incidence of violence [3,7,12-14]. Also, verbal, physical, and financial violence are related with economic situation of people so that they are prevalent in labors and poor communities [14]. Additionally other factors, for instance, illitary, not having children or being sterile (maiden) and living in rental house were known as probably causes of violence [15,16]. The first step for dealing domestic violence is systematically data collection about frequency, distribution and its outcome. And then the causes of that should be considered [17]. Regarding to high frequency and destructive effects of violence in the one hand and lack of comprehensive study in the other hand, this systematic review was performed to determine prevalence of physical violence against women in Iranian women.

This study is a systematic review to the estimation of the prevalence of physical violence against women in Iran community. Published studies in national and international journal were used to review. All studies were searched and selected from national (Iranian) and international databases such as SID (Scientific Information Database), Google Scholar, Medlib, Irondoc, Magiran, and Pub Med. The search terms were violence, domestic violence, misused women in the Persian and English language.

First of all, Iranian performed studies about violence against women were searched and collected. Then abstracts were reviewed by first author and selected for further reviewer if they had same key words in title and abstract. Any disagreement was discussed with third author. Therefore about 251 studies, performed between 2001 and 2014, were found and reviewed without considering any filtration for publication time, study language, and type of study. Then the manuscripts were included if they met the fallowing criteria; quantities and crosssectional studies, non-pregnant women with at least one time marriage, only physical-faced violence women, women who experienced violent behaviors by her husband. To minimize the bias, searching in each database was done by two authors, extracting data by one author, and checking was done by another authors. One of the two similar study was included If two or more studies had same data or result. Studies with different and independent publication time by same author were used for review. Out of 251 articles 20 have been indexed on English databases and others on Persian databases. The studies without full text were excluded from review (47 studies). Also, in the next step, 15 repetitive studies were deleted. Of the 189 remained manuscripts, 24 full-text studies were selected for next step. Because of reporting the mean instead of prevalence and not reporting prevalence for physical violence, 6 studies were deleted and eventually 18 studies were included for final review.

This systematic review was done on 9511 non-pregnant women referred to the health provider centers, police offices, and forensic between 2001 and 2014. Diagram 1 shows the flow of inclusion and exclusion of articles.

In the present study, prevalence of violence against women was estimated about 22.9% (CI: 22.2-23.6). This index ranged from 5.7 to 94.7% in different studies. The maximum frequency of the violence has been reported in Atef study, it was about 94% (426 of 450 women). The mentioned study has revealed that pregnancy, age, low education, number of children, addiction, unemployment spouse, and psychological disorders are the predictor factors for physical, sexual, and emotional misbehavior. Also, the lowest prevalence has been reported in Zahedan and Birjand, two cities in south east of Iran, the number of subjects and prevalence of domestic violence in the former was 354 and 5.4% and also 414 and 5.7% in the latter, respectively [17,18]. The instruments used in studies with highest and lowest prevalence were questionnaire and interview, it seem that this is the reason of remarkable difference in these studies.

Regarding to city, the most of studies have performed in Tehran and Ahvaz province, each of them have allocated 14% of total performed studies. About 33% articles (6 studies) and 55% (10 studies) have implemented on population and the referees to health provider centers. One study has been conducted on women who came to police office and one study has performed on referred women to the forensic. The sample size of 88% of article was up to 300 subjects. Obviously, different methods of sampling have been used in reviewed articles. About 23% of studies (n=4) have demonstrated convenience sampling method [17,19-22], 23% of studies (n=5) used clustering method [16,23-26], 3 studies used randomization [27-30], and other remained studies have conducted based up on other sampling methods such as quta,multi-stage,cluster sampling, and census.

In the reviewed studies, various tools have been used to gathering data, about 78% (14 studies) used just questionnaire, 3 studies used both questionnaire and interview, and one study used Zigmound test and Esmit for diagnosis of depression and anxiety [26]. The researcherdesigned questionnaire has been used in 10 studies and SCL-90 questionnaire in two studies [23,16]. One study has used domestic violence questionnaire, one study used Kansas marital satisfaction scale, scale Spanier, Sarason Life Experiences, Smith scale patriarchy [28], two studies have used questionnaire which the reliability and validity of that have been confirmed by other researchers. Additionally, one study did not report method of data collection and also the data in one another study have been extracted from records in police office [31]. As common point, every mentioned study have presented prevalence rate for violence against women (Table 1).

Table 1: Characteristics of reviewed duties.

The first study has been conducted by Arefi for determine of domestic violence against women on 272 women whom have referred to the police office by using census in Orumiyeh between March 2001 and end of March 2001. The highest rate of violence was in 17-20 years-old women (16.5%). Also, the highest rate of violence has been seen among women with the elementary education (56.6%) and illiterate women (24.6%). The results of this study have showed that physical violence has allocated the most figures (50%), and financial and psychological violence has taken place in the next rank. The first one has been 26.1% and the latter one 23.2%. Furthermore, the highest percentage of violence has been observed regarding to drug-related violence and financial-hereditary issues. In this study, there was no relationship between the job of men and violence [31]. Another study has been performed on 600 referred women to health provider centers by researcher-designed questionnaire to estimation of the prevalence of domestic violence in 2003 in Semnan. According to this study, prevalence of domestic violence has been 18.6 and there was relationship between physical violence and education, age at marriage, number of children, education of spouse, job of spouse, and addiction. Bruising head and face has been reported the most frequent hurt fallowing the violence against women (14.4%). Also, dizziness, bone fracture, and other cases has been reported 7.9, 1.4, and 6%, respectively [27].

A study by Hemmati was conducted to determine the prevalence of domestic violence and related factors on 300 households in 2003 in Islamabad of Zanjan. Data collection tool has been Kaneza questionnaire (to measure marital satisfaction), Spanner mutual understanding scale, Sarson life experiences scale (to assess the accidents of life) and patriarchy Smith scale (to measure the patriarchal ideology). The results of this study have shown that total rate of violence against women (physical and mental) is about 26%. Also, the results have revealed that the frequent type of physical violence has been slapping and beating. As well as, punching and kicking or pushing was frequent in terms of the extreme severity and times. The findings also have suggested that the number of children, education of women, income of women, marital satisfaction, job stress, personality traits, behaviors of husband, and life stress has correlated with violence [28]. Narimani et al. has implemented a study to determine the extent of men's violence against women and its related variables among 400 housekeeper women by cluster sampling in 2003 in the city of Ardabil. To collection of data a 14-item Sigmund and Asnyt test have been used to measure depression and anxiety, and assertiveness Kmbryl and Ridgecrest test to measure assertiveness, the Eysenck-57-items questionnaire to measure extraversion and introversion, and researcher-designed questionnaire have been used too. The results of this study have shown that the rate of physical violence figured 28.5%. In addition to physical violence, other types of violence have been checked. Psychological violence and social violence has been estimated 55.5 and 30%, respectively. As well as men's harshness against women were correlated with some demographic variables such as education, family social class, income, and education of men and the psychological variables such as anxiety, depression and assertiveness of women and men [26] (Figure 1).

Figure 1: Relevant studies identified and screened.

Atef Vahid has carried out a study, in Tehran, to determine the role of demographic and psychological factors in predicting violence on 450 married women for three months whom referred to police office and family court due to marital problems. The data collection instrument was demographic questionnaire and SCL-90-R. The results of this study have shown that demographic variables, age of pregnancy, lower education level, number of children, drug abuse, unemployment of spouse, psychiatric problems were significant predictors to experience various types of violence (physical, sexual and emotional). In addition, pregnancy, education, young and unemployment of women, and having high number of children are the most predictors to sever violence. Prevalence of emotional, sexual, and physical misbehavior have been reported 98.9 (445), 60.7 (273), and 94.7 (426), respectively. In relation to physical violence, 63.3% of women have suggested that were subjected to violence for some time, 32.2 often and 3.5% always [16].

A study has done by Najafi et al. to survey of type and severity of injuries caused by violence, in 2004, on 275 women referred to forensic city of Yasouj that had been faced violence for 6 months. The average age has been 8 ± 26 years and ranged 14-70 years. The results have shown that 31.1% of women have been faced violence by their husbands. In terms of injury site 46.5, 17.2, 15.7, 2.7, 13.3, 3.7, and 0.9% of wounds were in hands and legs, head, face, chest, abdomen and spine, respectively. About 38.8% of men beat women by his hands and at least about 0.9% using glass to harshness against women [32].

Razzaghi et al. have conducted a study titled as the prevalence of domestic violence and related factors on 396 married, 16-63 years old women, and averaged age 29 ± 8.53 referred to health provider centers in Sabzevar in 2007. The average age of their spouse was 33.97 ± 0.4. Data collection tool in this study has been a questionnaire derived from Domestic Violence Scale Index. The results have shown that the most prevalent violence imposed against women have been psychological violence (29.2%), sexual violence (28%), and then physical violence (10.8%). Educational level of couple, job of husband, remarried husband, addicted husband, experience of violent behavior in childhood, familial relationship, physical and nervous diseases, birthplace of couple and number of children have had significant relationship whit domestic violence. Among referred persons about 69.8% have never faced physical violence, 4.8% have experienced that some time, and 6% faced sever physical violence. There has been a significant and positive correlation between mental and physical abuse [20].

Jah et al. have implemented a study titled as the prevalence of domestic violence against women and some related factors from January 2007 to March 2008 on 1820 women aged 56-14 under coverage of 4 health centers in Ahwaz, Abadan, Dezful, and Andimeshk. Questionnaire and interview have been used to collection of data and convenience method for sampling. Abuse Assessment Screening Questionnaire after removing questions related to violence during pregnancy has been used. Based on the findings of this study, the prevalence of physical violence at any time of marriage has been 20.2%. The prevalence of psychological, sexual and other type of violence has been reported 41, 10.9, and 47.3% respectively. The results have shown that age, education and occupation female, ethnicity, city of residence and mental illness has had significant relationship with any type of violence. Physical and sexual violence has been common in Arab women and psychological violence and other kind of violence in non-Arab women. The prevalence of all forms of violence has fluctuated from 39.7% in under 25-years old mentor to 51.6% in 50-79 years-old men, it have showed an increase in the prevalence of violence along with aging in men [21].

Another study has been done in Birjand by Mobasheri. The aim of this study has been evaluation of the prevalence and demographic aspects of domestic violence against women on the 414 employed women and housewives. Instrument of this study was a self-design questionnaire, mean and standard deviation of age for women has been estimated 30.01 ± 6.6, for spouses 33.2 ± 7.1, for marriage age 21.51 ± 3.1 and for duration of marriage 8.35 ± 6.6. The results of this study suggest that 42.3% of the samples have faced to domestic violence. Also, there has been a significant difference between age of marriage and physical violence. As well as, there was significant relationship between severity of violence and job and polygamy. The prevalence of physical violence has been suggested 20.2% [17].

Hamule et al. a study was conducted on 354 married women by Ansari et al. to determine exposure to physical, psychological and sexual violence and related factors in Zahedan. The quota sampling method has been used to selection of subjects. And also, require information has been collected by interviews and questionnaires, validated in previous studies and confirmed in term of reliability. The findings have shown that exposure to physical, psychological and sexual violence are 5.4, 20.9, and 9.7%, respectively. Additionally, a significant correlation has been found between spouse education level, number of children, age at marriage, and type of violence. Also, there has been a correlation between ethnicity, education and occupation of spouse with physical and psychological violence. Furthermore, difference in age of couple and income has had significant relationship whit mental and sexual violence. In this study, exposure to physical violence has been 55 and 24% in Baluchian women and Persian women, respectively. As well as psychological violence has been reported 35 and 24% in Persian and Baluch tribe, respectively. The authors have shown a significant relationship between ethnicity and physical violence [33].

Bayati et al. have assessed the prevalence of misbehavior against women and some influencing factors among 1037 women living in Arak for more than a year from marriage date. The data-collecting method has been a self-designed questionnaire that included demographic profile of couple, types of violence (physical, verbal, emotional and financial) and factors affecting the incidence of violence. The mean age of women has been 28.5 ± 6.4, of their spouses 32.3 ± 7.8, and of the duration of common life 9.4 ± 5.6. The findings of this study have indicated that the most common form of violence has been emotional (64.6) and fallowed by verbal (57.1), financial (32.3), and physical violence (26.8). Also, significant correlation has been observed between violence and education, occupation, income of spouse, couple neurological disease, addiction of spouse and number of children [25].

Another study titled as "survey of frequency and types of violence against women and effective factors" has been done on 92 married and referred women to Amiralmomeni hospital by Mardani and et al in Ahvaz in 2007. The sample has been selected by convenience sampling method. Majority of subjects have been 20 to 25 years old, most of them had married in less than 20 years and duration of marriage had been between 5 and 10 years. The findings of this study have shown that 63, 52.2, and 42.4% of women have experienced physical violence, sexual violence, and emotional violence, respectively. In terms of physical violence, slapping and burning has allocated a frequency about 25.9 and 7.1%, respectively. Considering sexual violence, sexual intercourse without consent and using force to sex have been two violent behaviors. The former has allocated a frequency about 16.7% and the latter 4.2%. Furthermore, insulting (15.4%) and threatening to imprisonment in home (2.6%) have posed the matter emotional violence. Also, based on findings of this study the level of education, living in urban, and family relationship of couple have had significant correlation with violence [34].

Another study has performed by Meybodi and et al, titled as the prevalence of violence against women by their husbands, on 400 married women in Kerman in 2009. In this study random cluster sampling based on zip code has been used for selecting subjects. The average age of subjects has been 39.5 ± 12.1 years. The average age at marriage has been 19.8±3.8 and the average years of marital life 20±13.7 years. Data have been collected through researcher-design questionnaires and interviews. According to the findings, 46% of women have experienced various type of violence such as psychological violence (78.6%), physical (55.6%), sexual (28.6%) and economic (34.7%). As well as, domestic violence had a correlation with education men and women, job, living in the village to age 20 years, addiction of male and female and living with other family members. The greatest cause of violence, according to violating women, has been poor economic situation and husband's job [24].

The prevalence of domestic violence and its effect on mental health fields has been assessed on 500 patients referred to health centers of medical university of Shahid Beheshti in Tehran. Subjects have been selected by multistage cluster sampling method. Inclusion criteria of the study have been women's 65-15 years old and absence of depression in life time. Data have collected by measurement violence questionnaire and SCL90 questionnaire. The mean age of women has been 29.6 ± 7.9 years and the average age of their spouses' 34.8 ± 8.1 years. The results have shown that 84.8% of women have experienced different types of domestic violence over the marital life. The prevalence of various types of violence has been reported about 81.2, 41.8, 40.4% for emotional violence, sexual violence, and physical violence, respectively [23].

Another study has been done by Tarkashvand and colleagues aimed to determine the frequency of domestic violence against women on 540 women referred to 7 health centers of Rafsanjan. Subjects have been selected by multistage sampling method. The self-study questionnaire was used to collecting the information. Women aged 60-19 years with a mean 31.28 and standard deviation 7.83. The results of this study have shown that, totally, 50.9% of women have subjected to violence. The frequency of physical violence, verbal abuse, emotional violence, and sexual violence has been reported about 23.1, 38.1, 21.3, and 18.9%, respectively. Additionally, according to findings, there was significant relationship age of couple, education level of women, husband occupation, history of mental illness in the couple, number of marriage, and the number of disabled children in the family [9].

Nikbakht et al. the third study in Khuzestan province has been performed in 2013. to estimating the prevalence of domestic violence and it's risk factors on 368 married women aged 15-55 (36.8 ± 12.3). The convenience method has been used to selecting subjects. The data in this study have been collected by questionnaire and interview. The results of this study have revealed that the prevalence of violence in women has been 63.8%. Particularly, emotional violence has allocated the most frequency (58.8). Moreover, duration of marriage, number of children, age difference between spouses, age at marriage for male, female employment, unemployment and drug abuse by husbands have associated with violence [29].

Derakhshanpour and his colleagues have evaluated the prevalence of domestic violence against women on 500 women referred to the Shahid Mohammadi hospital between 2007 and 2008 in Bandar Abbass province. Recruiting subjects have been convenience sampling method. In this study, a researcher-designed questionnaire has been used to data collection. The age of women averaged 33.80±8.64, men 37.26 ± 9.53, and duration of marriage 10.53 ± 7.83 years. 460 (92%) of women has experienced domestic violence. Only 40 (8%) of surveyed women have not mentioned any violence. The most common form of violence against women has been psychological violence (54%) and other type of violence such as verbal violence, physical, and sexual has figured 31, 24.8, and 6.8%, respectively. Also in this study, education and addiction has considered two influential factors on domestic violence [22].

This study was conducted to determine the prevalence of physical violence against women in Iran, the prevalence of physical violence was estimated 22.9%. The prevalence of physical violence between different studies flactuated from 5.7 to 94.7%, it may be due to differences in sample size, data collection, location of study where the study was conducted and data collection centers. In developed countries, about 28% of women just one time has faced to violence by her husband while in developing countries it fluctuate from 18% to 67% [35], the results of this study also close to the developing regions. The study of World Health Organization [6] in different countries has shown that the prevalence of physical violence has been 6% in urban areas of Japan, the lowest rate among studied countries, 40 and 42% in urban and rural areas in Bangladesh, 16% in Cambodia, 10% in Philippines, between 30 and 40% in different parts of India, 34% in Egypt, 32% in the Zionist regime, and 52% in Gaza and the West Bank. The prevalence of physical violence is higher in the last mentioned countries than others. The prevalence of physical violence at workplace in our country and other countries have been reported between 16-36% [36-41], it is due to variation in populations study, and also because of different type of study, different cultures, and different social and economic context. In the present study, physical violence has taken first place in most of reviewed studies. In India, the prevalence of physical violence has reported about 31%, which has been more prevalent than other type of violence such psychological and sexual as. In another study in East India [4] physical violence has been estimated 52%, which has allocated secondary rank after sexual violence. In a study in Peru [42], physical violence has estimated about 34.2%. Also, another study in Nigeria [43] has classified the physical violence as a prevalent violence against women (55.6%). In a study by Clark and colleagues [44], physical violence has classified in second place (31.2%). In most studies, age of women has had a significant relationship with occurrence of violence against women; however some studies reported contradictory results. Also, the prevalence of physical violence has positive correlation whit age of men. But the finding of some studies was not similar to conducted studies in other countries [6].

The results of curried out studies in Iran indicate that education level especially university education of men and women lead to decreasing violence against women, which could be due to higher levels of culture and the better economic situation of family. In a study in USA, level of education has considered as a protective factor [45]. Another study has shown that living in rural areas, low education, living in poor families and unemployed husband are the most factors of physical violence against women [46]. In the other countries the figure of violence has decreased by increasing women's education. Furthermore, low-income women and housewives are faced to violence more than employed women [6]. It seems that the rise in women's educational level is along with financial independence of women, which could be a protective factor against physical violence.

According to the results of studies, employment of women significantly is related to the frequency of physical violence against women. Also, based upon some studies, there is noticeable relationship between unemployment of male and violence against wives, as well as significant relationship between engagement of men and violence towards his wife [47-49], which could be affected by economic problems. As well as income of family could affects this issue so that the figure of violence has suggested more percentage in low income family than high income family. Furthermore, low social class likely involves the amount of violence, so that the prevalence of physical violence in families with lower social class is more than families with higher social class. It seems that economic problems of families is one of the most outstanding factors that increase the stress and tensions in people and consequently it led to aggression in people in long term. In fact, the dissatisfaction of the financial situation in families can increase physical violence against women. The carried out studies, in Iran, have considered various factors which are matter in the incidence of physical violence against women, such as mental disorders of couple, familial relationship, the husband's second marriage, disabled child in the family. Also, according to the structure of Iranian's society and existence of different ethnicities, some studies have shown that there is a significant relationship between the incidence of physical violence and ethnicity, it could be the result of traditionalism and adhere to the system of patriarchy in the family. Meanwhile, the most important factors of violence in Bangladesh [50] have been insufficient family support from his wife, not a proper dowry to the bride, and religion of wife, while in Turkey prominent factor has been smoking women [51].

Different studies have evaluated physical violence by type and severity of physical violence. Various experienced forms of violence against women have reported, for instance; slapping, pushing, hitting with hands, beatings with fists, kicking, hitting with a belt, pushing, throwing objects, burning, strangling and stabbing. Moreover, violence has been classified by severity of violence from mild and minor injuries such as bruises and abrasions without serious injury or damage to severe or sustained violence such as fractures and burns. In all studies, low severity violence and without serious damage, such as slapping and hitting with fists and kicks, has been more common than severe violence such as burning and fracturing. Women who were subjected to violence may face a lot of problems and consequences. Some of these problems can interfere with social and family role and it results to failure doing housework, care of children, and away from work. Also some psychological complications, have been reported such low selfconfidence, anxiety and mental disorders as. Each of these issues can lead to complications and consequences of its own. For example, anxiety of mothers could lead to anxiety in children as well. Researches have shown that crime and anti-social behavior in children are common in such families. Additionally, battering could create many physical problems such as brain trauma, fractures, bruising, bruising, swelling, damage to internal organs and rupture of tissue. It may accelerate the progression of complications of some disease, such as tuberculosis, diabetes, heart and nerve disease or may promote silent lesions such as osteomyelitis, gastric and duodenal ulcers. All these events cause adverse effects on human health and society. Since marital satisfaction could affects physical violence and other domestic violence, so premarital education, counseling, group training in the field of consultation, and respect to wife could be considerable ways to decreasing physical violence and other domestic violence in community.

We would like to acknowledge all colleagues for her/him sponsor and generous cooperation on the draft and review of the manuscripts.