A Mixed Methods Study of Participant Reaction to Domestic Violence Research in Jordan

Abstract

Research on domestic violence against women has increased considerably over the past few decades. Most participants in such studies find the exercise worthwhile and of greater benefit than emotional cost; however, systematic examination of participant reaction to research on violence is considerably lacking, especially in the Middle East region. This study begins to fill this gap by examining women’s reactions to domestic violence research in Jordan and whether a personal history of violence is associated with unfavorable experiences. This sequential exploratory mixed methods study included 17 focus group discussions (FGD) with women in Amman followed by a survey conducted in reproductive health clinics throughout the country (pilot n = 30; survey n = 517). Open coding was used to identify the theme related to participant reaction in the FGD data. This construct was further examined by the subsequent survey that included dichotomous questions inquiring whether the respondent thought the study questions were important and whether they were angry or felt resentment as a result of the survey. One open-ended question on the survey provided additional qualitative data on the theme that was combined with the FGD data. Themes identified in the qualitative data pertained to expressions of gratitude and comments on the survey’s value. Findings of this study indicate that Jordanian women’s responses to the research process are similar to women currently represented by the extant literature in that a vast majority of its participants felt that the study was important (95%) and it did not evoke anger or resentment (96%). Many even found the study to be useful to them personally or to society. Among those who had a negative emotional reaction, most still found the research to be important. This study’s findings highlight the safety and potential benefits of ethically conducted violence research.

Keywords

domestic violence and cultural contexts violence exposure disclosure of violence

Introduction

Systematic examination of participant reaction to violence research is lacking, especially outside the United States. To the authors’ knowledge, women’s reactions to participating in intimate partner violence (IPV) research have not been systematically examined in a Middle Eastern country. This study begins to fill this gap by examining women’s reactions to domestic violence research in Jordan and whether a personal history of violence is associated with adverse participant reaction. Given the lack of research on women’s reactions to IPV research participation in Jordan and throughout the region, it is unclear if these studies are causing harm in their well-intentioned pursuit of knowledge.

This research is especially pertinent due to the fact that IPV research is gradually increasing. Hence, ever greater numbers of women are exposed to an unexamined research process. While the studies that have been conducted to date suggest that most participants will not react adversely to violence research (Griffin, Resick, Waldrop, & Mechanic, 2003; Newman & Kaloupek, 2004; Newman, Walker, & Gefland, 1999), the research base is founded on a limited number of studies, many of which have been conducted in the United States. Given the importance of the sociocultural and institutional contexts within which women experience IPV (Heise, 1998), the generalizabilty of previous findings to women living in Jordan is questionable. Therefore, this study begins to fill this gap by examining women’s responses to their participation in IPV research in Jordan.

Recent survey research has begun to characterize the extent, health effects, and attitudes toward the acceptability of IPV in Jordan. Estimates of ever physical IPV against women range from 21% in a community-based sample of reproductive age women (Department of Statistics [Jordan] and Macro International Inc, 2008) to 31% among women attending reproductive health clinics (Clark, Bloom, Hill, & Silverman, 2009a) to nearly 45% among refugee camp dwelling populations (Khawaja & Barazi, 2005). In addition, 12% to 15% of women have been shown to have experienced violence during pregnancy (Clark, Hill, Jabbar, & Silverman, 2009b; Oweis, Gharaibeh, & Alhourani, 2010). IPV in Jordan has been associated with unplanned pregnancy (Oweis et al., 2010) and with interference in women’s attempts to control their fertility (Clark et al., 2008). IPV has also been related to women’s reports of depressive symptoms (Al-Modallal, Abuidhail, Sowan, & Al-Rawashdeh, 2010). Widespread acceptance of violence against women, particularly against a wife perceived to be errant, has been documented with estimates ranging from 60% to 90% of individuals surveyed (Clark et al., 2009b; Department of Statistics [Jordan] and Macro International Inc, 2008; Haj-Yahia, 2002; Khawaja, 2004).

These survey results must be placed in the broader context of women’s status in Jordan. The Jordanian Constitution guarantees equal rights to all Jordanians (“The Constitution of the Hashemite Kingdom of Jordan,” 1952) but Jordanian Personal Status Law grants women custody but not guardianship of children, obliges women to be obedient and to cohabitate with their husbands or forfeit their financial support, and requires the testimony of two male witnesses to obtain a divorce on the grounds of domestic violence or forfeit all financial support including the dowry (Husseini, 2010). Since women’s participation in the formal labor force is very low (18%; Department of Statistics [Jordan], 2010), most women are financially dependent on their husbands or their natal families for survival. A woman’s family may offer her shelter and support if they are financial able, but this is not always the case, nor does the offer of shelter always extend to the woman’s children since they are counted among her husband’s family’s lineage (Clark, Silverman, Shahrouri, Everson-Rose, & Groce, 2010). Prior domestic violence research among Jordanian women has found that women’s financial dependence on men, the potential loss of their children, a lack of support from their family, and the social stigma of divorce compels many women to remain in violent relationships (Clark et al., 2010; Gharaibeh & Oweis, 2009; Oweis, Gharaibeh, Al-Natour, & Froelicher, 2009). These study findings have helped to shed light on the extent of the problem, its health consequences, and the legal, financial, and social barriers women face to living a life free of IPV.

Research conducted in Jordan reflects the larger trend in that research on domestic violence against women has increased considerably over the past few decades while systematic examination of women’s reaction to the research lags behind. This is a serious omission since violence and trauma research may elicit strong emotional reactions and may potentially harm the participant if not ethically conducted. Of the few studies that been conducted on participant reaction, one finds that a vast majority of participants in research on violence and trauma are not harmed by the process but instead find their participation meaningful (Widom & Czaja, 2005), beneficial (Griffin et al., 2003; Newman et al., 1999; Ruzek & Zatzick, 2000), and of greater importance than other personal questions (Cromer, Freyd, Binder, DePrince, & Becker-Blease, 2006). While a small percentage may be upset by the questions, most do not regret their participation and find their participation to be worth the emotional cost (Cromer et al., 2006; Draucker, 1999; Newman & Kaloupek, 2004; Ruzek & Zatzick, 2000; Widom & Czaja, 2005).

In addition to factors such as age (Galea et al., 2005; Ruzek & Zatzick, 2000), sex (Black, Kresnow, Simon, Arias, & Shelley, 2006; Galea et al., 2005), and mental and physical health states (Galea et al., 2005; Newman et al., 1999; Ruzek & Zatzick, 2000; Walker, Newman, Koss, & Bernstein, 1997), victimization status has been associated with participant distress in violence and trauma research. Becoming upset during the research process has been associated with a history of child maltreatment (Newman et al., 1999; Walker et al., 1997), intimate partner violence (IPV; Black et al., 2006), and other traumas (Johnson & Benight, 2003) although not unequivocally (Cromer et al., 2006; Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005; Ruzek & Zatzick, 2000).

In studies conducted outside of the United States, anecdotal reports indicate that for some participants the research is distressing but may also be a welcome opportunity to discuss aspects of their lives (Hunter et al., 2004; Jewkes, Watts, Abrahams, Penn-Kekana, & Garcia-Moreno, 2000). The World Health Organization’s (WHO) Multicountry Study on Women’s Health and Domestic Violence found that, on the whole, participants were grateful for the opportunity to discuss their experiences of violence with an empathetic, nonjudgmental interviewer (Jansen, Watts, Ellsberg, Heise, & García-Moreno, 2004). In addition to these impressions, the study also systematically examined the participants’ reactions to the questionnaire and found that a majority of the participants felt the same or better after taking the survey (Garcia-Moreno et al., 2005; Jansen et al., 2004). The current study aims to contribute to this emerging literature and to address a lack of knowledge on Middle Eastern women’s experiences by examining Jordanian women’s responses to IPV research.

Method

This sequential exploratory mixed methods study consisted of a series of focus group discussions (FGD) with women in Amman, Jordan, conducted between August and October, 2003, followed by a survey conducted between February and March, 2005 in reproductive health clinics throughout the country. The main purpose of the mixed methods study was developmental, in that the FGDs were conducted first to inform the development of the questionnaire (Greene, Caracelli, & Graham, 1989). The study generated three data sets: (a) qualitative FGD data, (b) quantitative survey data, and (c) qualitative data from an open-ended question on the questionnaire. The qualitative data from the FGDs and the survey’s open-ended question eventually were combined into one qualitative data set due to an iterative analysis strategy and the complementarity of the information contained in both data sets. The methods were mixed primarily in the display and interpretation of the findings although the iterative nature of the qualitative data analysis entailed some mixing at the data analysis stage.

Participant safety was paramount to the study. The study followed the World Health Organization’s ethical and safety guidelines for conducting research on domestic violence against women (World Health Organization, 2001) and the Institutional Review Board at Harvard School of Public Health and the scientific committee at the Faculty of Nursing at the University of Jordan approved both research protocols. Further approval of the protocols was obtained from the study’s partner organizations. Due to the fact that this was among the first studies on the topic, oral, not written, consent was sought for both components to protect the participants’ identities, and financial incentives were not offered to individual participants to avoid undue influence on women’s decision to participate. For both components, participants were offered a copy of the informed consent form and a small card containing information about domestic violence services in the area. Given the group format of a FGD, the questions sought the participants’ perceptions not personal experiences. A protocol was in place to remind women who started to reveal personal details during the FGDs that we could not protect their privacy in a group setting, and women were reminded throughout the discussion not to use names. However, during the course of the FGDs, the participants frequently wanted to talk more directly about themselves resulting in a data set of perceptions grounded in the lived experiences of a number of the participants. To protect the participants’ identities the discussions were not audio- or video-recorded. Since the survey was being conducted in reproductive health clinics, and participants would have ongoing contact with their providers, the survey was self-administrated with clinic staff participation restricted to the recruitment and informed consent processes. Clinic staff facilitating the survey were trained to assist the client if she was distraught by helping her to reach a domestic violence counselor via telephone; however, no client required this assistance. Further detail about the human subjects’ protections implemented in this study is available elsewhere (Clark, 2005).

FGD Sample, Data, and Process

FGDs (N = 17) were conducted with women recruited on the basis of their marital status by organizations participating in this study (Sisterhood is Global Institute, Young Women’s Christian Association, United Nations Relief and Works Agency for Palestinian Refugees in the Near East, the University of Jordan Faculty of Nursing and Community Service Office, and the Single Parents’ Club). Four of these groups were also chosen on the basis of IPV experience. The partner organizations invited their members to participate in a group discussion on women’s health and family relations that would be held at a particular day and time at the organization. Each organization was asked to provide between two and four groups. In the instances when 6 women did not arrive at the scheduled time of the focus group discussion, other women attending the organization were asked to participate under the same conditions. The groups ranged in size from 3 to 9 with an average of 6 participants per group.

At each research site the focus group moderator began the discussion by explaining the research process and obtaining oral consent from the participants. The moderator asked each participant to complete a short questionnaire on her age, marital status, number of children, highest level of education completed, and area of residence. The questionnaire was not used for the first FGD; therefore, complete demographic data are available for only 16 of the 17 discussions.

The FGDs lasted between 1.5 and 2 hours. The moderator facilitated the sessions using a guide that covered topics ranging from defining domestic violence to forms of assistance available to victims. The same questions were asked of each group. During each session, the note-taker recorded the discussion verbatim to the extent possible and kept track of events such as interruptions or instances when participants were emotional. All discussions were conducted in Arabic. The note-taker, who was fluent in both Arabic and English, translated the transcripts into English to facilitate analysis by study team members who were not fluent in Arabic. The FGD moderator’s review of the English transcripts attests to their concordance with the content of the discussions.

Survey Sample

The survey was conducted in Jordanian Association for Family Planning and Protection (JAFPP) clinics. At the time of the survey, JAFPP operated 19 clinics that provided a range of services such as family planning, general physicals, and antenatal, postnatal, and well-baby examinations. Routine screening for IPV did not occur.

Survey respondents were recruited using probability proportionate to size methodology (PPS; Kalton, 1983). PPS was used since the clinics in JAFPP’s system were of different sizes and therefore, clients at larger clinics would have a lower chance of being selected to participate. PPS methodology increases the chance that larger clinics are chosen for the sample in the first place offsetting the increased chance of participation of clients in smaller clinics. A pilot test was conducted (n = 30) followed by the full survey (n = 517). Seventy percent of the clients recruited for the full study agreed to participate. Participation statistics are not available for the pilot test. The data from the pilot and the survey were not different on sociodemographic characteristics (age, education, and parity), exposure to the various forms of violence (violence in childhood, IPV, and relative violence), or the two outcome measures (questions were important and participant was angry/resentful). Therefore, the two samples were combined. The statistical analyses were restricted to participants with no missing values on variables of interest leaving an analytic data set of 478 (4 excluded from pilot sample; 65 excluded from survey sample).

Survey Process and Measures

The study questionnaire was originally developed in English, translated into Arabic and back-translated to ensure consistency across versions (Brislin, 1970). Major content areas of the questionnaire included demographic, social support, childbearing and family planning information; experience with intimate partner violence; experience of violence from other family members, experience of physical violence during pregnancy; exposure to violence as a child; help seeking; and participant reaction to the questionnaire. The clients took between 25 and 40 min to complete the questionnaire.

The respondent’s opinions and reactions to their participation in the survey were elicited by the following questions. “Do you think this survey asked questions that are important?” “Do you feel anger or resentment after taking this survey?” “Is there anything you would like to add?” Three dichotomous measures of exposure to domestic violence were created from the survey questions that represented exposure to violence as a child, physical or sexual IPV, and violence from other family members after marriage. Exposure to violence in childhood was measured with the following question: “When you were a child, was there physical violence in your home?” Experience of IPV (physical or sexual) since marriage was based on the scale used by the World Health Organization’s (WHO) Women’s Health and Domestic Violence Against Women questionnaire (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006), which is based in part on the Conflict Tactics Scales (Garcia-Moreno et al., 2006; Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Violent experiences measured included being slapped or having something thrown at them that could hurt them; pushed, shoved, or having their hair pulled; hit with a fist or something that could hurt them; slapped or hit by their husband when they were pregnant; kicked, dragged, or beat up; choked or burnt on purpose; threatened with or having a gun, knife, or other weapon used against them; forced to have sexual intercourse when they did not want to; and forced to perform degrading sexual acts. Abuse from family members since marriage was measured by whether the respondent had ever been slapped or hit by a family member while pregnant and whether “Since marriage, has anyone in your family or your husband’s family insulted, belittled, humiliated, intimated, controlled, or threatened you; and since marriage, has anyone in your family or your husband’s family ever hit, slapped, insulted, kicked, or done anything else to physically hurt you?” Exposure to each form of violence was determined by an affirmative response to at least one item within each set of questions. A cumulative violence variable also was created, which indicated whether the respondent experienced no violence, one type of violence, or two or more types of violence.

Data Analysis: Qualitative

The analysis of the qualitative data was iterative starting first with initial data analysis conducted by the study’s primary investigator (CJC) in preparation for the subsequent survey. After completion of the survey, the data from the open-ended question on the survey was analyzed, the results of which informed further analysis of the FGD data. The two sources of qualitative data were eventually combined into one data set. The original analysis of the FGD transcripts was completed using open coding (Strauss & Corbin, 1998). Among the many themes identified in this analysis were data pertaining to the participants’ perceptions and experiences participating in the group. These data are the result of spontaneous comments made during the FGD since this topic was not originally anticipated. The emergence of this theme, however, influenced the inclusion of participant reaction questions on the questionnaire. Participant responses to the open-ended survey question were subjected to open and axial coding (Strauss & Corbin, 1998) by an analysis team, which consisted of the study’s primary investigator and two other study team members (MS, LH). MS was both the FGD moderator and the field supervisor for the survey. LH translated the comments on the questionnaire and developed the survey database. Five themes were identified in the data from the open-ended question: (a) information about the participant’s own relationship and circumstances, (b) comments on family relations and domestic violence in Jordan more generally; (c) methodological comments (e.g., suggestions about topics we should have included such as a section on child abuse); (d) expressions of gratitude and best wishes; and (e) comments on the survey’s value. The present analysis is focused on themes (d) and (e), which speak more directly to the participants’ reactions. The themes were applied to the FGD data by CJC. MS, and LH validated the coding of the FGD data. In the manuscript, the quotes have been lightly edited for comprehension.

Data Analysis: Quantitative

For the closed-ended questions on the survey, descriptive statistics were calculated and univariate logistic regression models were constructed to examine whether respondents’ experiences of violence were associated with reporting anger or resentment. Multivariate analysis could not be conducted due to a lack of variation in the outcome variables. A chi-square test was used to examine whether participants who reported anger or resentment were different from those who did not, regarding their opinion of the importance of the questions. Further analysis using chi-square tests was conducted to examine whether victims of violence were more or less likely to have expressed gratitude or commented on the survey’s value compared to nonvictims. A sensitivity analysis was conducted to examine differences on study variables between those included in the analytic sample and those excluded on the basis of missing values on study variables.

Results

Sample characteristics

Tables 1 and 2 display the sociodemographic characteristics of the samples. Most participants in both samples were of reproductive age. Participants in the survey sample were on average 31 years old (SD = 7) with 3 children (SD = 2). Average ages in the focus group discussions ranged from 20 to 44 and average number of children ranged from 0 to 5. A vast majority of the survey sample had at least a secondary education (88%, n = 422). The educational attainment of the FGD participants was also quite high on average (10-13 years) although several groups were conducted with women of lower educational attainment (4-5 years). The FGD participants were by design of different marital statuses (never married, currently married, divorced, widowed); however, the survey sample, due to its selection from reproductive health clinics, was comprised almost exclusively of currently married women (99%, n = 474). Those included in the survey sample did not differ from those excluded due to missing values with one exception; women included in the analyses were more educated than those excluded.

Table 1.

Survey Respondent Characteristics (N = 478)

Age, Mean (SD)	31 (7)
Married, % (No.)	99 (474)
Number of children, Mean (SD)	3 (2)
Educational Level, % (No.)
Less than secondary	12 (56)
Secondary	50 (241)
Higher	38 (181)
Survey asked important questions,% (No.)
No	5 (22)
Yes	95 (456)
Felt anger or resentment after survey, % (No.)
No	96 (459)
Yes	4 (19)
Exposure to violence in childhood, % (No.)
No	87 (414)
Yes	13 (64)
Intimate partner violence, % (No.)
No	60 (288)
Yes	40 (190)
Violence from other family members after marriage, % (No.)
No	73 (349)
Yes	27 (129)
Cumulative violence
None	48 (230)
1 type	29 (138)
2+ types	23 (110)

Table 2.

Sociodemographic Characteristics of the Focus Group Participants

Marital Status	Number of Groups	Average Age (Range)	Average Number Children (Range)	Average Years Education (Range)
Never married	4	20 (19-21)	0 (0-0)	13 (12-15)
Currently married	6	36 (30-45)	4 (2-6)	13 (10-18)
Divorced	4	35 (30-43)	3 (2-3)	10 (4-15)
Widowed	3	44 (41-46)	5 (3-6)	10 (5-15)

Source: Reprinted from Clark, C. J., Silverman, J. G., Shahrouri, M., Everson-Rose, S., Groce, N. (2010). The role of the extended family in women’s risk of intimate partner violence in Jordan. Social Science & Medicine, 70(1), 146, with permission from Elsevier.

Qualitative findings

The analysis of the written comments on the questionnaire indicated a general trend of satisfaction with study participation. In addition to comments sprinkled throughout the questionnaire to add additional detail or to clarify an answer, 182 out of the total 547 participants (33%) wrote some kind of comment to the question “Is there anything you would like to add?” Among these comments, 73 referred to expressions of gratitude and best wishes and 48 referred to the study’s value. The FGD participants contributed 10 additional comments about the study’s value and 1 expression of gratitude.

Expressions of gratitude took several forms. A number of the statements were simply messages of thanks and best wishes for our success. Others were more explicit in thanking the research team for being concerned about women, children, and the family in general.

Thanks for caring about the family. (37-year-old married survey participant—violence survivor)

Thanks for your concern for women and problems facing women. (29-year-old married survey participant)

Many of the statements of gratitude, however, were also tied to some value that the study was perceived to have. Many of respondents reported on the study’s value either to them personally or to society more generally. Socially, the results of the study were perceived to generate greater understanding of the issue and potentially inform efforts to better protect women and children.

This survey is important because it helps to understand and know lots of family problems in the society and helps to find solutions and protect families. Thanks. (26-year-old married survey participant— violence survivor)

The survey was also recognized as a service to society in part by raising awareness of women’s rights and by giving voice to an unspoken reality as the following quotation exemplifies.

Thanks for asking about things that really happen in houses, and no one can say anything about it. (30-year-old married survey participant—violence survivor)

Making the findings of the study widely available was perceived to be the route through which the study’s benefits might be realized.

We would like this research to be published so everyone could benefit from it. (21-year-old never married FGD participant)

Personal benefit from study participation was also mentioned by a number of study participants. For them, study participation offered an opportunity for reflection, which had a positive effect on their well-being.

The questions in this survey helped me in evaluating the relationship between me and my husband, which gave me comfort, and it gives many indications on the family relationship in general, thanks for this important study, wish you success. (36-year-old married survey participant—violence survivor)

Study participants also noted the benefits of being able to safely express themselves. For a number of participants, especially those who had suffered abuse, the study served as an outlet for the pain, frustration, and injustice they silently endured. These benefits were noted for both study formats.

This survey helped in getting out what is inside me. My bitter feelings and anger make me want to take revenge but I do not have a support. I wish fair revenge to every husband or person who treats his wife or children badly. (43-year-old married survey participant—violence survivor)

I feel very comfortable now. If every month we had a session like this it would be better . . . I felt so comfortable when I knew that there aren’t any names, my name isn’t going to be mentioned. I really feel relieved after talking to you all. I wish you could do it again every month. (43-year-old divorced FGD participant—violence survivor)

Not all participants thought the study was worthwhile or valuable. One FGD participant felt that the study was, “No action . . . only words” (32-year-old married FGD participant—violence survivor) and one survey participant questioned whether we were really getting access to the women most in need. No one in the FGDs expressed feelings of anger or resentment at their participation. Among the 19 survey participants who reported anger/resentment, 7 answered the question about whether they wanted to add anything. Among these participants, 3 discussed their personal experiences in greater detail, 1 was angry because of her friend’s situation, 1 wished for happiness for abused women, 1 felt that violence was increasing in Jordan and action should be taken, and 1 comment was unintelligible. These comments don’t indicate distress due to study participation. However, the majority of respondents’ who reported anger/resentment did not leave a comment. On the whole, however, the vast majority of study participants expressed positive sentiments about their participation.

Quantitative findings

The positive sentiments expressed by the participants in the FGDs and in response to the open-ended question on the survey are echoed by findings from the quantitative portion of the survey wherein 95% reported that the study questions were important (n = 456) and 96% (n = 459) were not angry or resentful from their participation. Among the survey respondents, 13% (n = 64) reported being exposed to violence in childhood, 40% (n = 190) to IPV, and 27% (n = 129) to violence from another family member since marriage. The results of the univariate logistic regressions (Table 3) suggest that participants who were abused at some point in their life were more likely to have reported being angry/resentful although none of the tests reached a traditional level of significance (p < .05). The relationship between reporting 2 or more types of violence exposure and anger/resentment was of borderline significance (OR = 3.06; 95% CI = [0.95, 9.86]; p value = .06). Although not statistically significant, a history of violence may be associated with greater emotional upset. However, among those who reported being angry or resentful, 89% (n = 17) reported that the questions were important. This percentage did not differ statistically from the percentage who thought the questions were important among those who were not angry or resentful (96%, n = 439; Fisher’s Exact Test p value = .22). Furthermore, violence victims (childhood, IPV, relative violence) were no more or less likely than nonvictims to have expressed gratitude for the survey or to have reported on the study’s value (all p values > .05).

Table 3.

Univariate Logistic Regression Models Predicting Anger/Resentment (N = 478)

	OR	95% CI	p value
Violence in childhood	1.77	[0.57, 5.52]	0.32
IPV	1.72	[0.69, 4.32]	0.25
Violence from other relative	2.03	[0.80, 5.17]	0.14
Cumulative violence
None	1.00
1 type	2.40	[0.75, 7.73]	0.14
2+ types	3.06	[0.95, 9.86]	0.06

Discussion

The results of this study shed light on women’s reactions to a domestic violence study in Jordan. This study found through both quantitative and qualitative formats that participating in the study was a positive experience for a vast majority of respondents, with potential personal or social benefit. While a history of abuse was found to be associated with greater distress, the study’s value was recognized even among the minority who were emotionally upset. The findings of this study add to the scant literature examining participant reaction to violence research and extend it by investigating the topic in a country and a region where, to the authors’ knowledge, no previous studies on this topic have been conducted. Overall, the findings of this study highlight the similarity across sociocultural contexts in the safety and potential value of ethically conducted violence research.

The finding that 95% of the survey respondents felt that the questionnaire was important is consistent with prior literature. In two large telephone surveys in the United States, 92% and 95% of the respondents, respectively, indicated that they thought questions about interpersonal violence should be asked (Black et al., 2006). In a study of university students, trauma questions were rated of greater importance than other types of psychological research questions investigated (Cromer et al., 2006). In a longitudinal study of child abuse, the participants reported that their participation was meaningful (Widom & Czaja, 2005).

This study’s findings pertaining to the potential for personal and social gain through study participation are also supported by the literature. In a large trauma-focused survey of health maintenance organization members, 23% reported benefiting from the survey; however, 86% of participants who were selected for an interview phase of the study reported benefiting from the process (Newman et al., 1999). In a survey of acutely injured persons presenting to a medical center, 79% of the participants reported that they benefited from their participation, while 82% reported that their efforts, stated in terms of volunteering, made them feel good about themselves (Ruzek & Zatzick, 2000). In a study of victims of sexual abuse, 96% of the participants found the study to be a positive experience, categorized broadly into aspects of increased self-reflection, increased self-awareness, feeling validated or less alone, feeling empowered, helping others through their participation, and taking various proactive steps in the healing process (Disch, 2001). However, 80% also had some negative reaction to the study highlighting that for some the study may be both difficult and beneficial.

This complex mix of potential gain and potential pain characterized the participation of some respondents in the current study although negative emotions were much less frequently reported (4%) in this study compared to prior research. Among those who were upset, a vast majority (89%) thought the research was important, a percentage that did not statistically differ from those who did not report being upset. This suggests that while there may be emotional costs to the study, these costs may indeed be well worth the benefit, a finding supported in the literature (Cromer et al., 2006; Draucker, 1999; Newman et al., 1999; Newman & Kaloupek, 2004; Walker et al., 1997). For example, in the survey of acutely injured patients referenced above, 95% reported that even if they knew in advance what participating in the study would be like, they would still agree to participate and 91% reported that participating in the study was worth any inconvenience (Ruzek & Zatzick, 2000). A similar mix of emotion and gain was demonstrated in an intensive, multimethod psychological examination of survivors of domestic violence. This study found that despite the fact that 42% reported experiencing strong or very strong emotions during the study process, 98% would be willing to participate again under the same conditions (Griffin et al., 2003).

Among the various forms of violence investigated, all suggested increased odds of reporting anger or resentment, although not statistically. This finding is in accord with much of the prior literature (Newman et al., 1999; Walker et al., 1997; Widom & Czaja, 2005). However, these findings are not unequivocal (Cromer et al., 2006; Ruzek & Zatzick, 2000). For example, in about half of the sites in the WHO multicountry study, IPV was not associated with the respondents’ feelings. In three of the sites, the participants who experienced IPV were more likely to report feeling good or better after participating, in four sites abused respondents were more likely to report feeling worse, and within one site, the results were mixed (Garcia-Moreno et al., 2005). However, the bulk of the evidence points to greater distress among those who have been victimized (Galea et al., 2005; Halek, Murdoch, & Fortier, 2005; Johnson & Benight, 2003). While victimized participants may have been more likely to report anger/resentment in this study, they were as likely to express gratitude for the survey and to comment on its value as participants who did not report victimization. A number also delineated personal benefit that they derived from the study suggesting that the role of victimization in women’s responses to violence research is multidimensional and should be examined accordingly.

Limitations to this study must be delineated. The sequential and exploratory nature of the mixed methods study was intended to allow us to identify relevant constructs to subsequently explore through the survey. However, the fact that participant reaction was not among the planned broad areas of examination, and the administration of the FGD guide was consistent across groups, meant that participant reaction was not explored in the depth that it might otherwise have been, especially with respect to the nature of negative reaction to the study. The fact that both positive and negative participant reaction was spontaneously mentioned and the quantitative component supports the findings of the qualitative portion suggests that our study is capturing the reactions of the participants. However, we cannot rule out social desirability as a contributing factor in our findings. In addition, the survey questions monitoring participant reaction referred to the questionnaire as a whole and not specifically to the violence-related portions. However, the majority of the study dealt with various forms of domestic violence and almost all of the respondents’ mentioned family relations and violence in their comments, even when they were making a methodological comment, suggesting that their ratings were influenced in large part by the violence questions.

We are unable to state unequivocally that the minority of survey participants who reported anger or resentment were unharmed. Comments from the subset of participants who reported anger/resentment do not indicate that the participants were distressed. And the bulk of the evidence to date suggests that when distress is evoked during violence or trauma research, it is usually short-lived (Galea et al., 2005; Griffin et al., 2003; Parslow, Jorm, O’Toole, Marshall, & Grayson, 2000) with no lasting harm (Draucker, 1999). Moreover, as was found in the current study, most research participants do not request mental health services subsequent to their participation (Edwards, Dube, Felitti, & Anda, 2007; Galea et al., 2005). However, most participants in this study who reported anger/resentment did not leave a comment and this issue was not probed for during the FGDs. Therefore, further research that has the ability to delve more deeply into potential negative participant reaction and to follow participants over time to track participant response, both immediate and delayed, is warranted.

The generalizability of the results may also have been hampered in part by the fact that the survey was administered to women who were on average more highly educated than the general population (Clark et al., 2009a). However, the similarity of this study’s findings to prior research that has been conducted among samples with low (Griffin et al., 2003), high (Cromer et al., 2006), and mixed (Ruzek & Zatzick, 2000) educational attainment suggests that education level is not likely a key determining factor in the way research participants respond to research. The consistency of findings across methods of this study, despite some differences in the characteristics of the participants in the two components supports at least some level of generalizability of the findings across sociodemographic groups in Jordan. Finally, several years have passed since the time the data were collected (2003 and 2005) and their relevance to the field could be questioned on this basis. However, the findings presented in this article are potentially of even greater relevance now given the continued proliferation of IPV studies and the general lack of research on participant reaction not just in Jordan, but throughout the region.

The findings of this study indicate that Jordanian women’s responses to the research process are similar to those of women currently represented by the extant literature with a vast majority responding favorably to the process with potentially even fewer women than in prior studies reporting a negative reaction. Many, including violence survivors, found the study to be useful to them personally or to society. Among those who had a negative emotional reaction, most still found the research to be important, suggesting that a distinction must be made between potentially inducing distress and causing psychological harm (Becker-Blease & Freyd, 2006). Nevertheless, more research is needed to understand the respondents who were affected by the research, both positively and negatively, to ensure that future research endeavors bolster the former and minimize the latter. A continued focus on the well-being of each and every participant will help to ensure that participants in domestic violence studies continue to respond favorably as research in the country and the region proliferates.

Footnotes

Acknowledgements

The authors wish to acknowledge representatives and participating staff at the Sisterhood is Global Institute, the Young Women’s Christian Association, the United Nations Relief and Works Agency for Palestinian Refugees in the Near East, the University of Jordan Faculty of Nursing and Community Service Office, the Single Parents’ Club, and the Jordanian Association for Family Planning and Protection for their contribution to the successful implementation of the study. David E. Bloom, Allan G. Hill, and Jay G. Silverman are acknowledged for their contribution to the study’s design.

Portions of this article were presented at the Eleventh Mediterranean Research Meeting, Florence and Montecatini Terme, March 24-27, 2010, organized by the Robert Schuman Centre for Advanced Studies at the European University Institute.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funds for this study were provided by the American Center of Oriental Research/CAORC, the U.S. Student Fulbright Program, and various grants from entities at Harvard University (Committee on General Scholarships, Weatherhead Center for International Affairs, Harvard Center for Population and Development Studies, and the Department of Global Health and Population). Support for Drs. Clark and Everson-Rose during preparation of this article was provided by the Program in Health Disparities Research at the University of Minnesota.

Bios

Cari Jo Clark, ScD, MPH, is assistant professor at the University of Minnesota Medical School and investigator in the Program in Health Disparities Research. Her background and training are in anthropology, reproductive health, global public health, and the health effects of traumatic and chronic stress. Specific topics of interest and expertise include domestic violence in the Middle East, intimate partner violence, and women’s mental, physical, and reproductive health and the chronic health effects of war-related trauma.

Manal Shahrouri, BSc, is senior research analyst at King Hussein Institute for Biotechnology and Cancer. Her background and training are in public health, biostatistics, and applied epidemiology and communicable and noncommunicable diseases. Specific topics of interest and expertise include domestic violence, reproductive health, family planning, and social welfare and protection affairs.

Louma Halasa, BSc, is a research consultant with experience conducting survey research and establishing, managing, and analyzing large databases. She has extensive experience working independently and for international organizations establishing the information structure upon which projects on based. Areas of interest and experience include maternal and child health, primary health care, and international development.

Inaam Khalaf, PhD, MA, BSN, is dean of the Faculty of Nursing, University of Jordan and a member in the board of trustees, Al Zaytoonah University. She earned her PhD in maternal child health nursing from New York University in 1989 and her master’s degree in advanced education in nursing in 1985. She is an expert in maternal child health nursing and in curriculum building, evaluation, and accreditation of programs in nursing and the health field.

Rachael Spencer, MPA, is a specialist in gender-based violence who has consulted for the New York City Mayor’s Office to Combat Domestic Violence and the United Nations Development Program Iraq-Office. Her background and training is in program management with an emphasis on partnership building and economics. Her topics of interest and expertise include domestic violence program management, economic empowerment of survivors of gender-based violence, and private–public partnership development.

Susan Everson-Rose, PhD, MPH, is an associate professor in the Department of Medicine and associate director of the program in health disparities research. Her background and training are in cardiovascular psychophysiology, behavioral medicine, stress mechanisms of disease, neuropsychology, and cardiovascular and social epidemiology. Her primary research program is focused on studying the roles of stress, negative emotions, and socioeconomic factors in the development and progression of cardiovascular diseases, stroke, and diabetes, and the biobehavioral and physiologic mechanisms underlying these associations.

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