Disclosure of Spousal Violence

Abstract

The objectives of this study were to identify reasons behind not disclosing spousal violence and examine relationships between these reasons and women’s demographic profile including the experience of spousal violence. Jordanian women (N = 709) aged 16 to 66 years (M = 32.6, SD = 8.7) attending health care centers were recruited. Results indicated that women’s intentions to maintain the family unit and use of patience with abuser represented the top two reasons for not disclosing violence. Non-significant relationships were, generally, identified between not disclosing spousal violence and women’s demographic profile. Women’s justification of spousal violence and witnessing parental violence were the proposed reasons for women’s lack of disclosure of violence. Implications for this study include health professionals’ use of evidence-based knowledge and skills to deal with victims of violence. Researchers’ roles include creating physical and emotional environment that urges disclosure of violence. Furthermore, they can contribute with health professionals in the implementation of health education programs directing victims and perpetrators in the places where they can be located. Proper collaboration between health professionals, researchers, and policy makers may significantly limit suffering of victims of violence.

Keywords

family unit disclosure of violence Jordan spousal violence

Introduction

Spousal violence is a crucial health problem affecting women in Jordan. Physical, sexual, and psychological violence are types of spousal violence experienced by Jordanian women (Clark, Bloom, Hill, & Silverman, 2009). In one study of 267 women residing in refugee camps in Jordan, 47.7% of the participants were victims of psychological violence from the spouse (Al-Modallal, 2012b). Women’s well-being is vulnerable as a result of spousal violence. Physical, mental, and social dimensions of health are jeopardized in response to women’s experiences of spousal violence. For example, depression, stress, and anxiety are increased in victimized women (Al-Modallal, 2012b). Furthermore, on the social dimension, women’s tendency to seek psychological support from family decreased as a result of their experiences of spousal violence (adjusted odds ratios [OR] = 0.53, 95% confidence interval [CI] = [0.29, 0.96]; Al-Modallal, 2012a). The relatively high prevalence rate of violence accompanied with lack of family help-seeking initiatives is in fact alarming.

Spousal violence has been addressed in literature concerning Middle Eastern, including Jordanian, women. Investigators in this field focused on different aspects of the problem in an effort to find future solutions to this global issue. One major factor associated with the occurrence of spousal violence in Jordan was lack of social resistance to the problem evidenced by women’s justification for the use of violence from the male spouse against them (Al-Badayneh, 2012; Al-Nsour, Khawaja, & Al-Kayyali, 2009; Boy & Kulczycki, 2008). Men, as well, share this attitude with women and believe in their right to use violence in some cases (Khawaja, Linos, & El-Roueiheb, 2008). Another factor for the occurrence of spousal violence was people’s misinterpretation of some religious (i.e., Islamic) values governing relationships between husband and wife (Haddad, Shotar, Younger, Alzyoud, & Bouhaidar, 2010). For example, it is stated in the Holy Quran that

But those [wives] from whom you fear arrogance—[first] advise them; [then if they persist], forsake them in bed; and [finally], strike them. But if they obey you [once more], seek no means against them. Indeed, Allah is ever Exalted and Grand. (Surat An-Nisa’ [The Women], The Holy Quran 4:34)

The word “strike” here is often misinterpreted. In fact it means that if the first two mentioned ways did not work with the arrogant woman, she can be stroked very slightly if it is useful. Striking in this context should not result in any type of trauma, meaning that it should not leave the woman injured, bruised, or even in pain.

Disclosure of spousal violence is one key element in identifying victimized women so that assistance and support can be provided. It is an action taken by the woman in response to her experience of violence. Disclosure of spousal violence can be conveyed to either informal parties like family and friends or to formal agencies like community institutions and police departments (Haj-Yahia, 2002). Women in Jordan varied in their agreement of using different outlets for disclosing spousal violence. For instance, in an exploratory study of 260 Jordanian men and women about their approach toward wife abuse, investigators found that 63.4% of the participants agreed on women’s choice to seek help from the family whereas only 29% agreed that they should file a complaint against the abusive spouse (Btoush & Haj-Yahia, 2008).

Women vary in their willingness to disclose violence, and these variations are related to differences in their characteristics. For example, White women are more likely to disclose violence compared with African American women (8.9% vs. 6.0%; McFarlane, Groff, O’Brien, & Watson, 2005). Physical violence is likely to be disclosed by young, less-educated, and poor women (Kramer, Lorenzon, & Mueller, 2004). On the contrary, employed women are likely to disclose violence compared with unemployed (Swanberg, Macke, & Logan, 2007). These findings indicate that different demographic characteristics play different roles in influencing women’s decisions to disclose or not disclose violence to others. Investigating these characteristics would be useful in this regard.

Screening for intimate partner violence victimization aims at early identification of victims of violence so that health services are provided and trauma and injury are prevented (Malecha, 2003). Screening for intimate partner victimization is a problem in different regions of the world. This problem is a two-part issue. Part of screening problem relies on health professionals as they do not have the initiative to screen women for violence victimization. For instance, in a study of 1,268 women accessing health care services, only 25% reported being screened for violence (Kramer et al., 2004). The other part of the problem relies on the victimized women as they do not declare being victimized unless being asked by health professionals (Kramer et al., 2004). Opposite findings in the same scope indicated willingness of women to freely participate in screening for violence experiences (Ross, Walther, & Epstein, 2004). These contradictory findings necessitate efforts to overcome screening problem. Therefore, screening for violence victimization should be a standardized practice adopted by health care facilities and organizations (Higgins & Hawkins, 2005) as well as work settings (Malecha, 2003).

Rationale for the Study

Spousal violence is considered a private matter in the Arab region (Douki, Nacef, Belhadj, Bouasker, & Ghachem, 2003). This attitude makes it unacceptable to disclose violence experiences to others outside the family unit, to formal or informal agencies. A few studies were identified as focusing on identifying reasons behind women’s lack of disclosure of spousal violence in Jordanian women (Al-Badayneh, 2012; Btoush & Haj-Yahia, 2008). Still, reasons behind lack of disclosure of violence were not the main focus of these studies, and results were not discussed in relation to personal and cultural attitudes and values of the participants. Hence, reasons behind a woman’s decision to disclose or hide experiences of spousal violence remain unknown and require scientific investigation. For this reason, this study was implemented.

Our research question, therefore, was

Research Question 1: What are the reasons behind women’s lack of disclosing or reporting spousal violence to extended family members or to friends in Jordan?

Specific objectives of the study include the following: (a) identifying prevalence of spousal violence in a convenience sample of women seeking health care in primary health care centers in Jordan, (b) identifying reasons behind women’s lack of disclosing spousal violence, and (c) examining relationships between women’s decision to not disclose spousal violence and their demographic profiles including type of violence victimization. This study included two hypotheses:

Hypothesis 1: Women would report different reasons for not disclosing spousal violence, and

Hypothesis 2: Women’s decision of not disclosing spousal violence would be significantly related to demographic characteristics and type of spousal violence they experienced.

Method

Design, Sample, and Setting

This study was a cross-sectional descriptive design. Women attending health care centers administered by the Jordanian Ministry of Health (MOH) and the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) in the cities of Amman, Irbid, and Zarqa were the sampled population. These three major cities were chosen because they are the most condensed Metropolitan cities in Jordan. A convenience sample of women attending these health care centers was recruited. No significant cultural or religious differences were present between attendees of different health care centers. All participants were Arab Muslims and no other ethnic populations were included in this study. In the meantime, differences in demographic characteristics between participants are likely. Such differences may include age, marital status, education level, and income. However, such demographic differences are not expected to influence participants’ backgrounds because they are from the same religious and cultural descent.

Inclusion criteria for participation in the study included (a) adult, married women; (b) visiting the health care center to address a health concern for oneself or a family member; and (c) residence within the boundaries of the cities of Amman, Irbid, or Zarqa.

Health care centers run by either the Jordanian MOH or the UNRWA represented the setting for the study. These health care centers were chosen because they are accessible for most of the population, and are accessed by a broad cross-section of Jordanian women. Health care centers run by the Jordanian MOH are distributed in various locations throughout cities and towns, whereas those run by the UNRWA health field program are located within the boundaries of the Palestine refugee camps in some Jordanian cities, including Amman, Irbid, and Zarqa. Health care services provided at the MOH and the UNRWA health care centers include treatment of acute and chronic conditions, vaccination, prenatal care, neonatal care, and a variety of other health services.

Data Collection

The study was approved by the Hashemite University, Jordanian MOH, and the UNRWA Health Department and Ethical Committee at Headquarters of the UNRWA in Amman-Jordan. Trained research assistants collected data from the participants over a period of 4 months. Instructions to research assistants were provided by the primary investigator in three separate sessions. Instructions included tutoring regarding the study protocol, the identification of study participants, and completion of questionnaires. Research assistants were also instructed regarding the goal of the study, the type of required data, participants’ rights including refusal options and confidentiality of reported data. Research assistants were provided with information about necessary community resources (i.e., counseling and sheltering services), including a description of their services and contact information to be given to women who revealed a need for such services.

Participants were sampled while waiting to be seen by a health professional at either the MOH or the UNRWA health care centers. Women were ready to provide necessary data after having all their questions answered by the research assistants based on the study protocol. Women who agreed to participate in the study were asked to sign the consent form prior to data collection. The self-reported questionnaire was then given to participants to be completed. Research assistants answered women’s questions regarding issues that were raised while completing the questionnaire. Completed questionnaires were collected by research assistants, and kept with the principal investigator for analysis.

Measures

Spousal violence was defined as “any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship” (World Health Organization [WHO], 2002, p. 89). In this study, the “spouse” was the male spouse whom the woman is committed to by a legal marriage certificate. We used questions adopted from the WHO Multi-country Study on Women’s Health and Domestic Violence Against Women (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006) to assess physical and sexual spousal violence and controlling behaviors by the spouse. These questions were used in this study for two main reasons. First, these items were previously used in a study of participants recruited from 10 countries mainly characterized as non-industrialized countries (Garcia-Moreno et al., 2006) similar to Jordan. Second, the items were tested for psychometric qualities in Jordanian women and results indicated their suitability of reflecting different types of violence against the female spouse (Clark et al., 2009). Below is a brief description of these questions.

Physical spousal violence was assessed by 10 items from the questions of the WHO Multi-country Study on Women’s Health and Domestic Violence Against Women. These items represented moderate and severe physical violence. Furthermore, 4 items were added; 2 items represented moderate violence (pinching and bending the arm) and 2 items represented severe violence (punching and beating a woman with a string like a waist belt or rope). These items were added because they give more information on tactics of violence experienced by women. Based on the definition of spousal violence provided by Garcia-Moreno and colleagues (2006), “the proportion of ever-partnered women who reported having experienced one or more acts of physical or sexual violence by a current or former partner at any point in their lives” (Garcia-Moreno et al., 2006, p. 1262), a woman’s report of experiencing at least one act of physical violence was coded as 1, and a report of experiencing no physical violence was coded as 0. Cronbach’s alpha for the physical violence items was .81 (Garcia-Moreno et al., 2006). In this study, the reported Cronbach’s alpha was .92.

Sexual violence was assessed by the question “Have you been physically forced to have sexual intercourse when you did not want to?” from the WHO study. Women’s responses to this question were either “yes” or ”no,” where a “yes” response indicated spousal sexual violence victimization.

Controlling behaviors, as a form of spousal violence, was defined as a husband’s power of being in command over the woman. The WHO Multi-country Study on Women’s Health and Domestic Violence Against Women presented the items of controlling behaviors (Garcia-Moreno et al., 2006). Controlling behaviors included items such as not allowing the woman to contact her natal family, not allowing her to see friends, and becoming angry if she spoke to a man. Items were rated as (once or twice, a few times, or many times). Positive and negative responses to the total score of this measure were coded as 1 and 0, respectively. Cronbach’s alpha for the controlling behaviors items was .73 (Garcia-Moreno et al., 2006).

Reasons behind lack of disclosing spousal violence were assessed by asking participants to report their agreement, or disagreement, to six possible reasons behind their decision of not disclosing violence. These reasons were (1) using patience with the spouse as a way to help him, gradually, quit spousal violence, (2) acceptance of spouse’s promises to stop future violence against the woman, (3) keeping the family unit intact, (4) fear of spouse, (5) financial dependence on the spouse, and (6) absence of another refuge to the woman and her family like a natal family. These reasons were categorized into two major categories based on the purpose behind their use by women. Reasons 1, 2, 3, and 4 were categorized as the “protection” factors because women mainly use them to protect self or family. Reasons 5 and 6 were categorized as the “lack” factors because they symbolize women’s lack of these attributes.

Reasons behind women’s decision of not disclosing violence were derived from reviewing related literature (Al-Badayneh, 2012; Al-Modallal, 2012a; Al-Nsour et al., 2009; Btoush & Haj-Yahia, 2008; Daniels, 2005; Douki et al., 2003; Haj-Yahia, 2000; Romans, Forte, Cohen, Du Mont, & Hyman, 2007; Stith, Smith, Penn, Ward, & Tritt, 2004; Valente, 2000). Furthermore, they were chosen because they were applicable to Jordanian women’s beliefs and attitudes toward marriage and marital relationships. Possible options to each reason were either “yes” or “no” on women’s agreement or disagreement to each reason, respectively. Cronbach’s alpha of these items in our study was .71.

Demographic variables hypothesized to have certain associations with women’s decision to disclose spousal violence were age greater than 40 years, presence of children, educational level higher than high school, pregnancy, employment, and place of residence. These variables were assessed by asking women to report whether each of these variables applies to them (coded as 1) or not (coded as 0).

The selected demographic variables were chosen because there were evidences from literature indicating the presence of certain relationships between them and women’s experiences of spousal violence. Some related literature indicated a negative relationship between women’s age and their exposure to physical violence (Carlson, McNutt, & Choi, 2003; Hazen, Connelly, Kelleher, Landsverk, & Barth, 2004; Kramer et al., 2004), and that higher educational levels protected women from spousal violence (Diaz-Olavarrieta, Ellertson, Paz, Ponce de Leon, & Alarcon-Segovia, 2002; Zink, Fisher, Regan, & Pabst, 2005). A positive relationship between women’s employment and experiences of spousal violence was reported as well (Brush, 2003).

Similar relationships were assumed to be present between spousal violence and the rest of the selected demographic characteristics. For instance, pregnant women are subject to spousal violence (Janssen et al., 2003; Kearney, Haggerty, Munro, & Hawkins, 2003). Pregnant women and women with children were expected to tolerate violence for the sake of staying with their children, and not leaving them especially if women’s financial resources are limited. As such, it was hypothesized that there were certain associations between these variables and women’s choice of either disclosing or not disclosing spousal violence.

Place of residence was another variable investigated in our participants. Each of the three Jordanian cities where the study took place has an urban region, a group of villages administratively related to the city, and one or two refugee camps. Women were asked to report the exact place of residence within the three Jordanian cities. Options to this question were urban region, village, or refugee camp.

Analysis

The first and second objectives of the study were analyzed using descriptive statistics. The third objective, that examined associations between reasons of lack of disclosure of violence and women’s demographic characteristics including type of violence they experienced, was examined using logistic regression. For this type of analysis to be implemented, each of the “exposure” variables (i.e., types of spousal violence and all demographic characteristics) and the “outcome” variables (i.e., reasons behind lack of disclosure) needed to be dichotomized. Results of logistic regression were presented using ORs associated with 95% CIs to evaluate significance of results.

Findings

The total number of women included in the study was 709. Their ages ranged between 16 and 66 years (M = 32.6, SD = 8.7). Except for “having children,” there were significant differences in most demographic characteristics of the participants based on type of health care center they visited (MOH or UNRWA health care centers). See Table 1 for more details. Regarding their experience of spousal violence, controlling behaviors by the spouse were the most frequently reported type of spousal violence (71.1%), followed by physical violence (54.9%), and sexual violence (25.0%). Most women experienced more than one type of spousal violence. For example, women who experienced physical violence and control behaviors constituted 41.5% (n = 294) of the victimized women. See Table 2 for more details on frequencies of women’s experiences of different combinations of spousal violence.

Table 1.

Differences in Demographic Characteristics of Participants Based on Type of Health Care Center.

Characteristic	Frequency (n)	%	χ² Value	p Value
Age			168	.0001
≤20 years	40	5.6
21-30 years	266	37.5
31-40 years	258	36.4
41-50 years	102	14.4
≥51 years	19	2.7
Missing	24	3.4
Children in the home			52.9	.97
No children	62	8.7
1-3 children	351	49.5
≥4 children	288	40.6
Missing	8	1.2
Education			134.6	<.0001
≤ 6th grade	34	4.8
7th-11th grade	130	18.3
High school	132	18.6
> High school	406	57.2
Missing	7	1.0
Pregnancy			9.7	.002
Yes	107	15.1
No	591	83.4
Missing	11	1.5
Joins the workforce			108.6	<.0001
Yes	127	17.9
No	575	81.1
Missing	7	1.0
Health insured			63.06	<.0001
Yes	382	53.9
No	324	45.7
Missing	3	0.4
City			634	<.0001
Amman	219	30.9
Irbid	222	31.3
Zarqa	213	30.0
Missing	55	7.8

Note. Type of health care centers includes Ministry of Health (MOH) and the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) health care centers.

Table 2.

Women’s Experiences of Spousal Violence.

Type of Violence	Frequency (n)	%
Physical violence	365	54.9
Sexual violence	174	25.0
Control violence	488	71.1
Physical and sexual violence	118	16.6
Physical violence and control	294	41.5
Sexual violence and control	144	20.3
Physical violence, sexual violence, and control	98	13.8

Women agreed with the six proposed reasons of not disclosing spousal violence. However, the reason concerning their desire to keep the family unit intact was the most frequently reported reason (n = 471, 66.8%). The second most common reason reported for not disclosing spousal violence was women’s use of patience as a way to help the husband quit spousal violence (n = 253, 35.8%). See Table 3 for women’s reasons of not disclosing spousal violence and keeping it confined to oneself.

Table 3.

Reasons Behind Women’s Decision for Not Disclosing Spousal Violence.

Reason of Not Disclosing Violence	Frequency (n)	%
Keeps the family unit intact	471	66.8
Uses patience as a means to help spouse quit violence	253	35.8
No shelter for self and family	143	20.3
Financial dependence on the spouse	132	18.7
Accepts spouse’s promises to quit future violence	100	14.2
Fears the spouse	96	13.6

Women’s decision of not disclosing spousal violence was generally not related to type of violence they experienced, whether it was physical violence, sexual violence, or controlling behaviors by the spouse (see Table 4). As seen in Table 5, except for “keeping the family unit intact,” which was a factor associated with two of women’s demographic characteristics, women’s reasons of not disclosing spousal violence were not related to characteristics of the participants presented in the study.

Table 4.

Relationship (Odds Ratios) Between Reasons of Not Disclosing Violence and Type of Spousal Violence.

Reporting “Yes”; n (%)	Physical Violence	Sexual Violence	Control Behavior
Uses patience as a means to help spouse quit violence	121 (33.2)	58 (33.5)	177 (36.5)
Uses patience as a means to help spouse quit violence	OR = 0.07	OR = 0.87	OR = 1.12
Accepts spouse’s promises to quit future violence	52 (14.2)	25 (14.5)	72 (14.8)
Accepts spouse’s promises to quit future violence	OR = 1.04	OR = 1.03	OR = 1.20
Keeps the family unit intact	247 (67.7)	108 (62.4)	320 (65.8)
Keeps the family unit intact	OR = 1.05	OR = 0.77	OR = 0.87
Fears the spouse	57 (15.6)	15 (14.5)	72 (14.8)
Fears the spouse	OR = 1.50	OR = 1.12	OR = 1.54
Financial dependence on the spouse	66 (18.1)	31 (17.9)	94 (19.3)
Financial dependence on the spouse	OR = 0.90	OR = 0.92	OR = 1.04
No shelter for self and family	80 (21.9)	45 (26.0)	98 (20.2)
No shelter for self and family	OR = 0.80	OR = 1.57^a	OR = 0.93

Note. CI = confidence interval.

95% CI = [1.05, 2.36] (significant).

Table 5.

Odds Ratios Associated With Women’s Decision of Not Disclosing Spousal Violence (N = 709).

	Reasons of Not Disclosing Spousal Violence
	Uses patience as a means to help spouse quit violence	Accepts spouse’s promises to quit future violence	Keeps the family unit intact	Fears the spouse	Financial dependence on the spouse	No shelter for self and family
	OR	OR	OR	OR	OR	OR
Characteristics	[95% CI]	[95% CI]	[95% CI]	[95% CI]	[95% CI]	[95% CI]
Age <40 years
Yes	0.69	0.89	1.30	1.41	1.41	1.11
No	[0.44, 1.07]	[0.50, 1.58]	[0.82, 2.07]	[0.81, 2.43]	[0.86, 2.30]	[0.68, 1.81]
Children
Yes	0.65	0.75	1.64	1.08	0.87	1.82
No	[0.38, 1.10]	[0.38, 1.50]	[0.97, 2.78]	[0.50, 2.35]	[0.46, 1.65]	[0.84, 3.91]
≥ High school
Yes	1.17	1.08	1.81^a	1.66	1.20	1.27
No	[0.78, 1.74]	[0.63, 1.85]	[1.16, 2.81]	[0.97, 2.84]	[0.74, 1.93]	[0.80, 2.03]
Pregnancy
Yes	0.81	0.82	1.56	0.57	0.85	0.69
No	[0.52, 1.25]	[0.43, 1.55]	[0.98, 2.50]	[0.27, 1.21]	[0.49, 1.49]	[0.39, 1.23]
Employed
Yes	0.83	1.55	1.49	1.29	1.51	1.70
No	[0.51, 1.34]	[0.85, 2.82]	[0.86, 2.58]	[0.70, 2.37]	[0.87, 2.61]	[0.99, 2.87]
Urban region
Yes	1.17	0.90	1.62^a	0.80	0.77	0.76
No	[0.82, 1.68]	[0.56, 1.45]	[1.13, 2.31]	[0.48, 1.30]	[0.50, 1.17]	[0.50, 1.14]
Health insurance
Yes	1.14	1.55	1.31	1.03	0.82	0.85
No	[0.81, 1.60]	[0.96, 2.51]	[0.93, 1.85]	[0.63, 1.68]	[0.54, 1.25]	[0.56, 1.28]

Note. CI = confidence interval.

Significant odds ratios.

Discussion

Prevalence rates of different types of spousal violence were relatively high in our sample. Others have reported that nearly half of the participants were victims of spousal violence (Al-Modallal, Abuidhail, Sowan, & Al-Rawashdeh, 2010), and their prevalence rate was similar to the violence prevalence rates reported in the current study. Although the current study was a descriptive study recruiting non-probability sample of women, the assumption associated with presence of spousal violence among different groups of women in Jordan is supported. This is because cross-sectional designs involve the collection of data representing one phenomenon at one time during the data collection period (Polit & Beck, 2012). Clarification of this assumption stems from the congruency in the results despite the variation of women’s characteristics in the current study and in the previously mentioned study among Jordanian women. For instance, socioeconomic indicators in the current study showed that more than 90% of the women had children and were financially dependent on the spouses, and only 17.9% were employed at the time of data collection. Furthermore, 41.7% had high school education or less. On the contrary, in Al-Modallal and colleagues’ study (2010), all the participants were working women, 43% of them reported fairly high monthly income, and 80% earned college and graduate degrees. Similarity of results despite the wide variation of women’s demographic characteristics in both studies was a good indicator of women’s vulnerability to violence from the spouse in Jordan.

Women reported different reasons for not disclosing spousal violence outside the family. However, their main focus was the family as 66.8% of them indicated that they do not disclose spousal violence to people outside the family for the reason of keeping the family unit intact. Keeping family issues and problems confined to family members is a very important aspect in the marital relationship. Spousal violence is considered as a family issue that should not be communicated or disseminated to others outside the family.

One interesting finding was that women use patience as a means of helping the spouse to quit violence (i.e., with the hope that patience will help the spouse to quit violence). This reason was reported by 35.8% of the participants. Use of patience is emphasized in people’s, including women’s, beliefs (Douki et al., 2003; Haj-Yahia, 2000). Women’s use of this strategy has two explanations. The first one is that women using this strategy do not use it because they accept being victimized, but rather because they believe that the problem of spousal violence will eventually end. Some women who experience violence believe that the husband will quit using violence against them in the future when he gets older, when he learns how to better deal with his wife, or when the children (if any) grow up. Women see such reasons as protective factors against their exposure to spousal violence. As such, some of the abused women tend to consider the period of violence as “a temporary period” that will come to an end one day and therefore use patience with violence experiences.

The second explanation is that women use patience as a means of ending violence because they fear the spouse or specifically they fear of future abuse from the spouse (Renker, 2006; Stith et al., 2004). Experiencing violence by itself increases women’s fearful attitudes (Forte, Cohen, Du Mont, Hyman, & Romans, 2005). Furthermore, women’s acknowledgment of power and control of the spouse (Renker, 2006) magnifies the “fear” factor in their lives. Fear of the spouse or fear of future abuse from the spouse had profound effect on women’s health especially mental health in terms of, for example, exhibiting severe depressive symptoms (Csoboth, Birkas, & Purebl, 2005).

The use of patience as a means of helping the spouse to quit violence (i.e., with the hope that patience will help the spouse to quit violence) has something to do with the spouse’s age and length of marriage. A brief reflection on this can be added. In a systematic literature review work of 35 studies, authors found that as women get older, their chance of being victimized by the spouses lessens (Al-Modallal, Peden, & Anderson, 2008). In Jordan, the mean age of marriage among females is 25.8 (Department of Statistics, 2014), and data from our study revealed that 74% of our participants were between the ages of 20 and 40. This means that our participants have been married for an average of 10 to 12 years. Our findings showed that 85 (12.3%) woman experienced spousal violence over 1 to 5 years of marriage and 27 (3.9%) woman experienced violence over 6 to 10 years of marriage. Connecting this information with the finding from Al-Modallal and colleagues’ study (2008), we can find justification for women’s use of patience as a means of helping the spouse to quit violence.

Lack of shelter for women and their families constituted the third most common reason for women’s decision of not disclosing spousal violence. Women who experience violence mainly seek shelter from the natal family (or family of origin). Some women who experience violence may not literally have a natal family, and this situation constituted a legitimate reason for them to stay in the marital relationship. Others who have a natal family are, sometimes, convinced to stay in the abusive marital relationship to avoid social stigma associated with leaving the marital relationship (Al-Badayneh, 2012). Furthermore, even if the abused women have a family, they may receive lower psychological support from family compared with those not abused (Al-Modallal, 2012a). Reasons for this lack of support included issues of obedience to the husband, belief in the husband’s right to discipline his wife (Al-Modallal, 2012a), and the woman’s feeling of being the reason for the husband’s use of violence (Btoush & Haj-Yahia, 2008). For these reasons, women may have stated that absence of a refuge to them in cases of violence is a reason for not disclosing spousal violence.

For the relationship between women’s decision to not disclose violence and type of violence on one side and their demographic characteristic on the other side, the findings implied that women’s decision to not disclose violence is a general attitude in Jordanian women, and does not differ based on demographic characteristics or type of violence they were exposed to. Several reasons play a role in women’s general attitude of not disclosing violence regardless of their demographic characteristics. One of these reasons is women’s justification of spousal violence (Al-Nsour et al., 2009; Boy & Kulczycki, 2008; Khawaja et al., 2008). In one study, 61.8% of the women indicated that spousal violence against them is acceptable in some situations such as in cases of disobedience to the husband (Khawaja et al., 2008).

A second reason behind women’s decision of not disclosing violence is the possibility of being raised in a family where violence was experienced against the mother (i.e., the woman had witnessed parental violence in childhood). Witnessing parental violence is a risk factor for spousal violence (Bensley, Van Eenwyk, & Wynkoop Simmons, 2003). Being raised in a family where violence was experienced against the mother may affect beliefs about spousal violence. Women may believe that violence within the marital relationship is an expected part of the relationship (Noland, Liller, McDermott, Coulter, & Seraphine, 2004). This understanding makes them more likely to consider spousal violence as a personal and private experience that should not be communicated with others. Furthermore, handling violence by disclosing it to others is a learned experience. When women, as children, witness violence and do not witness their mothers disclosing it because of their belief that violence is a private matter that should not be communicated, they, in turn, do not choose to disclose it when becoming victims of violence.

Despite what we found concerning disclosure of spousal violence, the influence of some emerging issues in this regard is likely to affect women’s attitudes toward disclosing spousal violence. The status of women in Jordan is going through radical transition in political, civilian, and educational aspects. For example, several legislative decrees have been established and activated to protect and serve women in cases of exposure to spousal violence. Furthermore, awareness agenda against spousal violence have been activated through different media resources (Al-Modallal et al., 2010). These factors may change cultural forces and eventually reform women’s attitudes and enhance the likelihood to disclose violence to health care workers. Still, reform of women’s attitudes toward disclosure of spousal violence requires years to occur after the implementation and activation of political and civilian laws and legislations.

Implications

In light of what have been mentioned, contributions of policy makers, health care professionals, and researchers should be activated. Policy makers should have a role in issuing and activating legislative decrees that warrant women’s right of safe living and serve them in cases of violence victimization.

Health professionals need to be equipped with necessary knowledge and skills to assess and intervene with women experiencing violence. Evidence-based knowledge and skills is required. Still, these qualities won’t be attained without adequate training. Proper collaboration between men, women, and health professionals aids in protecting victims from suffering health-related outcomes associated with violence. Furthermore, regular assessment of women, in terms of violence victimization and possible health outcomes, needs to be implemented on regular basis when dealing with women.

Researchers should identify major obstacles preventing women from disclosing violence. They can cooperate with health care workers in designing and implementing assessment tools that ease identifying abused women. They also can create physical and emotional environment that urges women to disclose violence. Finally, they can cooperate in implementing health education programs that focus on violence prevention.

Programs of violence prevention should be directed to men and women. Such prevention programs may include stress and anger management, problem solving skills and qualities, and coping with changes in roles. Violence prevention programs can be offered through lectures, discussion sessions, and workshops. Health professionals and social workers are able to provide such services to men and women in the places where they can be located. Such places may include schools (especially high schools), workplaces, and community settings.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Hashemite University–Jordan (Grant 29/15/8162).

Author Biography

Hanan Al-Modallal received her PhD from the University of Kentucky, USA. She is an associate professor working in the Department of Community and Mental Health Nursing at the Hashemite University, Zarqa-Jordan. She has continued her research with women who have experienced intimate partner violence with a focus on refugee populations and college women and on abused women’s vulnerability to mental health problems.

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