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Procedia Social and Behavioral Sciences 5 (2010) 10901097

WCPCG-2010

Prevalence of Domestic Violence and associated Depression in married women at a Tertiary care hospital in Karachi
Sobia Haqqia, Abul Faizib, Sobia Haqqi*
b a M.B.B.S., M.C.P.S, F.C.P.S, Consultant Psychiatrist M.B.B.S., Diplomat American board of Psychiatry and Neurology, Department of Psychiatry, The Aga khan University Hospital, Stadium Road PO Box 3500, Karachi 74800

Received January 11, 2010; revised January 29, 2010; accepted March 1, 2010

Abstract
Objectives To study the prevalence of domestic violence among married women presenting to the psychiatric setting at a tertiary care hospital in Karachi and to identify associated depression in these married females Design Cross-sectional, questionnaire-based study Setting Aga Khan University Hospital Psychiatry Department Participants 171 Married female patients presenting to outpatient and in-patient department of Psychiatry at Aga Khan University hospital Main outcome measures Proportion that had experienced domestic violence, different forms of such violence and associated depression. Results More than one form of Domestic violence was reported by 69.5% of total 171 females. Been shouted at, reported by 32.2%, been threatened by 25.1%, Slapping by 20.5%, kicking by 14%, been pushed or shoved reported by 21.1%, threaten or use of a weapon reported by 8.8%. 62% females were currently depressed. Conclusion A large number of married women presenting to a tertiary care hospital in Karachi, report to be enduring more than one form of domestic violence simultaneously. A good chunk of these women also report to be suffering from depression at the same time. 2010 Elsevier Ltd. All rights reserved.
Keywords: domestic violence, women, depression.

What is already known on this topic Violence against women, in its various forms, is endemic in communities and countries around the world. World health organization (WHO) reported the prevalence of Domestic Violence ranging from 20% to as high as 50% in 1997. Globally, it has been estimated that 1 woman in 3 has been beaten, forced into sex, or otherwise abused in her lifetim

1877-0428 2010 Published by Elsevier Ltd. doi:10.1016/j.sbspro.2010.07.241

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What this study adds Married women report a high prevalence of domestic violence More than one form of domestic violence is endured simultaneously Victims of domestic violence also reported being depressed. 1. Introduction

According to the United Nations definition, violence against women includes any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life.1 The most common type of violence against women worldwide is domestic violence or the physical, emotional and or sexual abuse of women by their intimate partners, which as reported by World health organization (WHO) ranged from 20% to as high as 50% in 1997.2,3 Globally, it has been estimated that 1 woman in 3 has been beaten, forced into sex, or otherwise abused in her lifetime. 4, 5 United Kingdom reports lifetime prevalence of domestic violence against women from 39% to 60%. 6, 7 A community survey found that 23% of women had ever been physically assaulted by a partner or former partner, with 4% experiencing violence within the previous 12 months.8 Recent primary care studies from outside the United Kingdom have reported rates of lifetime experience of domestic violence ranging from 12% to 46%9, 10, 11 and prevalence over the previous 12 months of 28%. 12, 13 The differences in prevalence are explained, in part, by the different definitions of domestic violence used in the studies. Some investigators focus on physical violence alone, whereas others include a broader range of abusive behaviors, including emotional and other non-physical abuse. Even these broader definitions of domestic violence fail to capture the complexity of abuse of women by men. 14, 15 In Arab and other Islamic countries, domestic violence is not yet considered a major concern despite its increasing frequency and serious consequences. Surveys in Egypt, Palestine, Israel and Tunisia show that at least one out of three women is beaten by her husband. 16 In neighboring country like India, nearly 25% of women suffer from physical abuse in their lifetime. In Utter Pradesh alone, 18 to 45% of married men in five districts had acknowledged physically abusing their wives17 Cambodia reports 16% of women being physically abused by the spouse18whereas in Thailand, 20% of the husbands acknowledged physically abusing their wives at least once in their married life.19, 20 Domestic violence is a major public health and human rights issue. The statistics on its physical, sexual, reproductive, emotional, and financial consequences are alarming. However, as Taft et al remind us, domestic violence affects entire families, including children, making the statistics even more shocking.21 The "subordinate status"1 of women leading to domestic violence, contributes to a significant health burden in women, as one-third of all the adult women in the world have experienced it2, 16,3,17. And a major causative factor in the various psychiatric sequels in the women who experience it22, 23. In Pakistani society, domestic violence is considered as a private family matter. A study done on suicidal patients in Pakistan reported that majority of the patients were married women and the major source of conflict was issues with husband (80%) and with in laws (43%).23A Karachi based study indicated that verbal, physical and emotional abuses were common leading to intimidation, emotional trauma, continued depression and inability to take even minor decisions and violence against women was estimated to be above 70%.22,24 In a study by Niaz, the incidence of depression and anxiety was found to be as high as 60% and 65% .5 Fikree and Bhatti have reported a prevalence of abuse of about 34% amongst married pregnant females.25Masood Ali Sheikh in Islamabad reported that violence in general increased during pregnancy (as high as 24.9%) whereas, nonconsensual sex was reported by 46.9 % of the women interviewed.26 As domestic violence against women becomes increasingly recognized and discussed, important questions are being raised concerning its magnitude in different settings, and its consequences and related risk factors. Likewise, there is increasing recognition of the need for better data on the effectiveness of different interventions.27, 28 and 29 In view of these facts we designed the study with the objectives to 1. Study the prevalence of domestic violence among married women presenting to the psychiatric setting at a tertiary care hospital in Karachi 2. Identify associated depression in married females subjected to domestic violence.

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2. Methods Study Design This was a questionnaire based cross-sectional study, carried out over 6 months at a tertiary care hospital in Karachi, Pakistan: Aga Khan University Hospital (A.K.U.H) AKUH is a 500- bed, private hospital. The weekly turnover in the out-patient department is 200-250 patients. The psychiatric facility comprises of a 16-bed inpatient ward, 26 outpatient clinics per week and an occupational therapy unit, besides emergency and liaison psychiatric services available twenty four hours a day, seven days a week.30 Pakistan , with a population of 160,000,000, lies between 23.30 and 36.45 North latitude and 61 and 75.30 East longitude in the northern hemisphere. It is surrounded by Afghanistan in the north-west, Iran in the west, India in the east, China in the north-east and Arabian Sea in the south. The life expectancy is 59 years for men and 60 years for women, with a 37.8 total Literacy rate. Questionnaires A questionnaire was designed by the authors for the initial interview, based on WHO-multi country study on womens health and domestic violence31, after taking written permission from the WHO authors for the use. The authors questionnaire comprised of two main sections, basic socio-demographic information in the first section, such as name, age, marital status, number of marriages, level of education, current employment status. Questions adapted from the WHO questionnaire (as previously mentioned) formed the second section of the authors questionnaire. There were separate questions for verbal, physical and sexual forms of domestic violence. The questionnaire itself is available from the author. The author (SH) carried out the data collection. A standardized, Urdu version of both questionnaires was used for patients who could not understand English. Married women presenting to the in-patient and the out-patient department of psychiatry were recruited, after taking informed consent and interviewed by the author (SH) in a separate room to maintain confidentiality. The socio-demographic details of the women were recorded. The women were asked if they had been subjected to domestic violence by their partner. Domestic violence was defined according to the WHO definition. Keeping in view the local cultural and religious norms, the partner was restricted to spouse to whom they were currently married to. The interview was concluded if they refused or denied having such experience. Those who answered in affirmative and agreed for further interview were asked questions regarding the type of domestic violence they were being subjected to. The Mini International Neuropsychiatry Interview 32 (version 5.0.0) was used by the author for evaluating depression in the study sample, which is a standardized diagnostic instrument for the diagnosis of Diagnostic and Statistical Manual, 4th ed (DSM-IV; American Psychiatric Association, 2000 and International Classification of Diseases (ICD)-10 psychiatric disorders (World Health Organization (1992) ), a valid and reliable diagnostic tool, having high Inter-rater and testretest reliabilities . To reduce the time of the interview, we excluded alcohol abuse and dependence, substance use disorders, psychotic disorders, personality disorder, because these disorders were beyond the scope of the present study. The suicide sub-section of M.I.N.I was also used to asses the risk of suicide amongst the severely depressed women. The suicide risk was further categorized into low, moderate and severe according to the scoring in the answers. Sampling Inclusion Criteria Currently married females living with husbands
0B

Exclusion Criteria Non consenting

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Ethical considerations: The study was conducted in compliance with the `ethical principles for medical research involving human subjects` 140 of Helsinki Declaration. Verbal informed consent was taken from our subjects before the interview. Their personal information (name, address, medical record number) was not recorded to maintain anonymity and ality. confidenti 120 Statistical methods: 100 The data was analyzed in the SPSS statistical package, version 14.0,33 (Chicago, Il, USA). Descriptive statistics oyed to determine the demographic and clinical variables. Chi-square test of association was applied, at a were empl80 was real. confidence interval of 95%, to determine if the association betweeneducational two variables level
60

160

RESULTS A total of 171 married females were included in this study.

20 DEMOGRAPHIC VARIABLES (figure 1) 40

no edu graduate inter

tric years 39.8 %( n=68). Majority0of the females were found to be in the age ranging between me 26-35 1525 females 26- 35were 3645ding4656-at 65the time of interview. f the resi in 55 Karachi 73.7% (n=126) o 35.1 %( n=60) had education until intermediate, 76.1% (n=133) of the females were Muslims, and 23% (n=40) of the females were working outside home. age

FIGURE1-Socio-demographics DOMESTIC VIOLENCE AND FREQUENCY OF DIFFERENT FORMS OF DOMESTIC VIOLENCE (Table 1) More than one form of domestic violence was reported by 69.5% (n=118) females, as shown in the table-1, thereby not making it possible for the authors to find out the exact prevalence of each form of domestic violence separately. 32.2% females (n=55) reported to have had been shouted/ yelled at by their husbands. 25.1% (n=43) of the females reported to had been threatened verbally by their husbands. Slapping was reported by 20.5% (n=35) females. Being kicked at was reported by 14% (n=24) of the females. 21.1% (n=36) females reported to have been pushed or shoved by their husbands. Threaten or actual use of a weapon against these women by their husbands was reported by 8.8% (n=15).
U

Table-1: frequency of diferent forms of domestic violence in married females presenting to the psychaitric facility at a tertiary care hospital in karachi* Different forms of Domestic violence (n=171) Shouted Threatened Slapped Kicked Pushed Used a weapon Number of cases (n) 55 43 35 24 36 15 Percent (%) 32.2 25.1 20.5 14 21.1 8.8

*Most women reported enduring multiple types of violence; hence percentages add up to more than 100% in all

Percent

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DEMOGRAPHIC VARIABLES AND THEIR ASSOCIATION WITH DOMESTIC VIOLENCE- Table-2 Level of education did show a significant association with domestic violence (p=.001).The sample was divided into 5 age ranges15-25, 26-35, 36-45, 46-55, and 55-60. However, there was insignificant association between the age (p=.645) and domestic violence and the employment status (p=0.349) of the selected sample also did not show any significant association with domestic violence.
U

Table -2: demographic variables and their relationship with domestic violence Domestic violence Yes n % 18.9 37.7 20.8 13.2 9.4 n 20 48 33 11 6 No % 16.9 40.7 28 9.3 5.1 .645 P value*

Demographic variables

Age 15-25 26-35 36-45 46-55 56-65 Level of education Metric Inter Graduate Others No edu. Employment status Working Not working 10 20 11 7 5

6 12 8 24 3

11.3 22.6 15.1 45.3 5.7

30 48 15 22 3

25.4 40.7 12.7 18.6 2.5 .001

10 43

10.9 81.1

30 88

25.4 74.6 .349

n=number of patients

Chi Square Test (p value= <0.05)

DOMESTIC VIOLENCE AND DEPRESSION: Our study report 62% (n=106) females to be suffering from depression at the time of interview, however, further statistical analysis would be required that might shed some light regarding association of severity of depression with domestic violence in these female victims.
110

Figure 2- Domestic violence and Depression

100 90 80 70

Count

60 yes no

depressed past 2 wk?

Discussion Our study was conducted to find out the prevalence of domestic violence in married women. However, as the results tell us, majority of the women were being subjugated to more than one form of domestic violence simultaneously, making it difficult to asses each form separately. The statistics do raise a concern regarding the practice of such brutal acts in our society.

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Domestic Violence and Frequency of Different Forms of Domestic Violence Our married women are being made the victims of domestic violence, something which is surprisingly not rare in the rest of the world also. 24,25,26,29, 34-41 We do not know whether the low response rate in our study produced an overestimate or underestimate of prevalence. It would have been unethical to collect data from the medical records of women who declined to answer the questionnaire. Looking at the demographics of the victims in our study, majority of them were adults as compared to minors. That leaves the author to hypothesize regarding the age group and occurrence of such crimes as according to recent findings the probability of a woman to be abused increases if she is young and illiterate and hails from a landless, poor family.42 Depression and domestic violence: Our study reports a huge number of the victims of domestic violence being depressed at the same time. Regarding an association of domestic violence and depression amongst the female victims, women experience depression about twice as much as men.43 This difference may be accounted for by women experiencing greater poverty, differing social roles and sex discrimination, more negative life events, and violence and abuse.43 Depression is the most frequent psychological response reported by female victims of partner abuse.44-48 Other psychological responses include Post Traumatic Stress Disorder 49-51; a propensity toward alcohol and/or substance abuse and an increased risk for affective disorder, dissociative identity disorder, somatization, suicidal ideation, panic disorder, and anxiety disorders. 51 The body of existing research on the connection between domestic violence victimization and depressive symptoms is overwhelming in its scope and complexity. Although there exists relative consistency concerning the positive association between these two phenomena, 52-56A meta-analysis on the prevalence of mental health problems among women with a history of violence from a partner found that compared with women who had not been abused just under a half of the abused women had clinical depression.57 Data on this subject are limited in the primary care setting.58, 59 Cascardi et al. 60 found that 56% of women seeking marital counseling who had experienced physical abuse in the past yearhad co-morbid Major Depressive Disorder, while Stein & Kennedy 61 observed a co-morbid rate of 43% major depressive disorder and PTSD in victims of Intimate Partner Violence recruited from domestic abuse agencies and community medical clinics 62 The association between depression and abuse by a partner in women presenting to their general practitioners is significant even after adjustment for social indicators associated with depression.63 This confirmed the findings from other settings of women experiencing current or past abuse by a partner.64,65,66 Although we cannot infer causation, we have some evidence that partner abuse may contribute to depression rather than the opposite.66 Limitations: 1. Restricting the study sample to women presenting to the psychiatry department only, limited our ability to apply the findings to a larger group of women. 2. The studys cross-sectional design precluded our establishing a causal role of violence leading to poor mental health. Conclusion: In summary, a large number of married women presenting to a tertiary care hospital in Karachi, report to be enduring more than one form of domestic violence. A good chunk of these women also report to be suffering from depression at the same time. The present study highlights the dire need for further research on domestic violence in Pakistan, not only to asses its prevalence but there is also a need of effective interventions to promote the necessary individual and societal changes to tackle current cases of intimate partner violence and to prevent new ones.

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Acknowledgements Our sincere gratitude to Mr. Dominic Dsouza, Administrative Officer, Department of Psychiatry,AKUH, for his immense support in the entire project. References:
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