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Nursing and Health Sciences (2015), 17, 26–32
Research Article
Israeli Arab Muslim women’s willingness to be screened for intimate partner violence: A survey Merav Ben Natan, PhD, RN,1,2 Hiba Muasi, RN, BA,1 Fidaa Farhan, RN, BA,1 Miada Shhada, RN, BA1 and Gada Masarwa, RN, BA1 1
Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera and 2Department of Nursing, School of Health Professions, Tel Aviv University, Tel Aviv, Israel
Abstract
In the present study, we explored whether the research model based on the Theory of Reasoned Action predicts Israeli Arab Muslim women’s willingness to be screened for intimate partner violence at healthcare facilities. Three hundred women completed a questionnaire. Most women (68.4%) expressed willingness to be screened, however, only 16% of them had been screened over the past year. Women’s beliefs about screening for intimate partner violence and the support of significant others were found to predict this willingness. The study may constitute an initial foundation for determining national policy with the aim of detecting and eradicating the phenomenon among this unique population.
Key words
Arab Muslim women, healthcare providers, intimate partner violence, Israel, screening.
INTRODUCTION Intimate partner violence (IPV) is defined as physical, sexual, or emotional abuse with coercive control of a woman by a man or woman partner who is, or was, in an intimate relationship with the woman (Feder et al., 2009). Intimate partner violence is a prevalent problem in Israel, with the number of women subjected to violence ranging from 145 000 to 200 000, that is, 7% of Israeli women have been subjected to IPV throughout their lifetime (Ben Natan & Rais, 2010). Some governments and professional organizations recommend screening all women for IPV (Taft et al., 2013). The Israeli Ministry of Health issued a General Director Circular (Ministry of Health, 2003) which states that every woman admitted to a healthcare facility should be asked, empathically, about her exposure to IPV. The screening is aimed at the identification of women subjected to IPV, defines further courses of action, and is adapted to Israeli society. There is evidence that screening instruments may identify women experiencing IPV (Nelson et al., 2012), although little is known about the proportions of false measurement (negatives or positives) (Taft et al., 2013). Many women felt that screening gave them the opportunity to disclose abuse, either then or at a later stage, and that without this opportunity it would be harder for them to seek help (Feder et al., Correspondence address: Merav Ben-Natan, Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, P.O.B. 169, Hadera 38100, Israel. Email: [email protected] Received 21 September 2013; revision received 24 November 2013; accepted 3 December 2013
© 2014 Wiley Publishing Asia Pty Ltd.
2009). Most women have had minimal impacts from possible adverse effects (Nelson et al., 2012). Experts point out that screening is not a stand-alone strategy and must be associated with effective support and follow-up, along with appropriate knowledge and training that enables healthcare providers to respond effectively (Solomon et al., 2012). In practice, screening rates remain low (O’Reilly et al., 2010). Telephone interviews conducted with 100 women treated in an obstetrics and gynecology department at a large hospital in central Israel over the past year revealed that only 12% of them were screened for IPV and received printed material and guidance on the subject (Ben Natan et al., 2012). Many varied factors prevent doctors and nurses from screening patients about violence (Gutmanis et al., 2007; Yonaka et al., 2007; Daugherty & Houry, 2008; O’Reilly et al., 2010; Robinson, 2010), for example, fear of offending the patient (Robinson, 2010) or lack of knowledge on how to screen (Gutmanis et al., 2007). Women, on their part, tend to avoid reporting having suffered abuse. Reasons for failure to disclose have been summarized in multiple studies and include fear of retaliation, of being blamed, concern that others would not understand, lack of confidentiality, presence of the partner, losing their children, economic or psychological dependence on the abuser, the promise of change, self-blame, low self-esteem, and shame (Bailey, 2010). However, when asked, they are more willing to report such incidents (Zink et al., 2006; Roelens et al., 2008). Women, both abused and non-abused (Bailey, 2010), are generally in favor of screening for IPV (Zeitler et al., 2006; Todahl & Walters, 2011; Sprague et al., 2013). doi: 10.1111/nhs.12125
Screening women for IPV
The reported lifetime prevalence of IPV in different Arab countries ranges from 23 to 35%. However, Arab culture emphasizes family solidarity, modesty, and reputation (honor); disclosing IPV to a physician may be viewed as wrong and as a form of family betrayal. Moreover, there is no societal consensus for action against IPV in Arab countries (Usta et al., 2012). In Arab societies, violence against women is commonly perceived as a private, personal, and familial problem, rather than a social and criminal problem requiring intervention of the social services and the police (Hajjar, 2004). In a review of regional literature, Boy and Kulczycki (2008) concluded that IPV in Arab societies is severe and chronically underreported; there are few legal, social service, or healthcare resources for victims and survivors, and there is such widespread tolerance of IPV by both men and women that most victims are unable or unwilling to seek help from legal authorities or from healthcare providers. Because of the social barriers in the Arab world, physicians and nurses miss opportunities to identify and assist women who are suffering (Usta et al., 2008). To date, little is known about Israeli Arab Muslim women’s attitudes, in particular, towards screening for IPV by healthcare providers.
The research model The research model was constructed based on the concepts of the Theory of Reasoned Action (TRA) designed by Ajzen and Fishbein (1980). The theory attempts to explain the relationship between beliefs, attitudes, intentions, and behavior. According to this theory, the most accurate determinant of behavior is behavioral intention. The direct determinants of people’s behavioral intentions are their attitudes towards performing the behavior and the subjective norms associated with the behavior. Attitude is determined by a person’s beliefs about the outcomes or attributes of performing a specific behavior (i.e., behavioral beliefs), weighted by evaluations of those outcomes or attributes. The subjective norm of a person is determined by whether important referents (i.e., people who are important to the person) approve or disapprove of the performance of a behavior (i.e., normative beliefs), weighted by the person’s motivation to comply with those referents. The TRA is a widely used behavioral prediction theory that represents a sociopsychological approach to understanding and predicting the determinants of health behavior: over the years, it has been applied to many diverse health-related behaviors, including weight loss, smoking, alcohol abuse, mammography screening, etc. (Redding et al., 2000). According to the theory, it can be assumed that Israeli Arab Muslim women’s willingness to be screened for IPV may be explained by their beliefs and attitudes towards screening, and their evaluation of social support. In addition, for a more holistic approach, other independent variables such as women’s age, their beliefs about IPV, and their knowledge of screening and reporting were included in the research model.
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Aim This study explored whether the research model predicts Israeli Arab Muslim women’s willingness to be screened for IPV.
METHODS Design, setting, and sample The study was a cross-sectional quantitative survey. A total sample size of 350 was determined. This size was calculated at 80% power with a 95% confidence interval for a two-tailed difference of means test. Calculations were based on seeking a difference of 0.5 on the Likert-type scale (range 1–4). The participants were recruited by a convenience sampling method. The researchers approached Arab Muslim women who attended a lecture on women’s health at several community healthcare clinics in two large cities in central Israel. These were chosen as the location for participants’ recruitment as a convenient way of reaching the study population, and as providing an opportunity to reach the women when not accompanied by their partners. The inclusion criteria were Arab Muslim women who had presented at a clinic or hospital at least once. The exclusion criteria were lack of fluent reading and writing in Arabic. The women were approached at the beginning of the lectures and women were asked to place the completed questionnaires in a closed box with a slot that was located near the reception desk in the healthcare clinics. The recruitment lasted approximately two months, between March and April 2013. Three hundred and fifty-four questionnaires were distributed to eligible women, and 300 were properly completed and returned, for a response rate of 85%.
Instrument The questionnaire was designed by the researchers based on the research model (Ajzen & Fishbein, 1980). It consisted of 52 items divided into the following subtopics: sociodemographic data (7), number of visits to healthcare facilities (2), being screened over the past year (yes or no) (2), knowledge of screening and reporting (6), beliefs about IPV (4), normative beliefs (4), subjective norms (4), behavioral beliefs about screening (4), behavioral attitudes towards screening (8), willingness to be screened for IPV during the next visit to a healthcare facility (3), and factors that would raise the respondent’s willingness to be screened (8). Items on knowledge of screening and reporting were ranked on a dichotomous true/false scale. Responses to items on normative beliefs, subjective norms, beliefs about IPV, behavioral beliefs about screening, behavioral attitudes towards screening, and willingness to be screened were ranked on a Likert scale of 1 (strongly disagree) to 4 (strongly agree). Factors that would raise the respondent’s willingness to be screened were ranked on a scale of 1–4, where 1 is “has no effect” and 4 is “has a large effect.” © 2014 Wiley Publishing Asia Pty Ltd.
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Table 1.
M. Ben Natan et al.
The study variables and typical items N†
Typical items
α‡
Sociodemographic data Visits to healthcare facilities
7 2
NA NA
Being screened over the past year
2
Knowledge of screening and reporting
6
Beliefs about IPV Normative beliefs Subjective norms
4 4 4
Behavioral beliefs about screening Behavioral attitudes towards screening
4 8
Willingness to be screened
3
Factors that would raise the respondent’s willingness to be screened
8
– “How many times have you visited a community healthcare clinic or family health center over the past year?” “Have you been asked about IPV during your visits to healthcare facilities over the past year?” “Israeli law obliges professionals to inform the police of every case of IPV against women” “Violence is not an appropriate way to teach good behavior” “My friends are in favor of screening women for IPV” “The view of my children on screening women for IPV is important to me” “Screening will lead to removal of my children” “Screening for violence perpetrated by my intimate partner is embarrassing” “My willingness to be screened for IPV on my next visit to a community healthcare setting is high” “Nonjudgmental screening has no effect – a large effect (scale) on my willingness to be screened for IPV”
Variables
NA NA 0.60 0.87 0.74 0.83 0.90 0.88 NA
†Number of items. ‡Cronbach’s. α. NA, not applicable.
Examples of typical items for measured variables, as well as Cronbach’s alpha coefficients for the subscales, are presented in Table 1. Three expert nurses specializing in violence against women examined the validity of the questionnaire as well as intelligible formulation of the items. Following their comments, some of the items were modified using more coherent wording in Hebrew. The questionnaire was then translated into Arabic. Back-translation was performed between Hebrew and Arabic. The revised questionnaire was piloted among 20 Arab Muslim women (who were subsequently included in the total sample), and showed good internal consistency and face validity.
Ethical considerations The study was approved by the ethics committee of the Tel Aviv University Department of Nursing. The aims and relevance of the study were verbally explained to all participants, and were further emphasized in a separate document accompanying the questionnaires. Voluntary participation was emphasized and informed consent obtained. The women who agreed to participate received an invitation to a series of lectures on women’s health organized by the researchers at the Pat Matthews Academic School of Nursing.
Data analysis Data analysis was performed with the Statistical Package for Social Sciences (SPSS-PC, Version 19, SPSS Inc., Chicago, IL, USA). To determine the percentage of respondents who agreed versus those who did not agree with various statements, ranking on the scale of 1–4 was regrouped into “did not agree” and “agree,” by grouping rankings of 1 and 2 into © 2014 Wiley Publishing Asia Pty Ltd.
“did not agree,” and 3 and 4 into “agree.” Pearson’s correlation was used to measure the strength of a linear association between the research model components and the willingness to be screened. Finally, multiple linear regression was performed to determine the model predictability. Statistical significance was set at P < 0.05.
RESULTS Sociodemographic characteristics, visits to healthcare facilities As indicated in Table 2, the respondents’ mean age was 33.31 years (SD = 10.5, range 18–67 years). Most of them were married (81.7%), educated (50% had an academic degree), were unemployed (47.3%) or salaried employees (42.3%), and had an average (35.3%) or below-average level of income (45.7%). The mean number of times that respondents had visited a community healthcare clinic or family health center over the past year was 3.81 (SD = 4.11, range 0–20), and the mean number of times that they had presented at a hospital was 0.94 (SD = 1.51, range 0–10).
Willingness to be screened for IPV and being screened over the past year Most women (68.4%) expressed willingness to be screened on their next visit to a healthcare facility. However, only 16% of the respondents had been screened over the past year.
Knowledge of screening and reporting The respondents had a low level of knowledge about screening for IPV (mean = 1.34, SD = 0.24, range 1–4). More than
Screening women for IPV
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Table 2. Respondents’ sociodemographic characteristics (n = 300) Variables Marital status
Level of education
Employment
Level of income
Categories
N
%
Single Married Divorced Widow Elementary Secondary Tertiary Academic Unemployed Salaried employee Self-employed Below average Average Above average
30 245 13 12 18 32 100 150 142 127 31 137 106 57
10 81.7 4.3 4 6 10.7 33.3 50 47.3 42.3 10.3 45.7 35.3 19
half the respondents (58.7%) did not know that the medical staff were obliged to screen women for IPV at each visit to a medical facility. Most of the respondents (64.3%) were not aware of the fact that Israeli law does not oblige healthcare providers to inform the police of every case of IPV against women unless the woman wishes to report.
Table 3. Regression of research model components on women’s willingness to be screened for IPV Independent variable
B
β
t
P value
Beliefs on IPV Normative beliefs Subjective norms Behavioral attitudes Behavioral beliefs
–0.022 0.226 0.085 –0.071 0.263
–0.021 0.268 0.095 –0.083 0.259
–0.327 4.228 1.580 –1.328 4.769
0.744 0.001 0.115 0.185 0.001
Subjective norms The views of respondents’ significant others – family members (79.4%), children (77.3%), and friends (70%) – on screening for IPV were important to the respondents.
Factors that would raise the respondent’s willingness to be screened Factors that would raise the respondent’s willingness to be screened were: maintaining privacy (78%), sufficient time for screening (71.7%), and nonjudgmental screening (66.4%).
Examination of the research model Beliefs about IPV The absolute majority of respondents (97.6%) agreed with the statement that violence is not an appropriate way to teach good behavior, 87.3% agreed that the Quran does not support violence against women, and 64% agreed that violence is unjustified even if a woman is suspected of being unfaithful. However, more than half of the respondents (61%) believed that violence against women should be resolved within the family.
Behavioral beliefs and attitudes towards screening for IPV Women’s beliefs and attitudes towards screening for IPV varied. On the one hand, they believed that screening provides battered women with information on who they can turn to (84.6%), reduces IPV (66%), and would not lead to removal of their children (59.4%). They also believed that screening is not insulting (57.3%) and would not lead to retaliation by their intimate partners (57%). On the other hand, 63% believed that screening will lead to harm to the family unit and even to dissolution of the family.
The current study found a weak positive correlation between beliefs about IPV and respondents’ willingness to be screened (r = 0.144, P < 0.05). A strong positive correlation was found between respondents’ normative beliefs and their willingness to be screened; namely, the more women perceive significant others (family members, children, and friends) as in favor of screening women for IPV, the higher their willingness to be screened (r = 0.416, P < 0.05). Additionally, a moderate positive correlation was found between respondents’ subjective norms and their willingness to be screened; namely, the more respondents perceived the view of significant others on screening women as important to them, the higher their willingness to be screened (r = 0.362, P < 0.05). A moderate positive correlation was found between respondents’ behavioral beliefs about screening and their willingness to be screened (r = 0.379, P < 0.05), and a weak positive correlation between respondents’ behavioral attitudes towards screening and their willingness to be screened (r = 0.173, P < 0.01). However, no correlation was found between respondents’ knowledge of screening and reporting, their age, and their willingness to be screened. Factors found to predict willingness to be screened were behavioral and normative beliefs (see Table 3). The research model predictability was found to be 34%.
Normative beliefs Approximately half of the respondents believed that their significant others – family members (54%), children (54.7%), and friends (59.7%) – held positive views on screening women for IPV.
DISCUSSION The aim of the research was to examine whether the research model, based on the TRA, predicted Israeli Arab Muslim © 2014 Wiley Publishing Asia Pty Ltd.
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women’s willingness to be screened for IPV. Research findings indicated that the research model partially predicted the phenomenon under study. The findings showed that respondents who perceived the support of significant others for screening women for IPV as strong expressed a higher willingness to be screened on their next visit to a healthcare facility. Social support has been shown to improve battered women’s mental health, willingness and ability to seek help from official sources (e.g., the justice system), and subsequent capacity to remain safe. Friends and relatives often provide women with emotional sustenance (e.g., advice, encouragement, or affirmation) and material assistance (such as financial help, babysitting, or a place to stay) (Liang et al., 2005; Haj-Yahia, 2013). It should be noted that approximately half of the respondents believed that their significant others (family members, children, or friends) held negative views on screening women for IPV. This finding may reflect cultural and social norms in Arab society, which emphasize family solidarity, modesty, and reputation (honor), and which might prevent women from seeking help (Usta et al., 2012). Indeed, a high proportion of the respondents (more than half) believed that violence against women should be resolved within the family. The findings showed that respondents who held positive behavioral beliefs and attitudes towards screening for IPV expressed a higher willingness to be screened. Women’s perception of screening as a safe and supportive tool that can help resolve their problems by exposing them to sources of information, ways of coping, and other official sources of support may encourage women to reach decisions and seek help more easily (Spangaro et al., 2010). However, consistent with other studies (Zink et al., 2006; Roelens et al., 2008; Bailey, 2010), a high proportion of the respondents still held negative beliefs and attitudes such as that screening is harmful and insulting, and might lead to removal of their children and to retaliation by their intimate partners, possibly resulting in a severing of the relationship and extreme danger for the women. One possible reason for this may be lack of knowledge. Indeed, respondents in the current study demonstrated a low level of knowledge, that is, most of them did not know the purpose of screening, its consequences, who is entitled to perform it, and the obligations of the healthcare worker who performs it. For example, most of the respondents were not aware of the fact that Israeli law does not oblige healthcare providers to inform the police of every case of IPV against women unless the woman wishes to report. This lack of knowledge may deter certain women from disclosing IPV out of fear of the possible consequences of this disclosure (Feder et al., 2009). In addition, the findings of the current study showed that respondents with negative attitudes towards IPV expressed higher willingness to be screened. One possible explanation may have to do with the fact that half the respondents had a higher education and may have a less traditional, more open way of life and thus view violence as an unacceptable phenomenon that should be reported and treated. Similarly, Sprague et al. (2013) found that increased willingness of respondents to be screened by healthcare providers was significantly associated with higher education. © 2014 Wiley Publishing Asia Pty Ltd.
M. Ben Natan et al.
In this study, no correlation was found between respondents’ age and their willingness to be screened. Similarly, McDonnell et al. (2006) found no difference in acceptability of screening by age. However, Zeitler et al. (2006) found that young women’s concerns about screening varied by age – those most likely to mind being screened were younger. This finding possibly indicates that age per se is not related to willingness to be screened, but is rather mediated by other factors, for example, women’s attitudes. Approximately 70% of the respondents expressed willingness to be screened on their next visit to a healthcare facility. This finding may indicate that addressing IPV through the healthcare system, if done properly, may be socially acceptable and non-offensive even to women living in conservative societies (Usta et al., 2012). The respondents emphasized privacy, sufficient time for screening, and nonjudgmental screening as factors that would raise their willingness to be screened, which is similar to findings in other studies (Feder et al., 2009). However, this percentage is lower than those reported in Western studies regarding acceptability of IPV screening (McDonnell et al., 2006; Zeitler et al., 2006; Sprague et al., 2013), possibly reflecting cultural and social norms in Arab society, as stated above. Although the research findings showed that most respondents expressed willingness to be screened for IPV at healthcare facilities, only 16% of them had been screened over the past year. This percentage is similar to that reported by Ben Natan et al. (2012), who surveyed a general population of Israeli women, both Jewish and Arab. However, the researchers did not report the proportion of Arab women in their survey, making it difficult to establish whether there is indeed a difference in screening rates between Jewish and Arab women in Israel. It should be noted that this percentage is slightly higher than that found by Klap et al. (2007) in their US survey, where only 7% of the women surveyed reported ever being asked about IPV by a healthcare professional. Finally, the research findings showed that the TRA can be applied to the phenomenon under study. Women’s beliefs on screening for IPV and the support of significant others were found to predict the women’s willingness to be screened, thus adding to the existing body of knowledge on this theory. However, the theory’s predictability of the topic studied was relatively low (34%). Empirical studies have shown that only 40% of the variance of behavior can be explained using TRA, as intention determinants are not limited to attitudes and subjective norms, and there may be other factors that influence behavior, for example, personality or unconscious motives (Ajzen, 1991; Werner, 2004), and these were not addressed in the present study. The sample was obtained through a convenience sampling method. There may have been a self-selection bias when recruiting participants. This sample is probably not representative of the population of Israeli Arab Muslim women at large, thus limiting the generalizability of findings to the more educated part of this population. Additionally, the questionnaire was based on women’s self-report, without clarifying the degree of congruence between reported and actual practices. Thus, research results might be biased.
Screening women for IPV
CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The study may constitute an initial foundation for determining national policy with the aim of detecting and eradicating IPV among this unique population. The study findings suggested that it is necessary to raise Israeli Arab Muslim women’s knowledge on screening via various strategies, for example by organizing lectures and workshops on violence against women and its management, in various community healthcare settings. This study revealed a low rate of screening for IPV among the population studied. The findings confirmed once again that only a small part of Israeli healthcare providers perform screening, and emphasized the need to continue raising healthcare providers’ awareness of the issue of violence and screening for violence, and of violence issues among the Israeli Arab Muslim population in particular, for example, by means of workshops. Healthcare professionals should be provided with proper knowledge and skills to perform screening effectively, in order to enable these women to use screening as an opportunity to disclose IPV. As Israeli Arab Muslim women are generally in favor of screening women for IPV, any stereotypes concerning these women’s willingness to be screened may be unjustified. However, this population does seem to be influenced by social and cultural norms. Therefore, the screening should be performed in a culturally sensitive way, while explaining its aim and assuring women that any subsequent course of action is completely dependent on their wish to do so. The findings suggested that there is a high probability that an Israeli Arab Muslim woman may choose not to be screened due to fear of retaliation from her partner or family members, thus requiring a sensitive approach on the part of healthcare providers. In order to receive a more accurate picture of Israeli Arab Muslim women’s beliefs and attitudes towards screening and disclosure of IPV, further research is needed for the purpose of reaching all strata of this unique population, and particularly the less educated.
ACKNOWLEDGMENTS The authors wish to thank all the women who participated in the study.
CONTRIBUTIONS Study Design:MBN, HM, FF, MS, GM. Data Collection and Analysis: MBN, HM, FF, MS, GM. Manuscript Writing: MBN, HM, FF, MS, GM.
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Nursing and Health Sciences (2015), 17, 26–32
Research Article
Israeli Arab Muslim women’s willingness to be screened for intimate partner violence: A survey Merav Ben Natan, PhD, RN,1,2 Hiba Muasi, RN, BA,1 Fidaa Farhan, RN, BA,1 Miada Shhada, RN, BA1 and Gada Masarwa, RN, BA1 1
Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera and 2Department of Nursing, School of Health Professions, Tel Aviv University, Tel Aviv, Israel
Abstract
In the present study, we explored whether the research model based on the Theory of Reasoned Action predicts Israeli Arab Muslim women’s willingness to be screened for intimate partner violence at healthcare facilities. Three hundred women completed a questionnaire. Most women (68.4%) expressed willingness to be screened, however, only 16% of them had been screened over the past year. Women’s beliefs about screening for intimate partner violence and the support of significant others were found to predict this willingness. The study may constitute an initial foundation for determining national policy with the aim of detecting and eradicating the phenomenon among this unique population.
Key words
Arab Muslim women, healthcare providers, intimate partner violence, Israel, screening.
INTRODUCTION Intimate partner violence (IPV) is defined as physical, sexual, or emotional abuse with coercive control of a woman by a man or woman partner who is, or was, in an intimate relationship with the woman (Feder et al., 2009). Intimate partner violence is a prevalent problem in Israel, with the number of women subjected to violence ranging from 145 000 to 200 000, that is, 7% of Israeli women have been subjected to IPV throughout their lifetime (Ben Natan & Rais, 2010). Some governments and professional organizations recommend screening all women for IPV (Taft et al., 2013). The Israeli Ministry of Health issued a General Director Circular (Ministry of Health, 2003) which states that every woman admitted to a healthcare facility should be asked, empathically, about her exposure to IPV. The screening is aimed at the identification of women subjected to IPV, defines further courses of action, and is adapted to Israeli society. There is evidence that screening instruments may identify women experiencing IPV (Nelson et al., 2012), although little is known about the proportions of false measurement (negatives or positives) (Taft et al., 2013). Many women felt that screening gave them the opportunity to disclose abuse, either then or at a later stage, and that without this opportunity it would be harder for them to seek help (Feder et al., Correspondence address: Merav Ben-Natan, Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, P.O.B. 169, Hadera 38100, Israel. Email: [email protected] Received 21 September 2013; revision received 24 November 2013; accepted 3 December 2013
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2009). Most women have had minimal impacts from possible adverse effects (Nelson et al., 2012). Experts point out that screening is not a stand-alone strategy and must be associated with effective support and follow-up, along with appropriate knowledge and training that enables healthcare providers to respond effectively (Solomon et al., 2012). In practice, screening rates remain low (O’Reilly et al., 2010). Telephone interviews conducted with 100 women treated in an obstetrics and gynecology department at a large hospital in central Israel over the past year revealed that only 12% of them were screened for IPV and received printed material and guidance on the subject (Ben Natan et al., 2012). Many varied factors prevent doctors and nurses from screening patients about violence (Gutmanis et al., 2007; Yonaka et al., 2007; Daugherty & Houry, 2008; O’Reilly et al., 2010; Robinson, 2010), for example, fear of offending the patient (Robinson, 2010) or lack of knowledge on how to screen (Gutmanis et al., 2007). Women, on their part, tend to avoid reporting having suffered abuse. Reasons for failure to disclose have been summarized in multiple studies and include fear of retaliation, of being blamed, concern that others would not understand, lack of confidentiality, presence of the partner, losing their children, economic or psychological dependence on the abuser, the promise of change, self-blame, low self-esteem, and shame (Bailey, 2010). However, when asked, they are more willing to report such incidents (Zink et al., 2006; Roelens et al., 2008). Women, both abused and non-abused (Bailey, 2010), are generally in favor of screening for IPV (Zeitler et al., 2006; Todahl & Walters, 2011; Sprague et al., 2013). doi: 10.1111/nhs.12125
Screening women for IPV
The reported lifetime prevalence of IPV in different Arab countries ranges from 23 to 35%. However, Arab culture emphasizes family solidarity, modesty, and reputation (honor); disclosing IPV to a physician may be viewed as wrong and as a form of family betrayal. Moreover, there is no societal consensus for action against IPV in Arab countries (Usta et al., 2012). In Arab societies, violence against women is commonly perceived as a private, personal, and familial problem, rather than a social and criminal problem requiring intervention of the social services and the police (Hajjar, 2004). In a review of regional literature, Boy and Kulczycki (2008) concluded that IPV in Arab societies is severe and chronically underreported; there are few legal, social service, or healthcare resources for victims and survivors, and there is such widespread tolerance of IPV by both men and women that most victims are unable or unwilling to seek help from legal authorities or from healthcare providers. Because of the social barriers in the Arab world, physicians and nurses miss opportunities to identify and assist women who are suffering (Usta et al., 2008). To date, little is known about Israeli Arab Muslim women’s attitudes, in particular, towards screening for IPV by healthcare providers.
The research model The research model was constructed based on the concepts of the Theory of Reasoned Action (TRA) designed by Ajzen and Fishbein (1980). The theory attempts to explain the relationship between beliefs, attitudes, intentions, and behavior. According to this theory, the most accurate determinant of behavior is behavioral intention. The direct determinants of people’s behavioral intentions are their attitudes towards performing the behavior and the subjective norms associated with the behavior. Attitude is determined by a person’s beliefs about the outcomes or attributes of performing a specific behavior (i.e., behavioral beliefs), weighted by evaluations of those outcomes or attributes. The subjective norm of a person is determined by whether important referents (i.e., people who are important to the person) approve or disapprove of the performance of a behavior (i.e., normative beliefs), weighted by the person’s motivation to comply with those referents. The TRA is a widely used behavioral prediction theory that represents a sociopsychological approach to understanding and predicting the determinants of health behavior: over the years, it has been applied to many diverse health-related behaviors, including weight loss, smoking, alcohol abuse, mammography screening, etc. (Redding et al., 2000). According to the theory, it can be assumed that Israeli Arab Muslim women’s willingness to be screened for IPV may be explained by their beliefs and attitudes towards screening, and their evaluation of social support. In addition, for a more holistic approach, other independent variables such as women’s age, their beliefs about IPV, and their knowledge of screening and reporting were included in the research model.
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Aim This study explored whether the research model predicts Israeli Arab Muslim women’s willingness to be screened for IPV.
METHODS Design, setting, and sample The study was a cross-sectional quantitative survey. A total sample size of 350 was determined. This size was calculated at 80% power with a 95% confidence interval for a two-tailed difference of means test. Calculations were based on seeking a difference of 0.5 on the Likert-type scale (range 1–4). The participants were recruited by a convenience sampling method. The researchers approached Arab Muslim women who attended a lecture on women’s health at several community healthcare clinics in two large cities in central Israel. These were chosen as the location for participants’ recruitment as a convenient way of reaching the study population, and as providing an opportunity to reach the women when not accompanied by their partners. The inclusion criteria were Arab Muslim women who had presented at a clinic or hospital at least once. The exclusion criteria were lack of fluent reading and writing in Arabic. The women were approached at the beginning of the lectures and women were asked to place the completed questionnaires in a closed box with a slot that was located near the reception desk in the healthcare clinics. The recruitment lasted approximately two months, between March and April 2013. Three hundred and fifty-four questionnaires were distributed to eligible women, and 300 were properly completed and returned, for a response rate of 85%.
Instrument The questionnaire was designed by the researchers based on the research model (Ajzen & Fishbein, 1980). It consisted of 52 items divided into the following subtopics: sociodemographic data (7), number of visits to healthcare facilities (2), being screened over the past year (yes or no) (2), knowledge of screening and reporting (6), beliefs about IPV (4), normative beliefs (4), subjective norms (4), behavioral beliefs about screening (4), behavioral attitudes towards screening (8), willingness to be screened for IPV during the next visit to a healthcare facility (3), and factors that would raise the respondent’s willingness to be screened (8). Items on knowledge of screening and reporting were ranked on a dichotomous true/false scale. Responses to items on normative beliefs, subjective norms, beliefs about IPV, behavioral beliefs about screening, behavioral attitudes towards screening, and willingness to be screened were ranked on a Likert scale of 1 (strongly disagree) to 4 (strongly agree). Factors that would raise the respondent’s willingness to be screened were ranked on a scale of 1–4, where 1 is “has no effect” and 4 is “has a large effect.” © 2014 Wiley Publishing Asia Pty Ltd.
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Table 1.
M. Ben Natan et al.
The study variables and typical items N†
Typical items
α‡
Sociodemographic data Visits to healthcare facilities
7 2
NA NA
Being screened over the past year
2
Knowledge of screening and reporting
6
Beliefs about IPV Normative beliefs Subjective norms
4 4 4
Behavioral beliefs about screening Behavioral attitudes towards screening
4 8
Willingness to be screened
3
Factors that would raise the respondent’s willingness to be screened
8
– “How many times have you visited a community healthcare clinic or family health center over the past year?” “Have you been asked about IPV during your visits to healthcare facilities over the past year?” “Israeli law obliges professionals to inform the police of every case of IPV against women” “Violence is not an appropriate way to teach good behavior” “My friends are in favor of screening women for IPV” “The view of my children on screening women for IPV is important to me” “Screening will lead to removal of my children” “Screening for violence perpetrated by my intimate partner is embarrassing” “My willingness to be screened for IPV on my next visit to a community healthcare setting is high” “Nonjudgmental screening has no effect – a large effect (scale) on my willingness to be screened for IPV”
Variables
NA NA 0.60 0.87 0.74 0.83 0.90 0.88 NA
†Number of items. ‡Cronbach’s. α. NA, not applicable.
Examples of typical items for measured variables, as well as Cronbach’s alpha coefficients for the subscales, are presented in Table 1. Three expert nurses specializing in violence against women examined the validity of the questionnaire as well as intelligible formulation of the items. Following their comments, some of the items were modified using more coherent wording in Hebrew. The questionnaire was then translated into Arabic. Back-translation was performed between Hebrew and Arabic. The revised questionnaire was piloted among 20 Arab Muslim women (who were subsequently included in the total sample), and showed good internal consistency and face validity.
Ethical considerations The study was approved by the ethics committee of the Tel Aviv University Department of Nursing. The aims and relevance of the study were verbally explained to all participants, and were further emphasized in a separate document accompanying the questionnaires. Voluntary participation was emphasized and informed consent obtained. The women who agreed to participate received an invitation to a series of lectures on women’s health organized by the researchers at the Pat Matthews Academic School of Nursing.
Data analysis Data analysis was performed with the Statistical Package for Social Sciences (SPSS-PC, Version 19, SPSS Inc., Chicago, IL, USA). To determine the percentage of respondents who agreed versus those who did not agree with various statements, ranking on the scale of 1–4 was regrouped into “did not agree” and “agree,” by grouping rankings of 1 and 2 into © 2014 Wiley Publishing Asia Pty Ltd.
“did not agree,” and 3 and 4 into “agree.” Pearson’s correlation was used to measure the strength of a linear association between the research model components and the willingness to be screened. Finally, multiple linear regression was performed to determine the model predictability. Statistical significance was set at P < 0.05.
RESULTS Sociodemographic characteristics, visits to healthcare facilities As indicated in Table 2, the respondents’ mean age was 33.31 years (SD = 10.5, range 18–67 years). Most of them were married (81.7%), educated (50% had an academic degree), were unemployed (47.3%) or salaried employees (42.3%), and had an average (35.3%) or below-average level of income (45.7%). The mean number of times that respondents had visited a community healthcare clinic or family health center over the past year was 3.81 (SD = 4.11, range 0–20), and the mean number of times that they had presented at a hospital was 0.94 (SD = 1.51, range 0–10).
Willingness to be screened for IPV and being screened over the past year Most women (68.4%) expressed willingness to be screened on their next visit to a healthcare facility. However, only 16% of the respondents had been screened over the past year.
Knowledge of screening and reporting The respondents had a low level of knowledge about screening for IPV (mean = 1.34, SD = 0.24, range 1–4). More than
Screening women for IPV
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Table 2. Respondents’ sociodemographic characteristics (n = 300) Variables Marital status
Level of education
Employment
Level of income
Categories
N
%
Single Married Divorced Widow Elementary Secondary Tertiary Academic Unemployed Salaried employee Self-employed Below average Average Above average
30 245 13 12 18 32 100 150 142 127 31 137 106 57
10 81.7 4.3 4 6 10.7 33.3 50 47.3 42.3 10.3 45.7 35.3 19
half the respondents (58.7%) did not know that the medical staff were obliged to screen women for IPV at each visit to a medical facility. Most of the respondents (64.3%) were not aware of the fact that Israeli law does not oblige healthcare providers to inform the police of every case of IPV against women unless the woman wishes to report.
Table 3. Regression of research model components on women’s willingness to be screened for IPV Independent variable
B
β
t
P value
Beliefs on IPV Normative beliefs Subjective norms Behavioral attitudes Behavioral beliefs
–0.022 0.226 0.085 –0.071 0.263
–0.021 0.268 0.095 –0.083 0.259
–0.327 4.228 1.580 –1.328 4.769
0.744 0.001 0.115 0.185 0.001
Subjective norms The views of respondents’ significant others – family members (79.4%), children (77.3%), and friends (70%) – on screening for IPV were important to the respondents.
Factors that would raise the respondent’s willingness to be screened Factors that would raise the respondent’s willingness to be screened were: maintaining privacy (78%), sufficient time for screening (71.7%), and nonjudgmental screening (66.4%).
Examination of the research model Beliefs about IPV The absolute majority of respondents (97.6%) agreed with the statement that violence is not an appropriate way to teach good behavior, 87.3% agreed that the Quran does not support violence against women, and 64% agreed that violence is unjustified even if a woman is suspected of being unfaithful. However, more than half of the respondents (61%) believed that violence against women should be resolved within the family.
Behavioral beliefs and attitudes towards screening for IPV Women’s beliefs and attitudes towards screening for IPV varied. On the one hand, they believed that screening provides battered women with information on who they can turn to (84.6%), reduces IPV (66%), and would not lead to removal of their children (59.4%). They also believed that screening is not insulting (57.3%) and would not lead to retaliation by their intimate partners (57%). On the other hand, 63% believed that screening will lead to harm to the family unit and even to dissolution of the family.
The current study found a weak positive correlation between beliefs about IPV and respondents’ willingness to be screened (r = 0.144, P < 0.05). A strong positive correlation was found between respondents’ normative beliefs and their willingness to be screened; namely, the more women perceive significant others (family members, children, and friends) as in favor of screening women for IPV, the higher their willingness to be screened (r = 0.416, P < 0.05). Additionally, a moderate positive correlation was found between respondents’ subjective norms and their willingness to be screened; namely, the more respondents perceived the view of significant others on screening women as important to them, the higher their willingness to be screened (r = 0.362, P < 0.05). A moderate positive correlation was found between respondents’ behavioral beliefs about screening and their willingness to be screened (r = 0.379, P < 0.05), and a weak positive correlation between respondents’ behavioral attitudes towards screening and their willingness to be screened (r = 0.173, P < 0.01). However, no correlation was found between respondents’ knowledge of screening and reporting, their age, and their willingness to be screened. Factors found to predict willingness to be screened were behavioral and normative beliefs (see Table 3). The research model predictability was found to be 34%.
Normative beliefs Approximately half of the respondents believed that their significant others – family members (54%), children (54.7%), and friends (59.7%) – held positive views on screening women for IPV.
DISCUSSION The aim of the research was to examine whether the research model, based on the TRA, predicted Israeli Arab Muslim © 2014 Wiley Publishing Asia Pty Ltd.
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women’s willingness to be screened for IPV. Research findings indicated that the research model partially predicted the phenomenon under study. The findings showed that respondents who perceived the support of significant others for screening women for IPV as strong expressed a higher willingness to be screened on their next visit to a healthcare facility. Social support has been shown to improve battered women’s mental health, willingness and ability to seek help from official sources (e.g., the justice system), and subsequent capacity to remain safe. Friends and relatives often provide women with emotional sustenance (e.g., advice, encouragement, or affirmation) and material assistance (such as financial help, babysitting, or a place to stay) (Liang et al., 2005; Haj-Yahia, 2013). It should be noted that approximately half of the respondents believed that their significant others (family members, children, or friends) held negative views on screening women for IPV. This finding may reflect cultural and social norms in Arab society, which emphasize family solidarity, modesty, and reputation (honor), and which might prevent women from seeking help (Usta et al., 2012). Indeed, a high proportion of the respondents (more than half) believed that violence against women should be resolved within the family. The findings showed that respondents who held positive behavioral beliefs and attitudes towards screening for IPV expressed a higher willingness to be screened. Women’s perception of screening as a safe and supportive tool that can help resolve their problems by exposing them to sources of information, ways of coping, and other official sources of support may encourage women to reach decisions and seek help more easily (Spangaro et al., 2010). However, consistent with other studies (Zink et al., 2006; Roelens et al., 2008; Bailey, 2010), a high proportion of the respondents still held negative beliefs and attitudes such as that screening is harmful and insulting, and might lead to removal of their children and to retaliation by their intimate partners, possibly resulting in a severing of the relationship and extreme danger for the women. One possible reason for this may be lack of knowledge. Indeed, respondents in the current study demonstrated a low level of knowledge, that is, most of them did not know the purpose of screening, its consequences, who is entitled to perform it, and the obligations of the healthcare worker who performs it. For example, most of the respondents were not aware of the fact that Israeli law does not oblige healthcare providers to inform the police of every case of IPV against women unless the woman wishes to report. This lack of knowledge may deter certain women from disclosing IPV out of fear of the possible consequences of this disclosure (Feder et al., 2009). In addition, the findings of the current study showed that respondents with negative attitudes towards IPV expressed higher willingness to be screened. One possible explanation may have to do with the fact that half the respondents had a higher education and may have a less traditional, more open way of life and thus view violence as an unacceptable phenomenon that should be reported and treated. Similarly, Sprague et al. (2013) found that increased willingness of respondents to be screened by healthcare providers was significantly associated with higher education. © 2014 Wiley Publishing Asia Pty Ltd.
M. Ben Natan et al.
In this study, no correlation was found between respondents’ age and their willingness to be screened. Similarly, McDonnell et al. (2006) found no difference in acceptability of screening by age. However, Zeitler et al. (2006) found that young women’s concerns about screening varied by age – those most likely to mind being screened were younger. This finding possibly indicates that age per se is not related to willingness to be screened, but is rather mediated by other factors, for example, women’s attitudes. Approximately 70% of the respondents expressed willingness to be screened on their next visit to a healthcare facility. This finding may indicate that addressing IPV through the healthcare system, if done properly, may be socially acceptable and non-offensive even to women living in conservative societies (Usta et al., 2012). The respondents emphasized privacy, sufficient time for screening, and nonjudgmental screening as factors that would raise their willingness to be screened, which is similar to findings in other studies (Feder et al., 2009). However, this percentage is lower than those reported in Western studies regarding acceptability of IPV screening (McDonnell et al., 2006; Zeitler et al., 2006; Sprague et al., 2013), possibly reflecting cultural and social norms in Arab society, as stated above. Although the research findings showed that most respondents expressed willingness to be screened for IPV at healthcare facilities, only 16% of them had been screened over the past year. This percentage is similar to that reported by Ben Natan et al. (2012), who surveyed a general population of Israeli women, both Jewish and Arab. However, the researchers did not report the proportion of Arab women in their survey, making it difficult to establish whether there is indeed a difference in screening rates between Jewish and Arab women in Israel. It should be noted that this percentage is slightly higher than that found by Klap et al. (2007) in their US survey, where only 7% of the women surveyed reported ever being asked about IPV by a healthcare professional. Finally, the research findings showed that the TRA can be applied to the phenomenon under study. Women’s beliefs on screening for IPV and the support of significant others were found to predict the women’s willingness to be screened, thus adding to the existing body of knowledge on this theory. However, the theory’s predictability of the topic studied was relatively low (34%). Empirical studies have shown that only 40% of the variance of behavior can be explained using TRA, as intention determinants are not limited to attitudes and subjective norms, and there may be other factors that influence behavior, for example, personality or unconscious motives (Ajzen, 1991; Werner, 2004), and these were not addressed in the present study. The sample was obtained through a convenience sampling method. There may have been a self-selection bias when recruiting participants. This sample is probably not representative of the population of Israeli Arab Muslim women at large, thus limiting the generalizability of findings to the more educated part of this population. Additionally, the questionnaire was based on women’s self-report, without clarifying the degree of congruence between reported and actual practices. Thus, research results might be biased.
Screening women for IPV
CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The study may constitute an initial foundation for determining national policy with the aim of detecting and eradicating IPV among this unique population. The study findings suggested that it is necessary to raise Israeli Arab Muslim women’s knowledge on screening via various strategies, for example by organizing lectures and workshops on violence against women and its management, in various community healthcare settings. This study revealed a low rate of screening for IPV among the population studied. The findings confirmed once again that only a small part of Israeli healthcare providers perform screening, and emphasized the need to continue raising healthcare providers’ awareness of the issue of violence and screening for violence, and of violence issues among the Israeli Arab Muslim population in particular, for example, by means of workshops. Healthcare professionals should be provided with proper knowledge and skills to perform screening effectively, in order to enable these women to use screening as an opportunity to disclose IPV. As Israeli Arab Muslim women are generally in favor of screening women for IPV, any stereotypes concerning these women’s willingness to be screened may be unjustified. However, this population does seem to be influenced by social and cultural norms. Therefore, the screening should be performed in a culturally sensitive way, while explaining its aim and assuring women that any subsequent course of action is completely dependent on their wish to do so. The findings suggested that there is a high probability that an Israeli Arab Muslim woman may choose not to be screened due to fear of retaliation from her partner or family members, thus requiring a sensitive approach on the part of healthcare providers. In order to receive a more accurate picture of Israeli Arab Muslim women’s beliefs and attitudes towards screening and disclosure of IPV, further research is needed for the purpose of reaching all strata of this unique population, and particularly the less educated.
ACKNOWLEDGMENTS The authors wish to thank all the women who participated in the study.
CONTRIBUTIONS Study Design:MBN, HM, FF, MS, GM. Data Collection and Analysis: MBN, HM, FF, MS, GM. Manuscript Writing: MBN, HM, FF, MS, GM.
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