Social Determinants of Domestic Violence Among Saudi Married Women in Riyadh,Kingdom of Saudi Arabia

Abstract

Intimate partner violence is a worldwide public health problem. The objectives of this study were to measure the prevalence and types of domestic violence, and to explore the association between social determinants (sociodemographic factors, husband-related factors, and social support) and violence against women by their intimate partner (husband). We conducted a cross-sectional survey in 18 randomly selected primary health care centers and 13 private institutions (teaching institutes, government offices, social welfare organizations) in Riyadh, Saudi Arabia. Female data collectors took interview from 1,883 married Saudi females aged 30 to 75 years. Interviews included sociodemographic information, reproductive health variables, and social support questionnaire. Violence was measured using modified Intimate Partner Violence Against Women questionnaire developed by the World Health Organization. Multivariate logistic regression analysis was conducted. The lifetime prevalence for any type of violence was 43.0% (n = 810). The most frequent type was controlling behavior (36.8%), followed by emotional violence (22%), sexual violence (12.7%), and physical violence (9.0%). Multivariate logistic regression analysis revealed that the following were associated with greater odds of reporting domestic violence: younger age 30 to 40 years (adjusted odds ratio [aOR] = 1.9, 95% confidence interval [CI] = [1.3, 3.0]), 41 to 50 years (aOR = 1.6, 95% CI = [1.1, 2.5]); lack of emotional support (aOR = 1.7, 95% CI = [1.2, 2.5]); lack of tangible support (aOR = 1.4, 95% CI = [1.1, 1.9]); and perceived poor self-health (aOR = 1.7, 95% CI = [1.0, 3.0]), husbands’ poor health (aOR = 1.9, 95% CI = [1.2, 2.0]), and polygamy (aOR = 1.6, 95% CI = [1.5, 2.6]). Domestic violence occurs frequently in Saudi Arabia. Both social conditions and social relations are significantly associated with domestic violence against Saudi women. Furthermore, improvement in implementation of the local policies and multisectoral protection services can prevent women from domestic violence.

Keywords

domestic violence husband young age social support perceived health

Introduction

Domestic violence, or more specifically intimate partner violence (IPV), against women is a common worldwide social and health problem (WHO, 2016). As defined by the United Nations General Assembly session, violence against women (VAW) is

any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. (United Nations General Assembly [UNGA], 1993)

The real prevalence of VAW is not known; hence, population-based surveys may provide the most accurate estimate of prevalence of domestic violence in nonconflict settings. The World Health Organization’s (WHO) multicountry study on women’s health and domestic VAW found that the lifetime prevalence of physical or sexual partner violence, or both, varied from 15% to 71% in 10 low- and middle-income countries (García-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006). In a more recent analysis by WHO, based on data from 80 countries, the global prevalence of IPV (physical and/or sexual) was 30.0% (WHO, 2013). Studies from Middle East and North Africa region (MENA) reported prevalence of ever experiencing violence (any type) ranged from 8.1% in Israel to 23% in Syria, and to as high as 65% in Turkey. However, various methodological differences were noted pertaining to the instrument utilized for the procedure to collect data and the selection and size of the sample. Hence, the findings may not be generalizable to whole of the MENA region (Boy & Kulczycki, 2008). Reports from MENA countries documented that at least one out of three women was a victim of IPV in Egypt, Palestine, and Tunisia, which is similar to the worldwide prevalence (Douki, Nacef, Belhadj, Bouasker, & Ghachem, 2003).

Until the 1990s, exploring VAW was a taboo in Saudi Arabia. As a result, research studies that have been conducted have had inconsistent findings and have been limited in generalizability probably due to small samples and specific studied population. Differences in the measuring tool may also be partially responsible for the inconsistent findings. Tashkandi and Rasheed conducted the first published study on domestic violence in 2004. This study was carried out in Medina, one of the historic cities of Saudi Arabia, and found that among 689 studied women, the lifetime prevalence of abuse was 57.7%. Among them, 25.7% reported physical abuse and 32.8% reported isolated emotional abuse (Tashkandi & Rasheed, 2009). A study conducted in outpatient clinics of three tertiary care hospitals in Jeddah, a cosmopolitan city, reported the lifetime prevalence of domestic violence as 34% among 2,301 women aged 15 to 70 years (both Saudi and non-Saudi), and among those, 29% reported emotional abuse, 11.6% physical abuse, and 4.8% sexual abuse (Fageeh, 2014). In another study from Jeddah, conducted among 200 married women recruited from 6 primary health care centers (PHCCs) using structured interview, the lifetime prevalence of physical violence was found to be 44.5% (Eldoseri, Tufts, Zhang, & Fish, 2014). A community-based study conducted in Eastern province (Khobar) of Saudi Arabia, on 2,000 married women (15-60 years) using structured interview, found the prevalence of lifetime overall domestic violence to be 39.3% (35.9% for mental, 17.9% for physical, and 6.9% for sexual; Afifi, Al-Muhaideb, Hadish, Ismail, & Al-Qeamy, 2011). More recently, a study was conducted in a single PHCC in Riyadh province, which found that 20% (144/720) of Saudi women were exposed to domestic violence during 1-year period. The emotional violence was reported by 69%, social violence by 34%, economic violence by 26%, physical violence by 20%, and sexual violence by 10% women (Barnawi, 2017). Another study conducted in Western (Taif) province of Saudi Arabia found the prevalence over the past 12 months to be comparatively low (11.9%) as compared with other areas of Saudi Arabia, and the authors attributed this low rate to differences in the methodology of the study (Alzahrani, Abaalkhail, & Ramadan, 2016).

Comprehensive research on VAW includes both, the predictors of violence (social determinants) and the consequences (impact) of domestic violence. The theoretical framework leading to violence has identified that predictors, that is, social determinants encompass both social conditions and social relations (WHO, 2005). Social conditions range from education and economy to position in the family and society, whereas social relations include relationship with husband, interaction and support from immediate and distant family members, neighbors, friends, coworkers, (WHO, 2005), and relationship with children (for elderly married women). Although both social conditions and relations are equally important, the role of social relations in context to VAW, especially pertaining to husband, children, family, and friends, has been lately recognized (Somach & AbouZeid, 2009). Risk factors related to husband may include age, being a smoker/alcoholic, low level of education, type of occupation, financial dependency, health, temperament, and childhood history of observing abuse (specially, pertaining to those who saw their mothers as victims of domestic violence; Fageeh, 2014; Somach & AbouZeid, 2009). Yüksel-Kaptanoğlu, from Turkey, reported similar risk factors for women at risk of being victimized; however, they found no association with employment status or educational level of the husband (Yüksel-Kaptanoğlu, Türkyılmaz, & Heise, 2012). Recently, the role of social support has acquired a significant place in the prevention and rehabilitation of victims of domestic violence (García-Moreno et al., 2006).

Various fatal and nonfatal consequences may occur depending on the type of violence. A review study on VAW found that several type of health consequences, including psychological as well as physical, were associated with VAW (Dillon, Hussain, Loxton, & Rahman, 2013). Physical and sexual violence may result in injuries, fractures, and chronic conditions like irritable bowel syndrome, infections, unwanted pregnancy, or gynecological problems (Trevillion, Oram, Feder, & Howard, 2012; WHO, 2013). Psychological abuse may result in depression, anxiety, stress, low self-esteem, and in the long run may lead to risk-taking behaviors (WHO, 2005). Previous literature has found that depression and anxiety, in turn, may lead to overeating and obesity, thus further increasing the risk of emotional verbal abuse (Afifi et al., 2011). Studies from Saudi Arabia have reported that perceived poor health, somatic symptoms (body aches, weakness, etc.), increased body mass index (BMI), depression, and stress are some of the common outcomes of violence (Afifi et al., 2011; Alzahrani et al., 2016; Barnawi, 2017; Eldoseri et al., 2014; Fageeh, 2014; Tashkandi & Rasheed, 2009).

In contrast to many other countries around the world, research on VAW is still in its early stage in Saudi Arabia. The comprehensive role of social determinants (individual, husband-related factors, and social support) in context to VAW has not been explored in detail before. To develop protection policies and empowerment programs, more studies are needed to explore the extent, factors, and impact of VAW on the individual and society. The aims of this study were to explore the prevalence of violence against married women by their husband in Riyadh city, to identify types and severity of violence, and to identify the factors (predictors) associated with violence. In addition, we explored the association between one of the consequences of violence by measuring the association between perceived health status of the participant and reported violence.

Method

Study Design, Setting, and Participants

This study was part of a large cross-sectional survey (Women in Saudi Arabia health examination survey, WISHES) to identify the prevalence and correlates of chronic diseases in females aged 30 to 75 years old in Riyadh, Saudi Arabia. There were two reasons to include women 30 years and above: first, majority of the chronic diseases commence at this age and second, majority of women at 30 years are mature enough to respond to questions on sensitive issues like violence. In this article, we present the part related to domestic violence against Saudi married women. Data were collected from December 2014 to June 2015.

Riyadh is the capital city, of Saudi Arabia, located in the center of the Arabian Peninsula on a large plateau and home to more than 6 million people (64% are Saudi citizens vs. 36% expatriates from all over the world; http://www.arriyadh.com 2013 [Riyadh in year 2013 Hijri, 2016]). Riyadh city comprises of five administrative regions. A list of 105 government-run PHCCs was obtained from the Ministry of health. These PHCCs are well equipped and are regularly visited by majority of Saudi women due to various reasons ranging from vaccination to chronic diseases. The web-based program (https://www.random.org/) was utilized to randomly select 25 PHCCs. However, due to ongoing renovation work at some of the PHCCs, we were able to enroll women from 18 PHCCs situated in different administrative regions.

Saudi Arabia is undergoing a transition phase where more and more women are entering different professions. Hence, to include working women, we included 13 private institutions (teaching institutes, including schools and technical colleges, government offices, social welfare organizations), along with PHCCs, to enroll eligible participants. About 90% (n = 1,695) women were selected and screened from PHCCs and 10% (n = 188) from private institutes.

Inclusion criteria was mentioned on roll-ups, pamphlets, and letters, stating that any Saudi women aged between 30 and 75 years, nonpregnant, and permanent resident of Riyadh can participate in this study. Non-Saudis and those with gross mental incapacity were not included in the study. Invitation flyers were written in local language, stating the main objective of : measuring the prevalence and identifying the significant correlates associated with chronic diseases among Saudi women in Riyadh. There was no compensation or any type of payment offered to the participants. Multiple strategies were adopted to invite the participants. These included placing advertisement and informational material at the selected PHCC (at least 1 week before the start of study), nearest and the largest shopping mall and mosque, and invitation by hand for other family members through patients /attendants visiting PHCC. Initially, 2,100 women were approached and invited to participate, and out of those, 2,029 fulfilled the eligibility criteria and were asked to read, understand, and sign the consent form in Arabic; 136 unmarried women were not included in this analysis and further 10 forms were discarded due to incomplete interviews. Hence, 1,883 (93%) married Saudi women were included in the final analysis.

The majority (68.0%) participated after viewing advertisements at the PHCC, and 24.0% participated due to invitations placed at entrances to malls or mosques. About 7% participated by receiving information from relatives/friends, and only 1% participated after receiving invitation at home (the door-to-door invitation strategy included 100 houses situated within half a kilometer of the selected PHCC; however, it was discontinued after covering four PHCCs due to low response rate).

Data Collection Procedure

A team of five female phlebotomists/data collectors were rigorously trained by the researchers to conduct the interviews. They were well-versed in both Arabic and English languages. The data collectors were trained on developing repo with the participant, explaining to her the reason and importance of the study, satisfying her apprehensions related to confidentiality, and making her feel comfortable in answering all type of questions. Trainings were followed by a pilot study, which was conducted on a separate sample of 50 participants to identify and overcome any logistic or technical issues. Complete confidentiality was maintained at all levels of the study. A separate room with closed doors was arranged for the interviews, each participant was designated a unique ID, and no disclosure of names or any other identity was made. Confidentiality was maintained during the data entry and analysis and write-up of manuscripts.

Ethical Considerations

The study was approved by the Institutional Review Board, King Saud University (E-12-658) and Institutional Review Board of Ministry of Health, Dammam (IRB ID MOH0151).

Data Collection Tools

A detailed questionnaire, included information on the sociodemographic profile, health status (including BMI and perceived health), reproductive health, availability of social support, and husband-related variables, was developed by the researchers. The IPV questionnaire from the WHO was modified and used for data collection. The sociodemographic profile included questions on age, educational attainment (self and spouse), occupation (self and spouse), area of residence, type of housing, monthly household income. In addition, health status of husband and number of wives was also inquired about. A detailed history on frequently occurring chronic diseases, including diabetes, hypertension, arthritis, cardiovascular disease, thyroid problems, and depression, was taken. In addition, participants were asked how they perceived their health status. Reproductive health questions inquired about age at marriage, contraceptive use, number of children, any miscarriages, and menopause status. Smoking status included questions on both active and passive smoking.

WHO Questionnaire on IPV

Direct, clearly worded questions were adapted from the WHO Multicountry Study on Women’s Health and Domestic Violence by their male intimate partners (WHO, 2005). This questionnaire has been translated and utilized in many countries across the world. The data collectors explained to women that they are being inquired about lifetime prevalence of any type of violence, namely physical, sexual, emotional, and controlling behavior caused by their husband. The participant was also allowed to discontinue or skip the question if she felt uncomfortable in answering. The specific items belonging to different type of violence are mentioned under Table 2. Two research experts translated and back translated the questionnaire from English to Arabic. Any disputes and ambiguity were discussed, and a final slightly modified version was produced and pretested. The questionnaire calculated total lifetime prevalence of VAW by intimate partner (domestic violence). Frequency for each item was measured by using Likert scale (all of the time [many times], most of the time [few times], sometime, bit of the time [rarely], and never). The Likert scaling part did not go through the formal validation process; however, face and content validity were performed by group of experts in the relevant area. The Cronbach’s alpha for the items calculating the total lifetime prevalence and for those measuring the frequency was 0.87 and 0.85, respectively.

In addition to WHO definitions (WHO, 2005), multiple discussions were conducted with the experts to reach a consensus for defining the moderate and severe act of violence. Moderate physical violence included being slapped, pushed, or shoved, whereas being hit with a fist, kicked, dragged, burned, threatened with a weapon, or having a weapon used against her were defined as severe physical violence. Items such as engaging in sexual intercourse out of fear and physically forced to have sexual intercourse were defined as moderate sexual violence, whereas made to do an unacceptable sexual act was considered as severe sexual violence. For emotional violence, items such as insulting, scaring, and intimidating were defined as moderate emotional acts whereas threatened to hurt was considered as severe act. Requiring the husband’s permission for seeking health care and restrictions in contacting her family were defined as severe acts under controlling behavior, whereas keeping away from friends, ignoring and treating differently, and being suspicious were considered as moderate acts. In addition to the above questionnaire, we inquired whether the woman experienced violence before the age of 15 years.

Social Support Survey Scale

Social support was measured through a validated questionnaire, the Social Support Survey Scale (Sherbourne & Stewart, 1991). It is a brief, four-itemed, multidimensional, and simple scale, which was developed for patients in the Medical Outcomes Study (MOS). It includes four functional support scale items, two questions asking about the emotional support, and included questions about “someone available who can listen to you when needed” and “someone available to confide in and talk to/discuss about yourself?” The other two questions measured the tangible support and asked about “if someone is available to take her to the doctor when needed?” and “if someone is available to help her with household chores?” These items were found to be reliable, valid, and stable over time. Each item was answered using the 5-point Likert scale ranging from all the time, most of the time, sometime, bit of time, and not at all. For the analysis purpose, responses like all the time and most of the time were added making one category (0), sometime and bit of the time were added to make another category (1), whereas not at all was coded as (2). The Cronbach’s alpha for the social support items was 0.83.

Anthropometric Measurements

Anthropometric indices included weight, measured with an electronic scale (Secca 220—Hamburg, Germany, 2009), and height, which was measured by following the standard protocol. Weight and height were used to calculate BMI as weight (kg)/(height in m²). BMI was categorized into three categories by using the internationally recommended cutoffs (WHO, 1997). Normal BMI was defined as 18.5 to 24.9, overweight was defined as BMI of 25.0 to 29.9, and obese was defined as BMI greater than or equal to 30.

Safety Protocol and Follow-Up

The safety and well-being of the participants was ensured at each stage. The participants who reported domestic violence were given the contact number of the National Family Safety Program (NFSP), which is a national program aiming to serve the victims of domestic abuse, and the national hotline for reporting the domestic violence (1919), and were asked to follow-up with their family physician. NFSP has workers and helpline available 24/7. This program not only provides social support but also provides legal support to the victims.

Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences computer software package (IBM SPSS statistics version 21.0). The violence scale comprised of six items (acts) under physical violence, three items (acts) each under sexual and emotional violence, and five items (acts) under controlling behavior. To measure lifetime prevalence (binary outcome variable), the total sum of all “yes” (1) items versus “no” (0) were calculated. Frequency was calculated by summing the 4-point Likert scale into two categories (all/most of the time vs. some/bit of the time) because of small number of responses against some items. Availability of social support was obtained from the 5-point Likert scale, ranging from all the time to not at all. In the final tables, 5-point scale was combined to make three categories: always/mostly, sometimes/rarely, and not at all.

Means and standard deviations were computed for continuous variables, and proportions were calculated for categorical variables. The chi-square test was used to assess the significant differences between the exposed and unexposed groups. The level of significance was kept at p < .05. Pearson coefficient value (r²) was calculated between sociodemographic and social support variables. Univariate analysis were conducted to identify variables (predictors) significantly associated with violence. Confounding variables causing a change of at least 10% in the estimates of association were retained in the model. Multivariate logistic regression analysis was performed to explore the association of hypothesized independent variables with violence. We used the “ENTER” method to identify the final significant variables. Variables were checked for potential interactions before developing the final model. The Hosmer Lemeshow goodness of fit test was used to assess the model fit.

Results

In total, 1,883 Saudi married women participated in the study. The average age (M and SD) of women who participated in the study was 44.7 (±10.7) years, ranging from 30 to 75 years (Table 1). The majority (83.6%) was currently married, and 60% were housewives and 22% were working in different occupations outside the home. About 60% women reported household income of 10,000 SAR or less. More than 50% lived in villa, followed by 25% living in an apartment. About 70% owned their residence and 25% lived in rented accommodation (Table 1). The majority (37%) of women had four to six children, and only 22% of the participants were using some type of contraceptive. More than a quarter (28.6%) of participants (n = 538) were postmenopausal. The majority (80%-82%) of participants mentioned having excellent/good health, whereas 3% to 5% perceived their health as poor. More than 60% of women were obese, with only 12% having normal BMI. About 2% of women were smokers, and a significant number (20.9%, n = 395) were exposed to passive smoke. About 3% to 4% of participants reported sexual abuse before the age of 15 years. Information on chronic diseases such as diabetes mellitus, hypertension, osteoporosis, and cardiovascular diseases had reported prevalences of 23% (435), 20% (389), 13% (241), and 2.4% (46), respectively (results not shown).

Table 1.

UOR and 95% CIs for Sociodemographic Characteristics, Health-Related and Spouse-Related Variables Associated With Violence in Saudi Married Women in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

Variable	N = 1,883	Abused (n = 810)n (%)	Not Abused (n = 1,073)n (%)	UOR (95% CI)
Age group (years)
61-75	147	47 (5.8)	100 (9.3)	1.0
51-60	373	154 (19.0)	219 (20.4)	1.5 [1.0, 2.2]
41-50	564	243 (30.0)	321 (29.9)	1.6 [1.1, 2.4]
30-40	799	366 (45.2)	433 (40.4)	1.8 [1.2, 2.6]
Marital status
Widow	203	55 (6.8)	148 (13.8)	1.0
Married	1,520	677 (83.6)	843 (78.6)	2.2 [1.5, 2.9]
Divorced/separated	160	78 (9.6)	82 (7.6)	2.5 [1.6, 3.9]
Education
Graduate/postgraduate	765	319 (39.4)	446 (41.6)	1.0
Intermediate and secondary	510	238 (29.4)	272 (25.3)	1.2 [0.9, 1.5]
Primary/illiterate	608	253 (31.2)	355 (33.1)	0.9 [0.8, 1.2]
Occupation
Working	408	180 (22.2)	228 (21.2)	1.00
Housewife	1,082	469 (57.9)	613 (57.1)	0.9 [0.7, 1.2]
Retired	393	161 (19.9)	232 (21.6)	0.9 [0.7, 1.2]
Monthly income (SAR)^a
>20,000 ($5,333)	153	63 (9.3)	90 (9.8)	1.00
>10,000-≤20,000	531	212 (31.1)	319 (34.6)	0.9 [0.6, 1.3]
≤10,000 ($2,666)	920	406 (59.6)	514 (55.7)	1.1 [0.8, 1.6]
Type of housing
Villa	1,177	477 (58.9)	700 (65.2)	1.0
Apartment	456	219 (27.0)	237 (22.1)	1.3 [1.1, 1.7]*
House	250	114 (14.1)	136 (12.7)	1.2 [0.9, 1.7]
Ownership of house
Self-owned	1,328	557 (68.7)	772 (72.0)	1.0
Rented	473	219 (26.9)	255 (23.8)	1.2 [0.9, 1.5]
Company owned	80	35 (4.3)	45 (4.2)	1.1 [0.7, 1.7]
Health- and reproductive health-related variables
Years since marriage
≥31	669	248 (30.6)	421 (39.2)	1.0
21-30	427	197 (24.3)	230 (21.4)	1.4 [1.1, 1.8]
11-20	446	212 (26.2)	234 (21.8)	1.5 [1.2, 1.9]
<10	341	153 (18.9)	188 (17.5)	1.4 [1.1, 1.8]
Number of children
1-3	610	259 (32.0)	351 (32.7)	1.0
4-6	704	327 (40.4)	377 (35.1)	1.1 [0.9, 1.5]
>6	569	224 (27.7)	345 (32.2)	0.8 [0.7, 1.1]
Number of miscarriages
None	1,030	427 (52.7)	603 (56.2)	1.0
One	453	211 (26.0)	242 (22.6)	1.2 [0.9, 1.5]
≥Two	400	172 (21.2)	228 (21.2)	1.0 [0.8, 1.3]
Use of contraceptives
No	1,467	619 (76.4)	619 (79.0)	1.0
Yes	416	191 (23.6)	225 (21.0)	1.2 [0.9, 1.4]
Perceived health
Excellent	240	90 (11.1)	150 (14.0)	1.0
Good	1,302	525 (64.9)	777 (72.4)	1.1 [0.8, 1.5]
Fair	264	153 (18.9)	111 (10.3)	2.3 [1.6, 3.2]
Poor	42	42 (5.2)	35 (3.3)	2.0 [1.2, 3.4]
Body mass index (kg/m²)
18-24.9	241	100 (12.3)	141 (13.1)	1.0
Overweight	550	242 (29.9)	308 (28.7)	1.1 [0.8, 1.5]
Obese	1,092	468 (57.8)	624 (58.2)	1.0 [0.7, 1.4]
Smoking status of women
No	1,848	792 (97.8)	1,056 (98.4)	1.0
Yes	35	18 (2.2)	17 (1.6)	1.4 [0.7, 2.7]
Past history of sexual abuse before age 15 years
No	1,814	774 (95.6)	1,040	1.0
Yes	69	36 (4.4)	33 (3.1)	1.5 [0.9, 2.4]
Spouse-related variables
Spouse education
Graduate/postgraduate	761	319 (39.4)	442 (41.2)	1.0
Intermediate and secondary	677	319 (39.4)	358 (33.4)	1.2 [1.0, 1.5]
Primary/illiterate	445	172 (21.2)	273 (25.4)	0.8 [0.7, 1.1]
Spouse occupation
Doctor/engineer/etc.^b	395	169 (20.9)	226 (21.1)	1.0
Military	273	115 (14.2)	158 (14.7)	0.9(0.7, 1.3)
Skilled worker^c	434	216 (26.7)	218 (20.3)	1.3 [1.0, 1.7]
Unskilled worker^d	330	110 (13.6)	220 (20.5)	0.7 [0.5, 0.9]
Unemployed	52	27 (3.3)	25 (2.3)	1.4 [0.8, 2.6]
Retired	399	173 (21.4)	226 (21.1)	1.0 [0.7, 1.3]
Smoking
No	1,488	626 (77.3)	862 (80.3)	1.0
Yes	395	184 (22.7)	211 (19.7)	1.2 [0.9, 1.5]
Number of wives
Only 1	1,491	605 (74.7)	886 (82.6)	1.0
≥2	392	205 (25.3)	187 (17.4)	1.3 [1.3, 2.0]
Husband having health problem
No	1,588	642 (79.3)	946 (88.2)	1.0
Yes	295	168 (20.7)	127 (11.8)	1.9 [1.5, 2.5]

Note. UOR = unadjusted odds ratios; CIs = confidence intervals.

Numbers are less because participants did not know or did not want to tell about monthly income.

Include lawyers, finance managers, etc.

Include teachers, technicians, pharmacists, nurses.

Include security guard, sales person, maintenance work, etc.

Information related to the participants’ husbands revealed that 40% of participants had a spouse with a college degree or postgraduate level of education, and more than 20% had a spouse who had a primary/illiterate education level (Table 1). In relation to occupation, the majority of spouses (26.7%) were skilled workers, followed by doctors/engineers (21.0%). A considerable proportion (13.6%) was unskilled workers, comprising security guard, sales person, maintenance work, and so on, and about 20% were retired. More than 20% of husbands were current smokers. Most participants (80%) were the only wife of their husband, and 20% said their husbands had two or more wives. Approximately 20% of husbands had some health problem, such as hypertension, diabetes, sexual problems, and so on.

The total lifetime prevalence for any type of violence was 43.0% (n = 810; Figure 1). The most frequently reported type of violence was controlling behavior, reported by 36.8% (693) participants, followed by emotional violence (22%, n = 412), sexual violence (12.7%, n = 240), and physical violence (9.0%, 170; Figure 1).

Figure 1.

Percentage of married Saudi women reporting total lifetime violence and different types of domestic violence in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

The most frequently reported and repeated acts of violence were controlling behaviors (Table 2). More than 80% of participants who reported controlling behaviors said they always/mostly required their husband’s permission to seek health care. Besides permission, 33% to 37% of participants mentioned that they experienced different controlling behaviors on always/mostly basis. Emotional violence, along with being the second most frequently reported type, was also associated with repeated acts of emotional trauma (Table 2). Out of those who experienced threatening behavior, about 60% experienced this behavior on a continuous basis. About 28% of the participants mentioned that they experienced insulting and scaring attitude on always/mostly basis.

Table 2.

Prevalence of Violence Reported by Saudi Married Women in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

Violence Type	Total n (%)	Always/Mostly n (%)	Sometimes/Bit of the Time n (%)
Controlling behavior
Try to keep you away from friends	257 (13.7)	92 (4.9)	165 (8.8)
Ignores and treats indifferently	390 (20.7)	134 (7.1)	256 (13.6)
Tries to restrict contact with family	193 (10.3)	73 (3.9)	120 (6.4)
Often suspicious of faithfulness	101 (5.4)	34 (1.8)	67 (3.6)
Take permission before seeking health care	411 (21.8)	332 (17.6)	79 (4.2)
Emotional violence
Insults and makes you feel bad	331 (17.6)	94 (5.0)	237 (12.6)
Scares or intimidate on purpose	265 (14.0)	74 (3.9)	191 (10.1)
Threatens to hurt	81 (4.3)	48 (2.5)	33 (1.8)
Sexual
Had sexual intercourse because of fear	168 (8.9)	45 (2.4)	123 (6.5)
Physically forced to have sexual intercourse	188 (9.9)	44 (2.3)	144 (7.6)
Force to do sexual act that is degrading or humiliating or unacceptable	39 (2.0)	8 (0.4)	31 (1.6)
Physical
Threatens to use or used gun, knife, etc.	31 (1.6)	12 (0.6)	19 (1.0)
Slapped/thrown something	131 (7.0)	17 (1.0)	114 (6.0)
Physically hits with fist, etc.	99 (5.3)	17 (0.9)	82 (4.4)
Pushes or shoves	98 (5.2)	16 (0.8)	82 (4.4)
Kicks, drags, or beat you up	54 (2.8)	10 (0.5)	44 (2.3)
Chokes or burns on purpose	19 (1.0)	6 (0.3)	13 (0.7)

Note. Same woman may have answered positively to more than one act of violence; therefore, total number not adding to 810.

Different acts under sexual violence ranged in prevalence of reporting from 2% to 10% (Table 2). Among those who suffered from different acts of sexual violence, 20.0% to 27.0% were exposed to the act on mostly/always basis. Although, sexual violence related to “humiliating and unacceptable sexual acts” was low in prevalence, but even then, one fourth (n = 8) out of 39 women experienced it on always/mostly basis. Physical violence, such as hitting, pushing, or kicking, was reported by 5% of women, and among these, 16% to 18% reported experiencing it frequently. Physical violence, such as using a gun or choking, was much less prevalent (about 1%-1.5%), and among those participants who reported it, 30% to 40% women reported experiencing it on always/mostly basis.

Controlling behavior (70.1%) and physical violence (67.0%) had a larger number of women exposed to severe acts, whereas emotional (80.3%) and sexual violence (84%) had a majority of women exposed to moderate acts of violence. However, both emotional (19.7%) and sexual (16%) violence involved a significant percentage of women who reported severe forms of these acts (Figure 2). We found that 21% (n = 396) of participants reported only one type of violence (controlling behavior, emotional, sexual, or physical), about 11% (204) mentioned two types of violence, 6.8% (129) reported experiencing three types of violence, and 4.3% (n = 81) reported experiencing all four types of violence during their lifetime (Figure 3.)

Figure 2.

Percentage of married Saudi women reporting moderate and severe forms of domestic violence in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

Figure 3.

Frequency of Saudi married women exposed to single or multiple types of violence in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

Univariate analyses revealed that younger age was associated with violence, with younger ages having higher odds of violence (51-60 years, odds ratio [OR] = 1.5, 95% confidence interval [CI] = [1.0, 2.2]; 41-50 years, OR = 1.6, 95% CI = [1.1, 2.4]; and 30-40 years, OR = 1.8, 95% CI = [1.2, 2.6]; reference category 61-75 years old; see Table 2). Married and divorced women had higher odds of violence (OR = 2.2, 95% CI = [1.5, 2.9] and OR = 2.5, 95% CI = [1.6, 3.9], respectively) compared with widows. Women living in apartment also had an increased odds of violence (OR = 1.3, 95% CI = [1.1, 1.7]) for violence compared with those living in a villa. Participants who had been married for 30 years or less had higher odds of reporting violence (<10 years, OR = 1.4, 95% CI = [1.1, 1.8]; 10-20 years, OR = 1.5, 95% CI = [1.2, 1.9]; 21-30 years, OR = 1.4, 95% CI = [1.1, 1.8]) compared with women married for more than 30 years. Perceiving one’s health as poor or fair were both associated with higher odds of reporting violence (OR = 2.0, 95% CI = [1.2, 3.4] and OR = 2.3, 95% CI = [1.6, 3.2], respectively) compared with those reporting excellent health. Women who had spouse with an intermediate/secondary level education versus graduate/postgraduate education (OR = 1.2, 95% CI = [1.0, 1.5]), skilled workers versus doctors/engineers (OR = 1.3, 95% CI = [1.0, 1.7]), having two or more wives versus one wife (OR = 1.3, 95% CI = [1.3, 2.0]), and husband having health problems (OR = 1.9, 95% CI = [1.5, 2.5]) were at higher odds for reporting violence. None of the chronic diseases were significantly associated with violence (results not shown).

Tangible social support in form of “being taken to the doctor” was available to the majority (73%) of respondents all the time, followed by help with daily chores (67% of participants). However, support in the form of emotional, informational, and positive social interaction was reported as available for only 62% of participants. Univariate analyses (Table 3) revealed that women having low social support related to someone who would listen and to whom the participant could talk (OR = 1.9, 95% CI = [1.3, 2.6]), someone who could take the woman to the doctor (OR = 1.7, 95% CI = [1.4, 2.2]), someone with whom to discuss problems (OR = 1.5, 95% CI = [1.2, 1.9]), or someone to help with daily chores (OR = 1.4, 95% CI = [1.1, 1.7]) were associated with higher odds of reporting violence compared with those having social support available all the time. A significant but weak negative correlation was observed between age in years and all four types of social support (–.17, p < .01), indicating decreased social support with increasing age. The correlation between monthly income levels and social support was also negative and significant (–.10, p = .04). No significant correlation was observed between social support and polygamy. Violence was reported more frequently in the early years of marriage as compared with women who were married since 30 years.

Table 3.

UOR and 95% CIs for Social Support Variables Associated With Violence in Saudi Married Women in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

Variable	N = 1,883	Abused n = 810n (%)	Not Abused n = 1,073n (%)	UOR (95% CI)
Social support
Someone to listen/and talk to
Mostly/always	1,170	468 (57.8)	702 (65.4)	1.0
Sometimes/rarely	567	261 (32.2)	306 (28.5)	1.3 (1.0, 1.5)
Not at all	146	81 (10.0)	65 (6.1)	1.9 (1.3, 2.6)
Someone to take you to the doctor
Mostly/always	1,379	556 (68.6)	823 (76.7)	1.0
Sometimes/rarely	362	196 (24.2)	166 (15.5)	1.7 (1.4, 2.2)
Not at all	142	58 (7.2)	84 (7.8)	1.0 (0.7, 1.4)
Someone to discuss problems
Mostly/always	1,175	456 (56.3)	719 (67.0)	1.0
Sometimes/rarely	552	271 (33.5)	281 (26.2)	1.5 (1.2, 1.9)
Not at all	156	83 (10.2)	73 (6.8)	1.8 (1.3, 2.5)
Someone to help with daily chores
Mostly/always	1,271	510 (63.0)	761 (70.9)	1.0
Sometimes/rarely	491	235 (29.0)	256 (23.9)	1.4 (1.1, 1.7)
Not at all	121	65 (8.0)	56 (5.2)	1.7 (1.2, 2.5)

Note. UOR = unadjusted odds ratios; CI = confidence interval.

The final analysis included the multivariate binary logistic regression modeling. Three different models were developed based on different set of predictors, except the last final model (Model IV), where we added the perceived health. The final Model IV revealed that young age, lack of social support and perceived poor health, and spouse health and polygamy were associated with violence (Table 4). Younger age groups (30-40 years: adjusted odds ratio [aOR] = 1.9, 95% CI = [1.3, 3.0]) was associated with increased odds of reporting violence compared with age 61 to 75 years. Women with low emotional support had higher odds of reporting violence (aOR = 1.7, 95% CI = [1.2, 2.5]) compared with those for whom social support was always/mostly available. Lack of tangible support to take the woman to the doctor was also associated with reporting violence (aOR = 1.4, 95% CI = [1.1, 1.9]) compared with those for whom social support was always/mostly available. Women having poor (aOR = 1.7, 95% CI = [1.0, 3.0]) and fair (aOR = 2.2, 95% CI = [2.1, 1.5]) perception about self-health had a higher odds for reporting violence compared with those who reported good/excellent perceived health. Women who reported their spouse as having two or more wives (aOR = 1.6, 95% CI = [1.2, 2.0]) and the spouse having a health problem (aOR = 1.9, 95% CI = [1.5, 2.6]) were at higher odds of reporting domestic violence. No association was observed with different chronic diseases, smoking, and reproductive health variables.

Table 4.

Adjusted Odds Ratios and 95% CIs for Sociodemographic, Spouse-Related Variables, Social Support and Perceived Health Associated With Violence in Saudi Married Women in Riyadh, Kingdom of Saudi Arabia (N = 1,883).

Variable	Model 1^a	Model 2^b	Model 3^c	Model 4^d
Age group (years)
61-75	1.0 (Ref)	1.0 (Ref)	1.0 (Ref)	1.0 (Ref)
51-60	1.8[1.1, 2.9]	1.6 [1.0, 2.7]	1.5 [0.9, 2.6]	1.6 [0.9, 2.8]
41-50	1.8 [1.1, 3.0]	1.9 [1.1, 3.1]	1.8 [1.1, 2.9]	1.8 [1.1, 3.1]
30-40	2.1 [1.3, 3.4]	2.4 [1.5, 4.1]	2.2 [1.3, 3.7]	2.4 [1.4, 4.0]
Number of wives husband has
Only 1	—	1.0 (Ref)	1.0 (Ref)	1.0 (ref)
≥2		1.6 [1.2, 2.1]	1.6 [1.2, 2.1]	1.6 [1.2, 2.0]
Husband health problem^e
No	—	1.0 (Ref)	1.0 (Ref)	1.0 (Ref)
Yes		1.9[1.4, 2.6]	1.9 [1.4, 2.6]	1.9 [1.5, 2.6]
Someone to discuss problems
Mostly/always	—	—	1.0 (Ref)	1.0 (Ref)
Sometimes/rarely			1.3 [1.0, 1.7]	1.3 [1.0, 1.6]
Not at all			1.7 [1.1, 2.6]	1.7 [1.2, 2.5]
Someone to take you to the doctor
Mostly/always	—	—	1.0 (Ref)	1.0 (Ref)
Sometimes/rarely			1.5 [1.1, 1.9]	1.4 [1.1, 1.9]
Not at all			0.8 [0.5, 1.2]	0.8 [0.5, 1.3]
Perceived health
Excellent	—	—	—	1.0 (Ref)
Good				1.1 [0.8, 1.5]
Fair				2.2 [2.1, 1.5]
Poor				1.5 [1.0, 3.0]

Note. CI = confidence interval.

Model adjusted for participant’s occupation and income.

Model adjusted for participant’s occupation and income; spouse education and occupation.

Model adjusted for participant’s occupation and income and doctor-diagnosed heath status; spouse education and occupation.

Responses to type of health problem included chronic diseases such as hypertension, diabetes mellitus, sexual problems, etc.

Discussion

This is one of the few studies conducted in Saudi Arabia that explored the prevalence and characteristics of domestic VAW, and more specifically IPV. IPV is a term that has replaced domestic violence, reflecting the “violence against women by husband or other intimate partner.” Such violence is now widely recognized as a serious public health problem that affects the well-being of women (WHO, 2013).

Until quite recently, VAW was a hidden problem in Saudi Arabia, but over the past few years, a growing body of evidence has highlighted the magnitude of this problem among women (Afifi et al., 2011; Alzahrani et al., 2016; Barnawi, 2017; Eldoseri et al., 2014; Fageeh, 2014; Tashkandi & Rasheed, 2009). The results of the current study clearly showed that IPV, which refers only to the husband in Saudi Arabian culture, is a frequent problem. The lifetime IPV rate of 43% observed in this study, for any type of violence, falls within the range reported by previous studies from Saudi Arabia (Eldoseri et al., 2014; Tashkandi & Rasheed, 2009). Overall, studies from the Arab region have provided contradicting results on the prevalence of IPV, and this variation could be due to methodological differences across the studies (Afifi et al., 2011; Alzahrani et al., 2016; Barnawi, 2017; Eldoseri et al., 2014; Fageeh, 2014; Tashkandi & Rasheed, 2009).

Controlling behavior was the most frequently reported persistent and severe type of abuse reported by Saudi women in our study (36.8%). In the WHO, multicountry study on IPV, the proportion of women who reported controlling behaviors by their husband or intimate partners ranged from 20% in Japan to 90% in Tanzania (WHO, 2005). In our report, the severe form of controlling behaviors was more frequently reported than the moderate form (80% reported having to seek husband’s permission to see a doctor all the time). This suggests great variation in the degree to which such severe controlling behaviors are acceptable normative behavior in patriarchal cultures (Almosaed, 2004; Somach & AbouZeid, 2009). Violation of basic women’s rights, such as prohibiting seeking health care or meeting one’s family, are severe acts and against the teachings of Islam (Kposowa & Aly Ezzat, 2019). Educating the masses in the context of Islamic teachings may help to change the thinking regarding such behavior (Kposowa & Aly Ezzat, 2019).

Although the prevalence of reporting physical abuse in this study was low in comparison with international data (WHO, 2005), the majority (67%) of those reporting such abuse reported the severe form; similar findings were reported by Tashkandi and Rasheed (2009). The low reporting may be due to the fact that in many societies, including Saudi Arabia, domestic VAW is considered a private matter (Almosaed, 2004; Kposowa & Aly Ezzat, 2019), until and unless it leads to fatal injuries. Such societies accept and justify domestic (specifically, controlling behavior and emotional violence) VAW based on cultural and social norms (Al-Badayneh, 2012; Kposowa & Aly Ezzat, 2019).

We observed that although the overall prevalence of reporting threatening behavior was low (whether emotionally or physically), majority of women reported it as always/mostly. A recent review by Guedes et al. has highlighted the similarities between VAW and violence against children (Guedes, Bott, Garcia-Moreno, & Colombini, 2016). Apart from observing violence during childhood, a child who experiences threatening behavior during childhood may tend to adapt it during adulthood. Therefore, just to focus on violence during childhood may not be sufficient; further, studies are required to study the overall upbringing of the perpetrator. In addition, “threatening attitude” is a convenient way of getting your commands fulfilled, which may make the spouse (women’s husband) gradually accustomed to it (Almosaed, 2004). Proper awareness and education can help in understanding the long-term health risks associated with “threatening attitude” in comparison with short-term gains (WHO, 2016). Participants reporting all four types of violence were younger (M age of 40 years) as compared with women reporting any single type of violence (M age of 46 years), emphasizing the role of age in getting exposed to violence.

Both, social conditions and social relations tend to play a significant role in causing violence against Saudi women. Our study found that young age of women (OR = 1.9), husband’s poor health status (OR = 1.9), polygamy (OR = 1.6), self-perceived poor health status of women (OR = 2.2), and lack of social support (OR = 1.7) were associated with abuse by husband. Young women in regional and global studies have repeatedly been shown to have higher rates of victimization compared with older ones (Abramsky et al., 2011; Kposowa & Aly Ezzat, 2019). This pattern may reflect that violence is more likely to begin early in many relationships and marriages (Alzahrani et al., 2016; Kposowa & Aly Ezzat, 2019). In addition, with increasing knowledge and access to information and services, younger women might be aware that IPV is unacceptable and, therefore, more likely to report it (WHO, 2013).

Although it is a subjective matter, self-reported health or poor perceived health is a well-established consequence of violence, as noted by research studies and reviews (Abramsky et al., 2011; Brewer, Roy, & Smith, 2010; Dillon et al., 2013; Tashkandi & Rasheed, 2009). In the WHO study on IPV, women who had ever experienced physical and/or sexual partner violence were more likely to report poor health than women who had never experienced partner violence (Abramsky et al., 2011). The perceived ill-health by abused women noted in this and other studies reveal that the physical effect of violence may last long after the actual violence has ended (Abramsky et al., 2011). Furthermore, the cumulative abuse may further affect health negatively (Abramsky et al., 2011). This factor not only is associated with abuse in a woman but also could be an indication of the long-term consequences of violence on the physical and mental health status of women (Brewer et al., 2010).

Poor social support was more likely to be associated with violence, and this is in consistency with studies from industrialized nations as well as developing countries (Coker et al., 2004; VanderEnde, Yount, Dynes, & Sibley, 2012). A recent report by United Nations Organization (UNO; 2015) found that majority of women suffering from domestic violence tend to seek help from their families and friends rather than from formal organizations. This may be because support in the form of families/friends is available all the time irrespective of any formalities and disclosures. A greater proportion of women (73%) in our study mentioned availability of tangible support all the time, in comparison with 62% women who mentioned availability of emotional support all the time. We may conclude that tangible support for transportation or household chores may not be an issue for Saudi women suffering from domestic violence; however, seeking permission for health care and emotional support should be available for all women. Along with formal organizations, social programs and small gatherings at the community level should be encouraged where women can mingle and acquire relevant information and feel emotionally supported.

In terms of husband-related risk factors, women in our study whose husbands had health problem had higher odds for reporting violence. The health problems ranged from common types of chronic diseases (hypertension, diabetes) to old-age problems. We recommend that health care providers should inquire about physical, mental, and sexual health during consultations, as this may be the underlying cause for frustration and violence (Somach & AbouZeid, 2009). We found that wives of husbands who had two or more wives were at higher odds of reporting violence compared with being a single wife. Furthermore, analysis revealed that physical (13% vs. 8%) and controlling (46% vs. 34%) behaviors, specifically, were more frequent among these women (husband having≥two wives). The fact that polygamy was associated with IPV is of concern, because this practice is frequent in Islamic societies; therefore, we need further studies from different countries to confirm this finding.

Our study had several strengths and a few limitations. First, this is one of the few community-based studies that has carefully looked at the social determinants and characteristics of the perpetrator. Second, validated instruments were used to measure domestic violence and social support. A team of experts helped us in categorizing the different acts of violence under moderate and severe category, which can be used by future studies as well. The few limitations included that results may be generalizable to urban areas of Saudi Arabia; however, studies from rural areas may show different findings. Another limitation was that we could not establish temporal relations of factors to reported violence and thus causality, as it was a cross-sectional study.

Conclusion and Recommendations

IPV is a frequent occurrence in Saudi Arabia, with younger women and those without social support reporting the highest prevalence. The high prevalence of VAW will lead to an increase in the long-term consequences like mental and physical health problems. A national strategy on domestic violence and an action plan for prevention and intervention were enacted upon based on newly approved national legislation (the law of protection from abuse, August 2013). However, the legislation actually needs to be implemented. Formation of formal/ informal social groups should be encouraged so that support is always available for such women. Furthermore, improvement of local policies, protection services, and legislation that focus on a multifactorial approach and provide responses to the problem should be introduced (Jewkes, Flood, & Lang, 2015; WHO, 2015). The implementation of a public health perspective will offer a way of capturing the many dimensions of the phenomenon to develop a better action plan based on evidence and best practices (Jewkes et al., 2015; WHO, 2015).

Footnotes

Acknowledgements

We shall like to thank the Deanship of Research, Research Chairs program, King Saudi University for facilitating us in conducting this study. We acknowledge the support provided by Princess Nora Bent Abdallah Research Chair for Women health research for successfully conducting this study. We would like to thank the Ministry of Health for their support and facilitating us to conduct this study in the primary health care centers. We also like to acknowledge all the participants for their time and cooperation.

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 financially supported by the Deanship of Research, Research Chairs Program, King Saud University, Riyadh.

Author Biographies

Aljohara M. Alquaiz is a family medicine professor and consultant family physician and director of the Princess Nora Bent Abdallah Research Chair for Women health Research. She has interest in the holistic health of women.

Maha Almuneef is a an associate professor and pediatric consultant and director of the National Family safety program. She has special interest in violence against women and is involved in developing safety policy and programs for women all over the Kingdom.

Ambreen Kazi is a family physician and a public health researcher. She has special interest in the mental and social health of women.

Aljohara Almeneessier is a family physician and vice dean in the department for Medical Education, Female section. She has special interest in women health.

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