Physical abuse among Syrian refugee women in Jordan

(	Noha Al-Shdayfat Correspondence: Noha Al-Shdayfat, PhD, RN Princess Salma Faculty of Nursing, Al al-Bayt University, PO Box: 130040, Mafraq 25113, Jordan Email: dr.nuhash@aabu.edu.jo; nohashdaifat@gmail.com

Abstract Background: Physical abuse of women is the most common form of female abuse all over the world. Objective: The current study aimed to investigate the prevalence of physical abuse and its association with some socio-demographic variables among Syrian refugee women in Jordan. Methods: 182 Syrian refugee women visited the Maternal and Child Health Centers (MCHC) in Mafraq district and participated in the current study during March 1, 2014 and June 1, 2014. The Arabic version of the NorVold Domestic Abuse Questionnaire (NORAQ) was used to collect data from the study participants. Results: The study findings revealed that about one third of the participants (57, 31.3%) experienced physical abuse (before and after refuge). Twenty seven participants (14.8%) reported being physically abused during the last year. Husbands were the perpetrators in 38.6% of the physical abuse acts reported by the participants, followed by fathers (14%) and brothers (10%). The bivariate analysis revealed that educated women, older women, those who come from small size families (<6 members), and those who got married at or after 21 years of age were less likely to report physical abuse. The regression model analysis showed that educational level of the physically abused women is the strongest contributing factor to predict their psychological suffering scale (Beta= -1.7, p < 0.05) followed by marital status and household income (Beta= -1.3, and 0.94 p < 0.05) respectively. Conclusion: The current study will pave the way to fill the gap in the literature in regard to physical abuse prevalence and the associated factors among Syrian refugee women in Jordan. However, further research will be needed to address this important issue. Key words: Physical abuse, Refugee, Syrian women, Jordan

Background
Physical abuse against women is defined by the United Nations as "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life."

Domestic violence is a worldwide public health concern. However, high vulnerability of women in developing countries increases the risk of being battered by husbands and / or a family member (1). Social and cultural norms in the Arabic societies allow men to discipline women by physical acts such as beating (2). In such patriarchal societies, the political and legal context may contribute to the increase in violence against women (3). Also, legislation and traditional practices do not criminalize violence against women, but justify it through religion, culture, and often the health authorities and security or legal authorities, consider violence against women as a family interest and must not be shared with the outsiders. Domestic violence prevalence against immigrant or refugee women in the host countries might not exceed the rates in the original countries. However, the vulnerability for refugee women is expected to escalate, because they lost their resources such as their families and support systems (4).

Violence against women in Arab world has not been sufficiently studied (5). High prevalence of physical abuse against women has been reported by few studies conducted in the Mediterranean and North Africa region. One of such studies that collected data on physical violence from 262 women living in Palestinian refugee camps in Jordan found that 44.7% of the women participants reported lifetime beating (3). Similarly, the findings of a study conducted in Saudi Arabia showed that 25.7% of the women in Medina district reported being physically abused by their husbands (6).

Some research suggested an association between poor socio-demographic conditions and physical abuse and wife beating. For example, the results of a survey carried out in 2005 on the prevalence of wife beating in Egypt revealed that women who live in urban areas were less likely to be beaten by husband than that of those who live in rural areas, and women whose first marriage was at 30 years old and more were at higher risk for wife beating (7). Women's age and educational level were also found to have an inverse association with physical violence against women (8, 9). Other research linked household income with physical wife abuse (10, 8)

In previous research physical abuse has been reported to coexist with emotional abuse (11, 5, 12, 2, and 13). In addition women who are physically abused by their husbands were often abused by another person such as a family member (11).

Reporting physical abuse to a health professional and/or talking about it to a friend or a family member is the first step to break the cycle of the domestic violence. Yet, many women hesitate to discuss their status with anyone because they fear to lose their husbands, housing and/or children (Gender-Based Violence Area of Responsibility (GBV AoR), DRAFT - Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action, 2014) especially if they are financially dependent on them. Other reason might be the socio-cultural norms in the Arab conservative societies that stigmatize the divorced or separated woman as a bad person. Thus, low reporting of physical abuse is expected, particularly, among the disadvantaged communities such as refugees and immigrants in developing countries where only 7% of gender based violence is officially reported cases.

Psychological consequences of women abuse might be similar or even more serious than that of physical consequences; depression is one of the most frequently reported psychological consequences of the physical abuse against women (14, 15).

Being the first to investigate physical violence against Syrian refugee women in Jordan, this study aimed to investigate lifelong prevalence and current prevalence (last year) of physical abuse. In addition, the study aimed to explore the association of some socio-demographic factors with the occurrence of physical abuse among Syrian refugee women in Jordan.

Methods

Ethical Approval
A descriptive cross-sectional design was used to investigate the prevalence of physical abuse among Syrian refugee women in Jordan. Ethical approval has been gained from the IRB committee in Al al-Bayt University and the Jordanian Ministry of Health. Also, consent to participate in the study was obtained from the women who were invited into the current study.

Population
Participants were recruited from Maternal and Child Health Clinics (MCHCs) in Mafraq governorate. All Syrian women who are able to read and write Arabic language, aged 18 or older, and visited the MCHCs during the period (March 1, 2014 and June 1, 2014) were invited to participate in the study. From the 280 women who were invited to participate, 205 women agreed to participate in the study with a response rate of 73%. However, 23 partially filled questionnaires were excluded from analysis. Accordingly, a convenient sample of 182 women was obtained.

Instrument
The validated Arabic version of the NorVold Domestic Abuse Questionnaire (NORAQ) was applied to measure the physical abuse. Permission to apply the instrument was gained from Linda Haddad who translated and validated the tool (11).

The NORAQ questionnaire includes five parts (emotional abuse, physical abuse, and sexual abuse, current experience of abuse, and experience of reporting abuse to primary care personnel.

Table 1: Detailed questions of physical abusive acts


The last section of the questionnaire included questions on socio-demographic characteristics of the participants, such as age, level of education, marital status, place of residence, family size, household income, marriage age, and working status. Age was categorized into 25 years or less, and 26 years and above. Level of education was also measured by a binary variable: primary education, and secondary or more. Household income distinguished women who live in a household with monthly income of 200 JD or less, and more than 200JD. Place of residence refers to rural and urban.

Procedure
Research assistants where trained to collect the data from the participants. They approached the women in the MCHCs. The questionnaires were distributed and explained to the participants. To ensure confidentiality participants who agreed to participate in the study were asked not to write their names or addresses.

Statistical Analysis
Statistical analysis was performed using SPSS for Windows 19. Descriptive statistics including frequencies were used to describe participants' characteristics. Chi square tests were used to describe association between women's exposure to physical abuse and some socio-demographic variables. Independent samples t test was used to assess for differences in psychological suffering scores between abused women from different socio-demographic groups. Linear regression models were applied to predict the contributing variables to physical abuse. A significance level of .05 was the cutoff point.

Results

Socio-demographic characteristics of the participants
Participants' ages ranged from 19 to 55. Sixty seven women (36.8 %) live in the rural areas and 115 women (63.2%) of them live in the city of Mafraq. Most of the participants (73.1%, N=133) had finished their primary education, and about one fifth (23.1%, N=42) of the participants had graduated from high schools, and only five participants (2.7 %) and two participants (1.1%) had graduated from a college and a university respectively. Most of the sample were married women (78.6%, N= 143) while the rest of the participants were single (9.9%, N=18), widowed (8.2%, N=15), and divorced (3.3%, N=6). Most of the participants' household income was 200 JD or less (88.5%, N=116).

Prevalence of physical abuse by socio-demographic characteristics of the participants
About one third of the participants (57, 31.3%) reported a lifetime experience of physical abuse (before and after refuge). Of these, more than one quarter (25.3%, 46 participants) reported mild physical abuse. Some 44 participants (24.2%) experienced moderate physical abuse. About 14 participants (7.7%) experienced severe physical abuse. The sum of the participants experienced the three types of physical abuse is more than 57 because many of them reported being exposed to more than one type of physical abuse (mild, moderate, and severe) (Table 1).

Twenty seven respondents (14.8%, 27) were exposed to physical abuse during the last year. Twenty two married participants (38.6%) reported that their husbands were responsible for the abuse that they were exposed to, followed by fathers (14%, 8 participants), and brothers (10%, 6 participants). About one quarter of the participants (23%, 43 participants) reported being physically and emotionally abused.

The bivariate analysis revealed that some socio-demographic characteristics are significantly associated with exposure to physical abuse among the Syrian refugee women. For example, educated women were less likely to report exposure to physical abuse than those who are less educated (x²=4.43, N = 182, p =0.035). Also, participants who live in households with large family size (6 members and more) were more likely to report being physically abused (x²=4.16, N = 182 p =0.041). Older participants (older than 25 years old) reported being exposed to physical abuse more than those who were aged 25 years or less (x²=4.57, N = 182 p =0.032). In addition, women who were married before their 20th birthday reported being physically abused more than those who were married in older age (x²=3.96, N = 155) p =0.047). However, other demographic groups within the study sample were not significantly associated with physical abuse (i.e. marital status, place of living, and household income).

Higher psychological suffering was reported by the participants who are married, less educated, living in large family size households, and living in urban area (see Table 3). Other factors such as household income, husbands' employment status, participants' age and marriage age showed no significance difference in terms of psychological suffering score.

Regression analysis findings showed that some socio-demographic variables of the participants were contributed to the variance in psychological suffering score (as reported by physically abused women). A significant regression model was found (the enter method was performed), F = 6.1, p = 0.00. The revealed model explains 31.5 percent of the variance in the participants' suffering score. The correlation matrix between the independent variables showed no evidence of multicolinearity. Educational level was the strongest contributor to the variance in the suffering score (Beta= -1.7) followed by marital status and household income with Beta values -1.3 and, 0.94. The regression analysis results shows that women who were educated, not married and have higher household income were less likely to report high scores in the psychological suffering scale.

Table 2: The associations between the psychological suffering and the participants' marital status, educational level, family size, and place of residence (N = 57)

The association of physical abuse with some mental health disorders was investigated. The findings showed that physical abuse is significantly associated with experiencing depression (x²=4.51, N = 182, p =0.034). On other hand, anguish feeling and insomnia were not found to be significantly associated with experiencing physical abuse among the study sample.

Discussion
The current study produced several interesting findings. First of all, though lifetime prevalence of physical abuse against refugee Syrian women was high (31.3 %) (i e it is higher than that in Saudi Arabia (25.7%)) (6). Yet, it seems relatively low compared to the findings of other investigations conducted in the region and other parts of the world. The prevalence rate of lifetime physical abuse of some regional studies' findings is higher, for example, 44.7% among Palestinian refugee women living in Palestinian refugee camps in Jordan reported lifetime physical abuse (3). The reason behind this might be that the Palestinian women in this study were recruited from the refugee camps while Syrian refugee women in the current study are non-camp dwellers. There is no doubt that comparing the current prevalence rates of physical abuse with that of previous research in the regional, refugees and immigrant populations is beneficial. Though, it is worth noting the timeframe and methodological variations among different studies.

Disadvantaged socioeconomic circumstances, in which the refugee women live, put them at higher risk of being victims of abuse. Similar to other studies, the results of the current study showed a significant association between low educational level and the likelihood to be a victim of physical abuse (8, 9) In contrast, the current study findings were incongruent with those of the previous research (8, 10) where the household income was not found to be associated with physical abuse. The current study revealed that less educated women and those who live in households with large family size and women who got married before their 20th birthday are more vulnerable to physical abuse. In addition, almost all women who participated in the study are housewives, thus they are financially dependent on their husbands or male family members.
The present study provides further evidence that physical abuse often coexists with emotional abuse among women. The current study findings are congruent with the previous studies (11, 5, 12, 2, 13); 23% of the participants reported that they were physically abused alongside the emotional abuse

A closer look at the current research findings showed that few participants had reported the exposure to physical abuse (one of the most under-reporting types of domestic abuse in the developing world). Only 6% of the Syrian refugee women who participated in the study reported the physical abuse to health care providers.

Limitations
The main limitation of the current study is that it employed a non-probability sampling technique (a convenient sample) which may affect the generizability of the findings. Also, the study participants were non-camp refugees. Thus, further research will be needed to understand the physical abuse phenomena among Syrian refugee women who live in devastating living circumstances in the refugee camps.

Recommendations
This is the first study to report physical violence and its associated factors among Syrian refugee women in a country that hosts refugees. Mental health services are needed and nurses and physicians should be trained to provide proper counseling for these women, particularly because we found a significant association between exposure to physical abuse and poor emotional health suggests a need to integrate mental health and GBV.

Finally, given that we report a relatively high prevalence of physical abuse yet we know current GBV programming for the non-camp population to be inadequate, we suggest an immediate scale-up of GBV interventions to prevent GBV and mitigate its consequences among Syrian refugee women in non-camp settings.

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