Stress Management and Health Promotion in a Sample of Women With Intimate Partner Violence: A Randomized Controlled Trial

Abstract

The aim of the present study was to investigate the effectiveness of a stress management program regarding mitigating psychological repercussions in women who experience intimate partner violence (IPV). This randomized controlled trial took place from January 2015 to June 2015, in Attica, Greece. A total of 60 women were randomly assigned into an intervention and control group, with the intervention group (n = 30) receiving stress management and a lifestyle program. Self-reported measures were used to assess stress, depression and anxiety levels, daily routine, severity of abuse, self-esteem, health locus of control, and self-efficacy. Statistical analysis showed a significant improvement in measures of stress, depression, anxiety, self-esteem, and self-efficacy in the intervention group. Daily routine and physical exercise also improved. Based on these findings, we strongly encourage health professionals to advise women experiencing current and past IPV to adopt stress management techniques to their daily program, as a further means of empowerment.

Keywords

stress stress management IPV self-esteem depression anxiety

Introduction

Intimate partner violence (IPV) is defined as physical, psychological, sexual, verbal, emotional, spiritual, financial, and social assault from the partner. This may be a single incident or have a repeated nature (Flury, Nyberg, & Riecher-Rössler, 2010; García-Moreno, Jansen, Ellsberg, Heise & Watts, 2005; Spinellis, 1997). According to a survey, usually female victims of violence manifest low levels of self-esteem, questioning and undermining their abilities and achievements (Artinopoulou & Farsedakis, 2003).

In addition, the majority of these women often believe in certain myths that exist regarding domestic violence such as (a) middle class women usually are not victims of violence compared with low socioeconomic status (SES) women, (b) minority women are more susceptible to IPV, (c) women who experience IPV are not educated and/or have vocational abilities, (d) violent partners are violent throughout all their social relationships, (e) violent partners are not usually successful in their vocational life, (f) women survivors of violence will always be treated as such, (g) long-lasting violent relationships can change for the better, and (h) IPV women deserve being assaulted and treated violently (Artinopoulou & Farsedakis, 2003; Walker, L., “Battered Woman”Athens, 1989).

Regarding epidemiology in most countries, IPV is now a major public health concern, regardless of cultural differences that depict gender inequalities (Dahlberg & Mercy, 2009). According to a survey of 35 countries, 10% to 52% of the women from the sample stated being physically abused by their husband/partner, whereas 10% to 30% reported being sexually abused (García-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). The European Women’s Lobby designates that domestic violence is the most prevalent form of female abuse (European Women’s Lobby, 1999). Another survey which was conducted in Greece (N = 1,200) regarding IPV indicates that 58% of the women who participated (ages 18-68) reported being verbally and emotionally abused. Only 3.6% stated being battered and 3.5% were forced to have sexual intercourse (Artinopoulou & Farsedakis, 2003).

In addition, there are many indications which reveal the adverse effects that IPV has on women’s health. According to current literature, IPV induces serious repercussions on women’s physical and psychological health (Ruiz-Pérez, Plazaola-Castaño, & del Río-Lozano, 2007). Women can suffer from musculoskeletal and chronic pain, neurological and cardiovascular diseases, asthma, sexually transmitted diseases (e.g., AIDS), irritable bowel syndrome, suicidal ideation, eating disorders, substance abuse, sleep disturbances, and so on (Akyuz, Seven, Şahiner, & Bilal, 2013; Ruiz-Pérez et al., 2007).

Other studies show that female violent survivors manifest a severely impaired daily function (e.g., difficulties in movement, disability, and so on; (Ellsberg, Jansen, Heise, Watts, & García-Moreno, 2008). Also, during pregnancy, they are more likely to have a miscarriage or give birth prematurely; suffer from irregular vaginal bleeding, dysmenorrhea, and pelvic inflammatory disease; and/or have increased vaginal secretions (Akyuz et al., 2013; Devries et al., 2010). It is noteworthy that IPV is responsible for the attenuation of the immune system, as well as the emergence of stress, anxiety, and depressive symptomatology (Chandra, Satyanarayana, & Carey, 2009; Coker, Smith, Bethea, King, & McKeown, 2000; Hathaway et al., 2000).

In addition, IPV also affects the psychological health of women victims. The relationship between stress and IPV is affected by age, comorbidity (e.g., depression), level or education, and women’s income (Salehi Fadardi, 2009; Savas & Agridag, 2010). Current literature states that the severity of domestic violence seems to interact with and/or predict depressive symptomatology and post-traumatic stress disorder (PTSD; Hughes, Cangiano, & Hopper, 2011; Woods, Hall, Campbell, & Angott, 2008).

More specifically, individuals appraise life events as stressful or not (Chrousos, 2009; Lazarus & Folkman, 1984), which is related to survival, well-being, and everyday function. Aberrant stress is incriminated for the emergence and/or relapse of physical and mental health diseases (Chrousos & Gold, 1992). There is mounting evidence stating that psychological distress interacts with IPV, resulting in negative affect and self-evaluations, lack of personal and social skills, low self-esteem, depression, and morbidity (Aguilar & Nightingale, 1994; Johnson, Zlotnick, & Perez, 2008). According to women victims of violence, self-reported stressors that affected frequency and duration of abuse were financial difficulties, substance abuse, unemployment or vocational uncertainty, children conduct disorders, and mental health of the partner (Krishnan, Hilbert, & McNeil, 2001). In a recent meta-analysis regarding mental health of women who experience IPV, results show that stress is evident in 84% and depression in 69% of the sample (Golding, 1999). Furthermore, PTSD appears to be the most prevalent form of aberrant stress response to IPV. PTSD symptoms (e.g., sleep disturbances, anxiety, etc.) may appear long after the abuse itself (Kemp, Rawlings, & Green, 1991; Logan, Walker, Jordan, & Leukefeld, 2006; Partner, 2014; Street & Arias, 2001; Sullivan & Holt, 2008). Although PTSD is an important health problem affecting these women, IPV has diverse repercussions on their mental health still, demanding comprehensive palliative interventions.

Also, chronic distress affects the lifestyle, of these women of violence. They are more prone to smoking, alcohol consumption, unhealthy dietary habits, lack of physical exercise, and so on. These behaviors emanate from the effort to cope with the stress of IPV, resulting in being dysfunctional and in the emergence of physical and mental health problems (Pelletier, Lytle, & Laska, 2016).

According to literature, effective approaches for prevention and management of IPV-related PTSD are cognitive behavioral therapy (CBT), psycho-education, stress management techniques (e.g., relaxation breathing [RB]), training for increasing self-esteem, and problem solving (Crespo & Arinero, 2010; Kim, Schneider, Kravitz, Mermier, & Burge, 2013; Leisring, 2013). CBT appears to be the most widely implemented therapeutic approach in treating PTSD among women who experience IPV and specifically in mitigating anxiety, psychosomatic disorders, bulimia, anger management, and stress (Eckhardt et al., 2013; Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Stress management interventions have been found effective in improving stress levels and its psychosocial repercussions. There is an abundance of studies reporting the importance of anger and stress management techniques in primary and secondary prevention of violence (Leisring, 2013). Mind-body interventions such as yoga, tai-chi, meditation, and RB seem to gain ground in a rating stress, depressive and PTSD symptomatology, self-esteem and anger, as well as increasing energy levels, pain resistance, and relaxation response in female survivors of violence (Crespo & Arinero, 2010). An Randomized Controlled Trial (RCT) implementing mindfulness techniques in low income African American women, victims of IPV for mitigating levels of PTSD, had promising results (Dutton, Bermudez, Matas, Majid, & Myers, 2013). Another study fostering RB and progressive muscular relaxation (PMR) training during an 8-week period in women victims of violence has been shown to be effective in improving sleep quality and quantity, health locus of control (HLC), depression, and stress coping mechanisms (Michalopoulou, E., Tzamalouka, G., Chrousos, G.P., & Darviri, C., 2015).

The aim of the present study was to investigate the effect of a stress management and health promotion program on women who experience IPV. Particular focus on stress, HLC, depression, and lifestyle was made.

Method

Trial Design

This was a two-armed, parallel group, randomized controlled study with a 1:1 allocation ratio of female violence survivor to intervention and control group with an 8-week follow-up period. After the initiation of the trial, no change of the initial protocol took place.

Participants and Procedure

This study was conducted with the aid of the General Secretary of gender equity, after approval from the ethics committee, from January 2015 to June 2015. During recruitment period, leaflets were available for women to be informed and volunteer in participating in this trial. Permission was given from the General Secretary for Gender Equality. Also, there was a written approval from the municipality of Lavrion, which is a small town located near to Athens. The individuals were verbally informed regarding the aim of the program. Verbal permission was given from non-governmental organization W.I.N. HELLAS (her headquarters is in Athens), EKKA (National Center for Social Solidarity), and Children’s Pediatric Hospital “Agia Sophia.” In all settings were given leaflets, referred to the purpose of the study, the program of stress management and information in order to contact with us for any question. Participants were fully informed about the aim of the study and provided their written consent. Eligible women were randomly allocated in intervention and control group, using the random number generator (random.org). The trial complied fully with the Declaration of Helsinki guidelines. The intervention group underwent a stress management program, comprising of 8 weekly sessions, whereas the control group did not receive any intervention. All eligible women were provided with a consent form which they had to sign to participate in this study. The study was approved by and complied fully with the Declaration of Helsinki.

A total of 60 women participated in the stress management program, 30 were allocated randomly in an intervention group and 30 in a control group control. Inclusion criteria for entering the study were (a) currently being victims of physical, psychological, sexual, or combined abuse (present and past); b) age between 18 and 70; and (c) literate in Greek. Exclusion criteria were (a) substance abuse (as ascertained by the available official medical records), (b) use of tricyclic antidepressants or diagnosis with any major psychiatric disorder, and (c) being under cortisone treatment for any reason. These criteria were necessary in an attempt to avoid being bias. All women were assessed using self-reported questionnaires pre- and post-intervention by A.K. and M.M. researchers. The study was not blind. No drop-out was recorded in either group.

Intervention

Both study groups were informed identically about the purpose of the current study as well as about stress and healthy lifestyle. The intervention group participated in a stress management and health promotion program for 1 hr per week for 8 weeks. The interventions were conducted at the university establishments such as at the establishments of specialized centers. In the first session, the initial assessment took place: Questionnaires were distributed and completed, and the participants were given all the necessary information about the program structure. During this session, an informative lecture on stress, lifestyle, HLC, and physical exercise was given. Women were also provided with details on where current literature was available and were, given a practical guide and a pedometer to monitor their progress. During the second session, women were trained in Biofeedback assisted abdominal breathing (using the Nexus® system). This is a interactive computer software system guiding the individual to practice abdominal breathing through continuing monitoring of both his or her heart rate and blood pressure. They were encouraged to implement RB twice per day (morning and evening). In the third session, the intervention group was introduced to another stress management technique, PMR. Training was performed with the aid of a CD under the presence of the researchers. Women were also advised to implement PMR twice a day. During the next session, the intervention group was introduced to cognitive reconstruction and gratitude techniques. Besides information, women were provided with specific exercises (e.g., positive aspects of themselves). The next session included dietary counseling and encouragement to comply with the stress management program. The sixth session was about training and implementation of guided imagery. Instructions were given via CD in the presence of the researchers. The forthcoming session goal was to discuss the progress as perceived by each participant regarding the relaxation techniques, to encourage compliance, and to solve possible questions. During the last session, participants completed the final measurements and returned their progress notes, where they recorded their physical activity (pedometer indications) and frequency of implementing the taught relaxation techniques (maximum 112). All of the women were given the opportunity to evaluate the program and their experience. At the end of the intervention, the control group was provided with all the Compact Disks (CDs) of the relaxation techniques.

Measures

Socio-demographic, health indices, daily routine, and quality of life variables

These variables included age, gender, marital status, education level, smoking, income satisfaction, caregiving (assessed by the question: “Are you currently responsible for the daily needs of people with disability,” answer: yes/no), daily routine, dietary choices, physical exercise, and so on (Darviri et al., 2014).

Depression, Anxiety, and Stress Scale (DASS-21)

The DASS-21 measurement consists of three subscales: Depression, Anxiety, and Stress (Lovibond & Lovibond, 1995). There are seven statements in each subscale which the individuals are asked to answer using a 5-point Likert-type scale (0 = it does not apply to me at all, 5 = it applies to me most of the times). Each subscale is scored by adding up all relevant questions and multiplying the total by 2. The score may indicate the severity of symptomatology, thus the greater the symptoms of depression, anxiety and stress are severer. This scale has been translated and validated for the Greek population with good psychometric properties (Lyrakos, Arvaniti, Smyrnioti, & Kostopanagiotou, 2011). The Cronbach’s α coefficient was for depression, .920 (initial) and .893 (final); for anxiety, .888 (initial) and .849 (final); and for stress, .884 (initial) and .857 (final).

Perceived Stress Scale 14 (PSS-14)

The PSS-14 Scale is a self-reported measurement, which assesses to what degree everyday situations are evaluated as stressful (Cohen, Kamarck, & Mermelstein, 1983). Frequency of feelings and thoughts is assessed for the previous month on a 5-point Likert-type scale (from 0 = never to 4 = very often). There are seven positive and seven negative items and the total score derives from adding all questions after reversing all positive elements. Scoring is from 0 to 56, with higher values indicating that the person had experienced high levels of perceived stress over the previous month. The questionnaire was validated in Greek and had good psychometric properties—Cronbach’s α .802 (initial) and .783 (final; Andreou et al., 2011).

Personal interview

At the end of the 8-week follow-up for detecting any major stressors (e.g., loss of an offspring), the Social Readjustment Scale was administered (Holmes & Rahe, 1967).

HLC

The questionnaire consists of 18 statements (Wallston, Wallston, & DeVellis, 1978). Each individual is asked to evaluate to what extent he or she agrees with each of these statements based on a 6-point Likert-type scale, where 1 represents total disagreement and 6 strong agreement. HLC consists of three subscales: “internal HLC” (HLC1), “external HLC” (HLC2), and “chance HLC” (HLC3). The HLC1 measures the degree to which an individual feels responsible for his or her health. The HLC2 measures the degree to which a person believes that other people are responsible for his or her health. Finally, theHLC3 represents the extent to which a person feels that chance determines his or her health. Score is calculated by summing up the responses for each subscale. Possible scores range from 6 to 36 points. Higher scores indicate higher “prevalence” of each type of faith for health. The instrument has been validated for the Greek population (Karademas, 2009).The internal validity for each subscale was found to be satisfactory for both the initial and final measurements—Cronbach’s α: Internal HLC, .685 (initial) and .670 (final); Chance, .776 (initial), .745 (final); and External HLC, .680 (initial), .639 (final).

Self-esteem

Self-esteem was assessed with the Darviri and Varvogli “Self-Esteem Assessment Questionnaire.” This self-reported measurement, which is in the process of being validated in a Greek population, comprises 59 questions, which focus on six fundamental fields that affect the way each individual sees himself or herself and how these perceptions influence his or her behavior. All statements are based on a 5-point Likert-type scale and assess the extent of agreement for each question—Cronbach’s α: .952 (initial) and .935 (final).

Spiritual Well-Being Scale

This scale consists of 20 statements and the participant is asked to express the degree of his or her agreement to each in a 6-point Likert-type scale (Paloutzian & Ellison, 1982). Possible answers range from “I agree” to “I strongly disagree.” Good psychometric properties have been recorded in the Greek population (Darvyri et al., 2014). The Cronbach’s α coefficient was, for the Spiritual subscale: .877 (initial), .865 (final); for the Religious subscale: .910 (initial), .901 (final); and for the Existential subscale: .751 (initial) and .680 (final).

Women Abuse Screening Tool (WAST)

This measurement assesses physical and emotional abuse of women in their family. It comprises of eight short questions, with three possible answers depending on the frequency and severity of the abuse. The first three statements aim to verify the existence of IPV, while the goal of the next five statements is to depict which form of abuse is placed upon the woman. This instrument appears to have good psychometric properties—Cronbach’s α: .809 (initial) and .752 (final; WAST; Vivilaki et al., 2010).

Self-Efficacy Scale

This self-reported measurement assesses the perception of each individual regarding his or her abilities to work through demanding situations and overcome everyday barriers (Schwarzer & Jerusalem, 1995). It is based on a 4-point Likert-type scale, ranging from 1 (not true at all) to 4 (very true). The total score is calculated by summing up all the statements. This instrument appears to have good psychometric properties in the Greek population—Cronbach’s α: .884 (initial) and .839 (final; Glynou, Schwarzer, & Jerusalem, 1994).

Coping Orientation to Problems Experienced (COPE)

Coping strategies are usually understood as ways of managing with stress and/or as mechanisms which an individual possesses and uses to successfully overcome external or internal demands that exceed one’s abilities. This measurement has been designed to evaluate the process of managing stress as well as the individual differences, while shedding light to coping strategies that function both as permanent assets of one’s personality and as reactions to specific stimuli (disposition vs. situation issue; Carver, Scheier, & Weintraub, 1989). This scale consists of 60 statements. Every person is asked to choose the extent to which he or she uses 15 coping strategies. These 15 subscales are divided into (a) strategies that aim to solve a problem (taking measures [CP1], designing [CP2], postponing other activities [CP3], self-restraint [CP4], social support-information seeking [CP5]) and (b) emotion regulation strategies (social-emotional support [CP6], positive reappraisal [CP7], acceptance [CP8], turning to religion [CP9], emotional relief [CP10], denial [CP11], relinquishment [CP12], mental disengagement [CP13], substance abuse [CP14], humor [CP15]). The Greek version comprises of 52 statements, and the subscales CP9, CP13, CP14, and CP15 are assessed with two and not four questions. The short form of this scale consists of 30 statements and is based on a 4-point Likert-type scale. Total score derives from summing up the scores of these four questions pertaining to each subscale. In the CP1 subscale are the following questions: 4, 23, 42, 52; the CP2 has questions 17, 29,35, 49; the CP3 has questions 14, 30, 38, 48; the CP4 has questions 9, 20, 37,44; the CP5 has questions 3, 13, 28, 40; the CP6 has questions 10, 21, 31, 46; the CP7 has questions 1, 27, 34, 52; the CP8 has questions 12, 19, 39, 47; CP9 has questions 7 and 43; the CP10 has questions 3, 16, 26, 41; the CP11 has questions, 5, 25, 36, 50; the CP12 has questions 8, 22, 33, 45; the CP13 has questions 2 and 15; the CP14 subscale has questions 11 and 24; and the CP15 has questions 18 and 32. This scale appears to have good psychometric properties—Cronbach’s α: .50 to .96, while only two subscales (denial and mental disengagement) have internal validity below .60 (Roussis, Triliva, & Kioseoglou, 2002).

Beck Depression Inventory (BDI)

This is a self-report measurement which consists of 21 themes with a purpose to record neurological and cognitive depressive symptoms. It is suitable for assessing depression in adults as well as adolescents (ages 13 and above; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Each theme is designed to correlate to a specific depressive symptom and comprises four self-evaluative statements. These statements express the severity of each symptom in a 4-point Likert-type scale (0 = complete absence of any symptom to 3 = severe depressive symptomatology). Subjects are asked to evaluate their mood for the past 4 weeks and the total score derives from summing up all statements (possible range 0-63). BDI appears to have good psychometric properties in the Greek population (Cronbach’s α: .84; Tzemos, 1991).

Participants’ evaluation

Each participant was asked to express the degree to which this intervention was satisfactory to them. They completed a “Study Satisfaction Scale” ranging from 0 (not satisfactory) to 10 (very satisfactory).

Statistical Methods

Demographics and baseline group characteristics are presented as means, standard deviation, and absolute and proportion values. Group comparisons were performed with Pearson’s chi-square and the Mann–Whitney U tests (Tables 1 to 3). We used the mean changes, calculating post-intervention minus baseline assessment, in PSS-14, HLC, the Healthy Lifestyle and Personal Control Questionnaire (HLPCQ), BDI, Daily Routine, Social Support, Spiritual Well-being, Self-Esteem, and COPE. The p value of significance for all analyses was .05. Effect size was calculated from the following formula r = Z/n^0.5, where 0.1 depicts a small effect size, 0.3 a medium effect size, and 0.5 a large effect size. For the statistical analysis, we used the SPSS software for Windows 21 (SPSS Inc., Chicago, IL).

Table 1.

Baseline Characteristics.

	Intervention Group (N = 30)	Control Group (N = 30)	p Value
Mean age ± SD	47.23 ± 9.96	48.77 ± 8.90	.532
Mean weight ± SD	68.1 ± 12.8	70.6 ± 12.1	.450
Mean height ± SD	161.9 ± 6.01	163.6 ± 5.6	.265
Family status N (%)			.854
Single	4 (13.3%)	3 (10%)
Married	18 (60%)	20 (66.7%)
Divorced	8 (26.7%)	7 (23.3%)
Current status n (%)			.210
Cohabitating	21 (70%)	26 (86.7%)
Living alone	9 (30%)	4 (13.3%)
Caregiver n (%)			.011
Yes	0 (0.0%)	7 (23.3%)
No	30 (100%)	23 (76.7%)
Educational status n (%)			.469
Elementary	3 (10%)	0
High school	15 (50%)	18 (60%)
Technological high school	6 (20%)	7 (23.3%)
College/university	6 (20%)	5 (16.7%)
Working status n (%)			.025
Unemployed	14 (46.7%)	7 (23.3%)
Full time	6 (20%)	16 (53.3)
Part time	10 (33.3%)	7 (23.3%)
Income satisfaction n (%)			.024
None	12 (40%)	3 (10%)
Slightly	6 (20%)	5 (16.7%)
Modest	12 (40%)	14 (46.7%)
Extreme	0	4 (13.3%)
Family income satisfaction n (%)			.064
None	7 (23.3%)	1 (3.3%)
Slightly	8 (26.7%)	9 (30%)
Modest	14 (46.7%)	15 (50%)
Extreme	1 (3.3%)	5 (16.7%)
Smoking status n (%)			.965
Smoker	12 (40%)	11(36.7%)
Non-smoker	17 (56.7%)	18 (60%)
Ex-smoker	1 (3.3%)	1 (3.3%)
Health status n (%)			.466
Poor	0	1(3.3%)
Modest	7 (23.3%)	5 (16.7%)
Good	20 (66.7%)	17 (56.7%)
Very good	3 (10%)	6 (20%)
Excellent		1 (3.3%)

Note. Chi-square statistics were used for categorical data and for numerical, we have used the non-parametric tests of Mann–Whitney.

p < .05.

Table 2.

Baseline Measurements.

	Intervention Group (N = 30)	Control Group (N = 30)	p Value
Mean perceived stress ± SD	32.4 ± 7.9	31 ± 5.6	.5
Mean self-esteem ± SD	174.6 ± 34	191.8 ± 27.9	.06
Mean dietary choices ± SD	14.7 ± 2.5	15.3 ± 3.2	.5
Mean avoidance of dietary harm choices ± SD	9.2 ± 2.2	10.3 ± 2.7	.1
Mean daily routine ± SD	18.8 ± 3.9	16.9 ± 5.2	.08
Mean physical exercise ± SD	4.2 ± 1.7	3.9 ± 2	.4
Mean social support and emotional control ± SD	10.4 ± 2.5	12.2 ± 3.2	.04*
Mean healthy lifestyle and personal control ± SD	57.4 ± 9.3	58.6 ± 11.6	.8
Mean internal locus of Control ± SD	28.2 ± 3.6	24.6 ± 4.9	.01*
Mean chance HLC ± SD	17.1 ± 6.5	18.1 ± 6.7	.5
Mean external locus of control ± SD	23.1 ± 5.9	22.9 ± 4.6	.8
Mean depression ± SD	8.3 ± 5.6	6 ± 4.7	.053
Mean anxiety ± SD	9 ± 5.4	5.2 ± 3.7	.005*
Mean stress ± SD	10.8 ± 5.2	9.2 ± 4.8	.3
Mean BDI ± SD	39.1 ± 9.3	37.9 ± 9.5	.7
Mean spiritual well-being ± SD	74.8 ± 18.5	72.1 ± 16.7	.5
Mean religious well-being ± SD	37.6 ± 13.3	34.6 ± 12.6	.4
Mean existential well-being ± SD	37.2 ± 7.3	37.4 ± 8.6	.8
Mean taking measures (COPE) ± SD	10.5 ± 2.7	10.4 ± 3.1	.8
Mean planning ± SD	10.7 ± 2.5	10.8 ± 3.1	.7
Mean postponing ± SD	9.8 ± 2.2	9.9 ± 2.2	.8
Mean self-restraint ± SD	10 ± 2.5	10.4 ± 2.7	.5
Mean information seeking and social support ± SD	10.7 ± 2.6	10.2 ± 3.3	.4
Mean emotional social support ± SD	10.9 ± 3.1	9.5 ± 3.2	.1
Mean positive reappraisal ± SD	11.9 ± 2.1	10.8 ± 2.3	.06
Mean acceptance ± SD	11.1 ± 2.4	10.8 ± 2.5	.6
Mean turning to religion ± SD	4.8 ± 2.3	4.4 ± 2.1	.5
Mean focusing and expressing feelings ± SD	10.9 ± 2.7	10.2 ± 2.6	.4
Mean denial ± SD	7 ± 2.5	9 ± 2.6	.004*
Mean relinquishment ± SD	6.7 ± 2.5	8.1 ± 2.6	.02*
Mean mental disengagement ± SD	5 ± 1.5	5 ± 1.7	.9
Mean substance use ± SD	3.2 ± 1.4	3.2 ± 1.6	.9
Mean humor ± SD	3.1 ± 1.3	3.2 ± 1.3	.6
Mean self-efficacy ± SD	25.3 ± 5.9	24.8 ± 5.5	.4
Mean BMI ± SD	25.9 ± 4.5	26.6 ± 5.7	.7
Mean abuse ± SD	18.5 ± 2	17.3 ± 3.2	.2

Note. Mann–Whitney U tests. HLC = health locus of control; BDI = Beck Depression Index; BMI = body mass index.

p < .05.

Table 3.

Outcomes.

	Intervention Group (N = 30)	Control Group (N = 30)	p Value	Effect Size r
Δ_Mean perceived stress ± SD	−7.1 ± 5.6	1.5 ± 6.2	.000*	.6
Δ_Mean self-esteem ± SD	12.1 ± 18.6	−2.9 ± 15.7	.000*	.6
Δ_Mean Dietary choices ± T.A.	2.8 ± 2.4	−0,03 ± 2.8	.000*	.5
Δ_Mean avoidance of dietary harm choices ± SD	1.5 ± 1.6	−0.2 ± 1.8	.003*	.4
Δ_Mean daily routine ± SD	3.7 ± 2.9	−0.2 ± 3.5	.000*	.5
Δ_Mean physical exercise ± SD	1.4 ± 1.4	0.03 ± 1.5	.003*	.4
Δ_Mean social support and emotional control ± SD	1.6 ± 1.9	−1 ± 2.6	.000*	.5
Δ_Healthy lifestyle and personal control ± SD	10.9 ± 8	−1.5 ± 11	.000*	.6
Δ_Mean internal HLC ± SD	−0.4 ± 3.9	−0.2 ± 2.5	.3	.2
Δ_Mean chance HLC ± SD	0.1 ± 4.3	0.4 ± 3.02	.7	.05
Δ_Mean external HLC ± SD	−0.4 ± 2.3	−0.16 ± 1.9	.6	.06
Δ_Mean depression ± SD	−3.4 ± 4.15	2.2 ± 3.3	.000*	.7
Δ_Mean anxiety ± SD	−4.2 ± 3.8	2.8 ± 2.9	.000*	.8
Δ_Mean stress ± SD	−3.9 ± 3.6	2.3 ± 2.2	.000*	.8
Δ_Mean BDI ± SD	−5.8 ± 4.5	4.3 ± 3.8	.000*	.8
Δ_Mean spiritual well-being ± SD	1.4 ± 7.8	−0.8 ± 5.9	.2	.2
Δ_Mean religious well-being ± SD	0.3 ± 4.5	0.3 ± 3.3	.7	.04
Δ_Mean existential well-being ± SD	1.1 ± 4.2	−1.1 ± 3.4	.061	.3
Δ_Mean taking measures (COPE) ± SD	0.5 ± 2.1	−0.3 ± 1.8	.4	.1
Δ_Mean planning ± SD	0.5 ± 1.7	−0.5 ± 1.3	.005*	.4
Δ_Mean postponing ± SD	0.3 ± 1.5	−0.03 ± 1.6	.5	.08
Δ_Mean self-restraint ± SD	0.5 ± 1.7	0.03 ± 1.3	.2	.2
Δ_Mean information seeking and social support ± SD	1.03 ± 1.6	−0.2 ± 1.7	.004*	.4
Δ_Mean emotional social support ± T.A.	0.5 ± 1.7	−0.2 ± 1.7	.1	.2
Δ_Mean positive reappraisal ± SD	1 ± 1.5	0.2 ± 1.4	.003*	.4
Δ_Mean acceptance ± SD	−0.9 ± 1.7	−0.2 ± 1.5	.1	.2
Δ_Mean turning to religion ± SD	−0.03 ± 0.7	0.2 ± 0.8	.3	.1
Δ_Mean focusing and expressing feelings ± SD	0.3 ± 2	−0.1 ± 1.6	.2	.2
Δ_Mean denial ± SD	0.5 ± 1.6	0.3 ± 1.6	.7	.05
Δ_Mean relinquishment ± SD	0.1 ± 2.2	−0.03 ± 2.3	.9	.003
Δ_Mean mental disengagement ± SD	0.9 ± 1.2	−0.2 ± 1.2	.001*	.04
Δ_Mean substance use ± SD	−0.2 ± 0.9	0.6 ± 1.2	.009*	.3
Δ_Mean humor ± SD	0.1 ± 1.1	0.2 ± 0.9	.7	.04
Δ_Mean self-efficacy ± SD	2.0 ± 2.8	0.7 ± 3.1	.1	.2
Δ_Mean BMI ± SD	−0.2 ± 0.3	0.06 ± 0.4	.003*	.4
Δ_Mean abuse ± SD	−0.8 ± 1.5	−0.3 ± 1	.2	.2

Note. For categorical data, chi-square statistics were performed, and for numerical data, non-parametric tests of Mann–Whitney were used. HLC = health locus of control; BDI = Beck Depression Index; BMI = body mass index.

p < .05.

Results

Table 1 describes baseline characteristics. The mean age of the women participating in the study was 47.23 for the intervention group and 48.77 for the control group. Regarding bodyweight, the average in the intervention group was 68.1 kg and 70.6 kg in the control group, while mean height was 161.9 cm and 163.1 cm respectively. Most women were married (60% in the intervention group and 66.7% in control group) and only a 26.7% of the women in the intervention group had been divorced (vs. 23.3% in control group). Furthermore, the percentage of cohabitance was about 70% in the intervention group (vs. 86.7% in controls). Nearly two out of 10 women of the sample were caregivers.

Regarding education level, the majority of the women were high school graduates (33.3% vs. 43.3% in the intervention and the control group, respectively). In the intervention group, nearly half of them were unemployed (46.7%), compared with control group in which 53.3% had full-time employment. As for income satisfaction, 40% of the intervention group and 46.7% of the control group reported being modestly satisfied. The same trend was recorded for family income satisfaction (46.7% vs. 50%; for the intervention and control group, respectively). As far as smoking, most women in both groups were non smokers (56.7% vs. 60%).

Regarding perceived health status, the majority of the women described their health as good (66.7% in the intervention group and 56.7% in the control group). Furthermore, the most prevalent abuse was psychological, followed by physical and finally sexual.

Table 2 describes baseline psychometric characteristics, which are presented as means and standard deviations. Significant statistical differences were found regarding social support and emotional control, internal locus of control (p = .001), anxiety, denial, and relinquishment.

In Table 3, the mean changes of primary outcomes are presented. It seems that there is a large reduction in perceived stress levels (7.1 units), while in the control group, there is an increase in post-intervention stress. Also, there was an increase in self-esteem (vs. control group where we recorded a reduction).

A statistical significant and medium effect increase in the intervention group was also recorded regarding dietary habits, dietary harm avoidance, daily habits, physical exercise, social support and emotional control, healthy lifestyle and personal control, and HLC (Internal and Chance).

Regarding depression, anxiety, and stress, there was a large and significant improvement with ensuing reduction in depressive symptomatology, anxiety, and stress in the intervention group. Depressive symptoms as assessed by the BDI also manifested a statistically significant decrease post-intervention.

As far as spirituality is concerned, the intervention group recorded a significant increase in religious and existential well-being. Also, regarding coping, there was also a statistically significant increase in taking measures, planning, self-restrain, social support and information seeking, humor, emotional social support, expression, denial, mental disengagement (p = .001), and positive reappraisal. Acceptance, substance use, and turning to religion were reduced in the intervention group. Furthermore, there was a significant increase in self-efficacy, a decrease in BMI and in IPV post-intervention.

Discussion

This stress management and health promotion program aspired to bring a positive effect in mitigating stress, depression, anxiety, abuse “repercussions,” and quality of life in women with a history of IPV, with the use of counseling regarding diet, physical exercise, and stress management techniques. Our results can be generalized only to women with the same characteristics presented in Table 1. As such, we cannot easily decide if they can be of any value to women with different characteristics. It is even more difficult to speak about other societies with different socio-cultural traits.

According to current literature on IPV therapeutic approaches, the more prevalent and effective interventions are those implementing CBT, stress management techniques, and mind-body practices (Clark et al., 2014; Crespo & Arinero, 2010; Kim et al., 2013; Leisring, 2013). The results of our study seem to be consistent with previous trials on IPV regarding (a)improving stress, depression, and anxiety (Clark et al., 2014; Dutton et al., 2013; Michalopoulou et al., 2015); (b) increasing self-esteem; and (c) increasing positive habits in daily routine (Dutton et al., 2013; Michalopoulou et al., 2015)” As far as stress, depression, and anxiety are concerned, there is mounting evidence that non-pharmacological interventions merit positive effects (Clark et al., 2014; Crespo & Arinero, 2010; Michalopoulou et al., 2015; Tarquinio et al., 2012).

This effect is noteworthy as current literature states the negative consequences deriving from distress such as unhealthy lifestyle, unemployment, substance abuse, sleep disturbances, and so on (Aguilar & Nightingale, 1994; Chrousos & Gold, 1992; Golding, 1999; Johnson et al., 2008; Kimerling et al., 2009; Pelletier et al., 2016). Thus, improvement in stress, anxiety, and depressive symptoms could contribute to improved health indices, both physical and mental health, and quality of life (Clark et al., 2014; Crespo & Arinero, 2010; Michalopoulou et al., 2015; Tarquinio et al., 2012). This positive trend recorded in our study could be attributed to the comprehensive nature of the intervention which combined several stress management techniques, dietary and physical exercise counseling, as well as techniques similar to CBT, such as a form of cognitive reconstruction. For extracting more secure results, a larger sample would be necessary.

This study has a number of limitations regarding both trial procedure (e.g., session duration) and sample size, which was relatively small. The most important barrier to overcome was that of sample recruitment, given that many women who experience IPV are reluctant in seeking help and trusting. This fact may affect their disclosure when answering the self-reported measurements, fearing that “telling the truth” might expose them. Other limitations were (a) the difficulty in monitoring compliance to the program, despite the daily record diaries provided to each participant; (b) not being able to verify that for sure that women did not receive any other intervention such as counseling out of the context of this study; and (c) the non-blind character of the study. Generalization of our results could be feasible in female survivors of violence without history of substance abuse and psychiatric disorders.

In conclusion, stress management interventions may be of importance in improving the physical and psychological well-being of women who were victims of domestic violence. Future studies may extend these findings using a larger sample size and/or implementing other stress management techniques. It would be recommended to health professionals to implement such time and cost efficient programs, as their benefits are a permanent asset to IPV women.

Footnotes

Authors’ Note

Chrousos P. George and Darviri Christina contributed equally and shared last authorship.

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) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Anastasia Kokka is a sociologist and student of the postgraduate program “Science of stress and health promotion” of the Medical School of the National University of Athens. Her research interests include intimate partner violence, stress of abused women, and the effectiveness of stress management.

Maria Mikelatou is a psychologist and student of the postgraduate program “Science of stress and health promotion” of the Medical School of the National University of Athens. Her research focuses on women who are abused by their partners, stress that created them, and the effectiveness of stress management methods.

Georgia Fouka is an associate professor and head of the nursing department of Technological Educational Institute of Athens (TEI). Her research interests involve the use and adherence to medications, community health nursing, and family nursing. She is teaching the courses of community nursing and health promotion in pre-registration as well as postgraduate programs. She has published more than 27 papers in scientific journals and supplements cited in numerous international journals and she has presented more than 40 conference papers. She has taken part in Erasmus teachers’ exchange programs and she is currently involved in an international research program.

Liza Varvogli is a licensed psychologist and she holds a post-doctoral degree from Harvard Medical School. From 2009 until now, she is an adjunct professor at the National & Kapodistrian Univeristy of Athens, Greece.

George P. Chrousos is a professor and chairman of the Department of Pediatrics at the Athens University Medical School. He was previously former senior investigator, director of the Pediatric Endocrinology Section and Training Program, and chief of the pediatric and reproductive endocrinology branch of the National Institute of Child Health and Human Development, National Institutes of Health. He was professor of pediatrics, physiology, and biophysics at Georgetown University Medical School. He is among the 200 most prominent clinical investigators in the world. He has authored more than 1,000 scientific publications, has edited 23 books, and his work has amassed over 40,000 citations.

Christina Darviri is a professor of prevention and health promotion and since 2008, the scientific coordinator of the MSc title “The Science of Stress and Health Promotion” at the Medical School of the Kapodistrian University of Athens, Greece. She lectures on stress-related nosology, lifestyle and stress, efficient stress management, and the connection between stress and health promotion overall. She has been the principal investigator of many research projects focusing mainly on healthy longevity and how lifestyle impacts stress.

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