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POPULATIONS AT RISK ACROSS THE LIFESPAN:POPULATION STUDIES Patterns of Coping with Partner Violence: Experiences of Refugee Women in Jordan Hanan Al-Modallal, Ph.D., R.N. Department of Community and Mental Health Nursing, Hashemite University, Zarqa, Jordan Correspondence to: Hanan Al-Modallal, Assistant Professor, Department of Community and Mental Health Nursing, Hashemite University College of Nursing, Zarqa-Jordan. E-mail: [email protected] ABSTRACT Objective: The relationship between intimate partner violence (IPV) and women’s use of negative and positive coping strategies was investigated. Design and Sample: For this cross-sectional study, a convenience sample of 300 refugee women was recruited from health care centers in three cities in Jordan. Logistic regression adjusted to women’s demographic characteris- tics was used. Results: The study’s results revealed that, compared to non victims, victimized women showed a lower tendency to receive psychological support from the family (adjusted OR = 0.53, 95% CI = 0.29 0.96), to smoke (adjusted OR = 0.28, 95% CI = 0.09 0.82), to use tranquilizers (adjusted OR = 0.014, 95% CI = 0.00-0.86), to think of suicide (adjusted OR = 0.04, 95% CI = 0.009 0.15), and to attempt suicidal actions (adjusted OR = 0.02, 95% CI = 0.002 0.19). Conclusions: The study indicated that women’s lack of use of negative coping strategies (smok- ing, use of tranquilizers, suicidal thoughts, and suicidal actions) was promising. However, the lack of use of positive coping strategies (disclosure of abuse, psychological support from friends, and help from family/friends) was somewhat concerning. The role of health care professionals may be helpful in this context. Counseling and support to IPV victims via effective listening, nonjudgmental discus- sions, and provision of information can be offered by health professionals as part of the treatment in health care centers. Key words: coping, family support, Jordan, partner violence, smoking, suicide. Intimate partner violence (IPV) has been recog- nized as a rising issue worldwide. Middle Eastern countries widely suffer this malady as well (Boy & Kulczycki, 2008). Out of women reporting regular victimization of physical abuse in Aleppo-Syria, nearly 92% reported being victimized by the hus- band (Maziak & Asfar, 2003). Jordanian women are prone to different types of IPV. The prevalence rates are 31.2% and 73.4% for physical and psycho- logical types of violence, respectively (Clark, Bloom, Hill & Silverman, 2009). Background Refugee women living in Middle Eastern countries are subjects to IPV. Palestinian refugee women are among those who moved to Jordan as a result of Arab-Israeli conflict, and are considered to be a sig- nificant part of the Jordanian society. When IPV was examined in these women, wife beating was found to have reached a prevalence rate of 42.5% (Khawaja & Barazi, 2005). A little less than one fifth of the Palestinian refugees in Jordan live in camps (United Nations Relief & Works Agency for Palestine Refugees (UNRWA), [UNRWA], 2011). These camps are gen- erally characterized as overpopulated. Palestinian women have been living in Jordan for over 60 years and share many cultural similarities with Jordanians in terms of practices, family values, child rearing, and marriage. Some women in 1 Public Health Nursing 0737-1209/© 2012 Wiley Periodicals, Inc. doi: 10.1111/j.1525-1446.2012.01018.x

Patterns of Coping with Partner Violence: Experiences of Refugee Women in Jordan

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Page 1: Patterns of Coping with Partner Violence: Experiences of Refugee Women in Jordan

POPULATIONS AT RISK ACROSS THE LIFESPAN: POPULATION STUDIES

Patterns of Coping with PartnerViolence: Experiences of RefugeeWomen in JordanHanan Al-Modallal, Ph.D., R.N.Department of Community and Mental Health Nursing, Hashemite University, Zarqa, Jordan

Correspondence to:

Hanan Al-Modallal, Assistant Professor, Department of Community and Mental Health Nursing, Hashemite University College of Nursing,

Zarqa-Jordan. E-mail: [email protected]

ABSTRACT Objective: The relationship between intimate partner violence (IPV) and women’suse of negative and positive coping strategies was investigated. Design and Sample: For thiscross-sectional study, a convenience sample of 300 refugee women was recruited from health carecenters in three cities in Jordan. Logistic regression adjusted to women’s demographic characteris-tics was used. Results: The study’s results revealed that, compared to non victims, victimizedwomen showed a lower tendency to receive psychological support from the family (adjustedOR = 0.53, 95% CI = 0.29 –0.96), to smoke (adjusted OR = 0.28, 95% CI = 0.09 –0.82), to usetranquilizers (adjusted OR = 0.014, 95% CI = 0.00-0.86), to think of suicide (adjusted OR = 0.04,95% CI = 0.009 –0.15), and to attempt suicidal actions (adjusted OR = 0.02, 95% CI = 0.002 –0.19). Conclusions: The study indicated that women’s lack of use of negative coping strategies (smok-ing, use of tranquilizers, suicidal thoughts, and suicidal actions) was promising. However, the lack ofuse of positive coping strategies (disclosure of abuse, psychological support from friends, and helpfrom family/friends) was somewhat concerning. The role of health care professionals may be helpfulin this context. Counseling and support to IPV victims via effective listening, nonjudgmental discus-sions, and provision of information can be offered by health professionals as part of the treatment inhealth care centers.

Key words: coping, family support, Jordan, partner violence, smoking, suicide.

Intimate partner violence (IPV) has been recog-nized as a rising issue worldwide. Middle Easterncountries widely suffer this malady as well (Boy &Kulczycki, 2008). Out of women reporting regularvictimization of physical abuse in Aleppo-Syria,nearly 92% reported being victimized by the hus-band (Maziak & Asfar, 2003). Jordanian womenare prone to different types of IPV. The prevalencerates are 31.2% and 73.4% for physical and psycho-logical types of violence, respectively (Clark, Bloom,Hill & Silverman, 2009).

BackgroundRefugee women living in Middle Eastern countriesare subjects to IPV. Palestinian refugee women are

among those who moved to Jordan as a result ofArab-Israeli conflict, and are considered to be a sig-nificant part of the Jordanian society. When IPVwas examined in these women, wife beating wasfound to have reached a prevalence rate of 42.5%(Khawaja & Barazi, 2005).

A little less than one fifth of the Palestinianrefugees in Jordan live in camps (United NationsRelief & Works Agency for Palestine Refugees(UNRWA), [UNRWA], 2011). These camps are gen-erally characterized as overpopulated. Palestinianwomen have been living in Jordan for over60 years and share many cultural similarities withJordanians in terms of practices, family values,child rearing, and marriage. Some women in

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0737-1209/© 2012 Wiley Periodicals, Inc.doi: 10.1111/j.1525-1446.2012.01018.x

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refugee camps suffer the problem of early marriage,which may increase their exposure to IPV victim-ization. The effect of younger age on women’s vul-nerability to violence by the partner has beensupported (Carlson, McNutt & Choi, 2003; Hazen,Connelly, Kelleher, Landsverk & Barth, 2004; Kra-mer, Lorenzon & Mueller, 2004). Furthermore, thepower and dominance of the men is a generalattitude in Jordanian society (Al-Krenawi, 1998,2000). Early marriage and dominance of the men,accompanied with problems suffered by the major-ity of refugees in camps including poverty, unem-ployment, and stressful living conditions, arefactors that support the assumption that women ofthis community are prone to IPV and its undesir-able consequences. This assumption has been sup-ported earlier by earlier investigations (Khawaja,2004; Khawaja & Barazi, 2005; Khawaja, Linos &El-Roueiheb, 2008).

Women respond to the stress of IPV victimiza-tion either negatively or positively. The negativeresponses to IPV victimization can be exhibited indeveloping some mental health problems such asdepression and dysphoria (Evans-Campbell, Lind-horst, Huang & Walters, 2006), and can even reachthe extreme response of suicide (Daniels, 2005;McFarlane et al., 2005). On the other hand, victim-ized women can respond positively to this stressorand seek help and support from the family (Cokeret al., 2002) and coworkers (Swanberg, Macke &Logan, 2006).

Coping with IPV victimization has been previ-ously studied by many scholars (Haj Yahia, 2002;Swanberg et al., 2006). Patterns of coping with IPVrevealed by Arab women include changing behav-iors toward the husband, assuming responsibilityfor abuse, seeking help from formal and informalagencies, and finally seeking to break up the familybond (Haj Yahia, 2002).

Research questionsUp to our knowledge, coping with IPV victimizationis not adequately studied among refugee women inthe Middle East. Therefore, this study aims ataddressing this issue. The specific objectives of thestudy are: (1) describing women’s negative andpositive coping responses to IPV victimization, and(2) examining the relationship between IPV victim-ization and victims’ coping mechanisms to thisstressor.

Methods

Design and sampleFor this cross-sectional study, women wererecruited from health care centers available in refu-gee camps in Jordan. These centers are foundedand run by the UNRWA. The refugees visit thesecenters for checkups, vaccination, and treatment.The participants were women committed to an inti-mate relationship via either engagement or mar-riage. This criterion was set because women wereasked about violence committed by the male inti-mate partner against them. Women needed to beable to read to complete the questionnaire, andthey should not be accompanied by the intimatepartner to prevent biased reporting of data.Approval for the study was obtained from theHealth Department and Ethical Committee Head-quarter of the UNRWA in Jordan and HashemiteUniversity.

A convenience sample of women visitingUNRWA health care centers in the cities ofAmman, Zarqa, and Irbid was targeted. Womenwere approached in waiting rooms of different clin-ics in these health care centers. They were informedabout the study aim and objectives and were askedabout their willingness to participate in the study.Those who showed interest in the study were askedto sign the consent form. The study questionnairewas given afterward to be completed. Women werereminded that the survey was anonymous, no iden-tifiers were needed as part of the collected data,and their decline from participation was an option.The percentage of those who were eligible partici-pants and returned the questionnaire was 92%.Completed questionnaires were collected by theresearch assistants and kept with the primaryinvestigator for coding, entry, and analysis.

MeasuresPartner violence victimization was measured by theAbuse Assessment Screen (AAS; Soeken, McFar-lane, Parker & Lominack, 1998). The AAS is a 5-item tool used to assess women’s recent (last year)experiences of IPV. The responses to these itemswere either “yes” or “no”; a “yes” response indicatespresence of the abuse experience, and a “no”response indicates its lack. The AAS is widely usedto assess partner violence among women of differ-ent characteristics (Bohn, Tebben & Campbell,

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2004; Coker, Sanderson, Fadden & Pirisi, 2000;Curry, 1998). The AAS was used to screen abuseamong women representing different cultures andwas found suitable for making a change in abusescreening (Higgins & Hawkins, 2005). In thisstudy, women’s indication of experiencing anyincidence of IPV was coded as “1”, and “0”, other-wise. Cronbach’s alpha for the AAS in our samplewas 0.70.

Coping was defined as women’s positive andnegative responses to IPV victimization. The posi-tive coping strategies were measured by four ques-tions developed by the investigator. Women wereasked to rate on a 4-point rating scale the extent towhich they: (1) disclose the experience of IPV vic-timization with family/friends, (2) get psychologicalsupport from the family, (3) get psychological sup-port from friends, and (4) get help to deal with IPVvictimization from the family/friends. These fourquestions were used because disclosing and seekinghelp for abuse from important figures in the com-munity and from formal agencies is not a preferredoption for Jordanian women (Btoush & Haj-Yahia,2008). In addition, women in this society prefer tolimit the circle of possible helpers in cases ofabuse to family and friends only. The responses toeach of the four items were as follows: 0 = not atall, 1 = minimal, 2 = fairly high, and 3 = very high.For this study, women’s ratings of 0 and 1 werecoded as “0”, and “1” for ratings of 2 and 3. Cron-bach’s alpha for the positive coping strategies was0.74.

Furthermore, the Rosenberg Self-Esteem scale(RSE; Rosenberg, 1965) was used to measure posi-tive coping with IPV. The RSE scale assesses a per-son’s level of agreement to 10 statements reflectingself-esteem level. The higher the final self-esteemscore, the greater the indication of higher self-esteem level of the participant. Self-esteem wasused to assess positive coping because it was usedearlier and had a relatively high reliability coeffi-cient level (Cronbach’s alpha = 0.78) for Jordanianwomen. In addition, self-esteem values negativelycorrelated with IPV experience in the same partici-pants (Al-Modallal et al., 2012). For the purpose ofthis study, scores below 15 were coded as “0”, sug-gesting low self-esteem level, and scores of 15 orgreater were coded as “1”, suggesting high self-esteem level. Cronbach’s alpha of 0.83 was reportedfor the RSE scale (Hatcher & Hall, 2009).

Negative coping strategies with IPV victimiza-tion were assessed by asking the target womenquestions about smoking, use of tranquillizers,sleepiness problems, and suicide. We asked aboutthese strategies because they are among the com-mon strategies that women would consider in casesof trauma such as violence from the partner. Four“yes–no” questions were directed to the participantsasking them to report whether, and as a responseto violence from the partner, they: (1) becamesmokers, (2) used tranquilizers based on a prescrip-tion, (3) had suicidal thoughts, and/or (4) hadattempted a suicidal action. The responses to eachof these questions were dichotomized where a “yes”response was coded as “1” and a “no” response wascoded as “0”.

Moreover, negative coping was assessed by ask-ing women to report sleep problems. The EpworthSleepiness Scale (ESS) is an 8-item scale assessingthe likelihood of dozing off in eight different situa-tions such as while “watching TV” and “sitting inac-tive in a public place” (Johns, 1991). One of thefactors associated with violence is sleeping prob-lems (Al-Modallal, Hall & Anderson, 2008; Cald-well & Redeker, 2005; Eby, 2004). Sleepingproblems, including short sleep time and inter-rupted sleeping during the night, result in poorsleep quality of the individual (Humphreys & Lee,2005). As a result, probability of dozing off in situ-ations such as while watching TV and while sittinginactive is very likely. For this reason, the ESS wasused. Possible scores of the ESS range between 0and 24. Scores of 10 or greater indicate the pres-ence of sleepiness problem. For the purpose of thisstudy, scores of 10 or greater were coded as “1” andscore of 9 or less were coded as “0”. The ESS has areported Cronbach’s alpha of 0.79 (Heaton &Anderson, 2007).

Analytic strategyBivariate relationships were implemented to findwhether or not there were demographic differencesbetween abused and non abused participants. Fre-quencies and percentages were used to meet thefirst objective followed by bivariate analysis to testfor significant coping differences between the twogroups. Logistic regression analyses were used forthe second objective. All assessment measures weredichotomized, and logistic regression was used toexamine the risks of using positive and negative

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coping strategies in response to the IPV experience.Logistic regression analyses were adjusted forwomen’s demographic characteristics including age,women’s educational level, spouses’ educationallevel, income, number of children, job, pregnancy,and health insurance. These factors were recog-nized as possible confounders for the relationshipbetween IPV and coping strategies. For example,women of low educational level, low income, andthose burdened with child responsibilities would beless likely to disclose abuse experience for the sakeof keeping the family unit. On the other hand, hav-ing a job, having health insurance benefits, andbeing pregnant would be factors facilitatingwomen’s disclosure of abuse to either coworkers orhealth professionals.

Results

The participants’ ages ranged from 16 to 62 years.Except for age (X2 = 15.9, p = 0.03), bivariate anal-ysis did not show significant demographic differ-ences between abused and non abused participants.

Women’s demographic characteristics by theirexperience of IPV are presented in Table 1.

Nearly 43% of the participants reported IPVvictimization. In response, women tended to usepositive coping strategies to deal with incidences ofpartner violence more frequently compared to usingnegative coping strategies. For instance, womentended to show high self-esteem make up (n = 223,85.4%) and to seek help from family and friends(n = 132, 46.5%) in cases of exposure to violenceby the partner. On the other hand, experiencingsleepiness problems, which symbolizes a negativecoping strategy, constituted the highest reportednegative strategy (n = 117, 41.5%) adopted by thosewomen in cases of violence. Bivariate analysisresults yielded significant differences in smoking(p = 0.01), suicidal thoughts (p < 0001), andsuicidal attempts (p < 0001) between abused andnon abused women. See Table 2 for additionalinformation.

When the relationship between women’s expo-sure to IPV and their use of coping strategies weretested using logistic regression, results indicated

TABLE 1. Demographic Characteristics of the Participants (n = 300)

CharacteristicExperiencingIPV n (%)

Not experiencingIPV n (%) p value

Age�20 8 (6.5) 15 (9.4) 0.0321–30 56 (45.5) 73 (45.9)31–40 47 (38.2) 44 (27.6)41–50 11 (8.9) 21 (13.2)�51 1 (0.8) 6 (3.7)

Have children 120 (95.3) 145 (88.4) 0.11Does not have children 6 (4.8) 19 (11.6)Level of education

<6th grade 10 (8.0) 13 (7.9) 0.247th to 12th grade 56 (44.8) 66 (40.2)Some college 40 (32.0) 47 (28.7)Higher 19 (15.2) 38 (23.2)

Spouses’ Level of Education<6th grade 16 (12.8) 23 (14.1) 0.187th to 12th grade 64 (51.2) 64 (39.2)Some college 28 (22.4) 42 (25.8)Higher 17 (13.6) 34 (20.9)

Employed 16 (12.7) 24 (14.8) 0.20Unemployed 110 (87.3) 138 (85.2)Monthly Income (Jordanian Dinar; 1JD � 1.4 US Dollar)

�200 JD 64 (50.8) 74 (45.1) 0.06201–500 JD 58 (46) 71 (43.3)�501 JD 4 (3.2) 19 (11.5)

Insured 43 (34.1) 62 (37.8) 0.52Uninsured 83 (65.9) 102 (62.2)

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that women tended to use negative coping strate-gies to deal with IPV. For instance, compared tonon victimized participants, those who were victimsof IPV were more likely to smoke (crudeOR = 3.05, 95% CI = 1.33–7.0), to think of suicide(crude OR = 11.94, 95% CI = 4.51–31.61), and toattempt suicidal actions (crude OR = 9.06, 95%CI = 2.6–31.51).

The examined relationships were then adjustedto women’s characteristics including age, educa-tional level, spouses’ educational level, income,number of children, job, pregnancy, and healthinsurance. By doing so, relationships were flipped.Compared to their counterparts, victimized womenwere less likely to smoke (adjusted OR = 0.28, 95%CI = 0.09–0.82), to use tranquilizers (adjustedOR = 0.014, 95% CI = 0.00–0.86), to think of sui-cide (adjusted OR = 0.04, 95% CI = 0.009–0.15),and to attempt suicide (adjusted OR = 0.02, 95%CI = 0.002–0.19). For the use of positive copingstrategies, the only significant relationship wasfound between IPV and women’s seeking of psycho-logical support from the family (adjustedOR = 0.53, 95% CI = 0.29–0.96). See Table 3.

Discussion

This study was the first to examine the relationshipbetween IPV victimization and the use of copingstrategies in Palestinian women accommodated inrefugee camps in Jordan. The results indicated that43.4% of these women lived the experience of IPV.This result may be explained by the notion that IPVis somewhat accepted in some Middle Eastern

cultures, especially if the victims are less educatedresiding in rural areas (Boy & Kulczycki, 2008),such as our participants.

The results of the crude odds ratios indicatedthat victimized women tended to use negative cop-ing strategies to deal with violence. When thetested relationships were adjusted to women’s char-acteristics, women’s victimization constituted a fac-tor lowering the tendency of using negative copingstrategies. These findings indicated that women’sdemographic characteristics played an importantrole in confounding the relationship between IPVand coping. Therefore, demographic variables needto be taken into consideration in similar futurestudies.

Cigarette smoking was not significantly relatedto IPV victimization knowing that stress is a lead-ing cause for cigarette smoking (Burgan, 2001),and IPV can be identified as a significant source ofstress. Smoking has become epidemic among peo-ple of different age groups. In the big cities in Jor-dan, women may smoke in public (in their cars, inthe street, and in coffee shops) with no or veryminimal comments on this behavior from the gen-eral public. However, the case is different in ruraland conservative areas such as refugee camps,where cigarette smoking by women is viewed as anunacceptable behavior. People in camps live invery closed neighborhoods where women are clo-sely observed by the family, relatives, and neigh-bors. Since smoking is considered unacceptable,women tended to avoid this behavior, even incases of stress, for the sake of their reputation anddignity.

TABLE 2. Positive and Negative Coping Strategies by IPV Experience

Coping strategy With IPV n (%) No IPV n (%) Total sample n (%) p value

Positive coping strategiesDisclosure to family/friend 51 (41.5) 69 (42.6) 120 (42.1) 0.94Family psychological support 51 (42.1) 53 (33.1) 104 (37) 0.15Friend psychological support 39 (32.2) 48 (30.8) 78 (31.4) 0.90Help from family/friend 49 (40.5) 83 (50.9) 132 (46.5) 0.11High self-esteem 95 (81.2) 128 (88.9) 223 (85.4) 0.12

Negative Coping StrategiesSmoking 19 (15.2) 9 (5.6) 28 (9.8) 0.01Use tranquilizers 7 (5.6) 2 (1.2) 9 (3.1) 0.08Sleep problems 53 (43.1) 64 (40.3) 117 (41.5) 0.72Suicide thoughts 34 (27.4) 5 (3.1) 39 (13.6) <.0001Suicide attempts 18 (14.5) 3 (1.8) 21 (7.3) <.0001

IPV, intimate partner violence.

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The related literature pointed to the fact thatpartner violence (specifically physical aggression)was associated with the use of tranquilizers by thevictims (Slashinski, Coker & Davis, 2003). Our par-ticipants did not exhibit this relationship. There aretwo possible explanations for this finding. The firstone is that most women in the study did not havehealth insurance. The psychological trauma associ-ated with IPV victimization needs to be treated bypsychologists or mental health specialists. Aswomen do not have health insurance, the probabil-ity of consulting a psychologist is limited takinginto consideration the poor socioeconomic status ofthe participants and the expenses needed for suchconsultation.

The second explanation for lower use of tran-quilizers among victims is the possible socialstigma associated with experiencing a mentalhealth problem and, consequently, using medica-tions for treatment. Mental illnesses are almostalways associated with stigma for the patient. Stig-matization has several aspects such as interper-sonal interaction and public images of mentalillnesses (Schulze & Angermeyer, 2003). These twoaspects are applicable to women’s culture in Jor-dan. Women who seek medical help from a psy-chologist may be stigmatized by people from theirclose social environment. Therefore, they withdrawfrom contacting people within this environmentincluding their close family and neighbors. The

TABLE 3. Odds Ratios of Coping Strategies among Participants Who Experienced Intimate Partner Violencea

Coping strategyN within

abuse strata (%)N within no

abuse strata (%)Crude odds

ratio (95% CI)Adjusted oddsratio (95% CI)b

Positive coping strategiesDisclosure to family/friend

Yes 51 (41.5) 69 (42.6) 0.96 (0.59–1.54) 0.94 (0.54–1.64)No 72 (58.5) 93 (57.4)

Family psychological supportYes 51 (42.1) 53 (33.1) 1.47 (0.9–2.4) 0.53 (0.29–0.96)No 70 (57.9) 107 (66.9)

Friend psychological supportYes 39 (32.2) 48 (30.8) 1.07 (0.64–1.78) 0.74 (0.40–1.38)No 82 (67.8) 108 (69.2)

Help from family/friendYes 49 (40.5) 83 (50.9) 0.66 (0.41–1.06) 0.63 (0.36–1.1)No 72 (59.5) 80 (49.1)

Self-esteemHigh 95 (81.2) 128 (88.9) 0.54 (0.27–1.08) 1.06 (0.61–1.84)Low 22 (18.8) 16 (11.1)

Negative coping strategiesSmoking

Yes 19 (15.2) 9 (5.6) 3.05 (1.33–7.0) 0.28 (0.09–0.82)No 106 (84.8) 153 (94.4)

Use tranquilizersYes 7 (5.6) 2 (1.2) 4.79 (0.98–23.46) 0.014 (0.00–0.86)No 117 (94.4) 160 (98.8)

Sleep problemsYes 53 (43.1) 64 (40.3) 1.12 (0.70–1.81) 0.64 (0.37–1.13)No 70 (56.9) 95 (59.7)

Suicide thoughtsYes 34 (27.4) 5 (3.1) 11.94 (4.51–31.61) 0.04 (0.009–0.15)No 90 (72.6) 158 (96.9)

Suicide attemptsYes 18 (14.5) 3 (1.8) 9.06 (2.6–31.51) 0.02 (0.002–0.19)No 106 (85.5) 160 (98.2)

aReferent category is non abused women.bAdjusted for age, women’s educational level, spouses’ educational level, income, number of children, job, pregnancy, andhealth insurance.

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external context including the society may havenegative views toward mentally ill patients. Theseviews would hurt and negatively impact women’sself-esteem. In Jordan, educated people such ascollege students had positive attitudes toward men-tal health illnesses (Hamaideh & Mudallal, 2009).Unfortunately, the culture where our participantscame from may not possess these attitudes. Thereasons that would possibly explain presence ofpublic stigma toward mental illnesses are the rela-tively low level of education in this population andtheir poor knowledge with regard to the nature ofmental illnesses. For these two reasons, data didnot show evidence of using tranquilizers inresponse to IPV victimization.

Suicide, including suicidal thoughts and sui-cidal actions, were not associated with IPV victim-ization. Literature provided adequate evidence forthe effect of IPV victimization on victims’ suicidalthoughts and actions (Coker et al., 2002; Hurwitz,Gupta, Liu, Silverman & Raj, 2006; McFarlaneet al., 2005; Pico-Alfonso et al., 2006). Our find-ings contradicted what was reported in theliterature. The explanation of this finding stemsfrom Jordanian women’s consideration of IPV as akind of stress. In response to such stress, they tendto shift their focus away from taking one’s own lifeto supplications and prayers; “O you who havebelieved, seek help through patience andprayer. Indeed, Allah is with the patient.” (TheHoly Quran, Surat Al-Baqarah [The Cow], 2:153).This may be the explanation for what we found inthis investigation.

The only significant positive coping strategyassociated with IPV victimization was family psy-chological support. What was interesting in thisstudy was that victimized women tended to havelower psychological support from the family com-pared to non victimized; which partially contradictswhat was reported in earlier research (Carlson,McNutt, Choi & Rose, 2002). The literature pro-vided sound evidence indicating that social supporthelps buffer relationship between violence andother negative outcomes of violence such as poorpsychological health status (Holt & Espelage, 2005)and suicidal thoughts and attempts (Daniels,2005). For instance, high social support scoreswere associated with low poor mental health (aRR= 0.5, 95% CI = 0.3–0.6), low anxiety level (aRR =0.3, 95% CI = 0.2–0.4), and low suicide attempts

(aRR = 0.6, 95% CI = 0.4–0.9) (Coker et al.,2002).

The question addressed in this instance is thereason for having a negative association betweenIPV and social support. The answer can beexplained in light of circumstances exclusive to Ara-bic culture. Arab women in general live in a conser-vative culture (Hammad, Kysia, Rabah, Hassoun &Connelly, 1999) where families are dominated bythe man (Al-Krenawi, 1998, 2000), who is mainlythe husband. The social and financial dominance ofmen reinforces their use of violence against femalespouses (Kulwicki, 2002). Because of this, womenmay not get required support from their families,as families mainly believe that the husband has theright to discipline his wife if she makes a mistakeor shows disobedience to him. In addition, awoman may be blamed as well for the violence(Btoush & Haj-Yahia, 2008) and be convinced thatshe was the reason for her husband’s use of vio-lence against her. For these reasons, women in thisstudy may not have chosen to seek family supportfor violence.

RecommendationsThis study shows that IPV victimization is a factorlimiting women’s use of negative coping strategies.This finding is promising as self-hurting methodsare not adopted by these women in cases of victim-ization. On the other hand, nonsignificant associa-tions between IPV and the use of positive copingstrategies are worrying. This would have a seriouslong-term impact on the victims. Women may livethrough years of violence without disclosing victim-ization to family or friends. Therefore, violencescreening strategies should be implemented inUNRWA health care centers, the feasible refuge ofwomen for health services. In addition, IPV consul-tation services should be provided as part of thehealth services provided by health professionals inthese centers. If social support cannot be providedby family or friends, it certainly can be provided byhealth professionals to reduce negative impacts ofIPV (Curry, Durham, Bullock, Bloom & Davis,2006). This intervention is crucial since victimizedwomen from this culture may become prone todeveloping mental health sequela as they do nothave the necessary protective factors including edu-cation, employment, and absence of economichardship (Carlson et al., 2002).

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