Factors Affecting Domestic Violence: A Qualitative Study

ORIGINAL ARTICLE Background: It seems that violence is a critical issue that requires further research in order to offer new effective solutions in tune with the needs and context of the societies. The current study aimed to explore the influential factors for the incidence of domestic violence. Methods: The current research is a qualitative study conducted using content analysis. Study population included all patients admitted in the hospital to receive healthcare services. The sampling was conducted by interviewing with 50% of the hospitalized patients to assess their primary status, followed by selecting those who were found to be faced with violence. At this stage, 40 patients hospitalized as a result of domestic violence were included. Semistructured interviews and open-ended questions were used to collect data. Results: The interviews revealed that poverty; addiction, underlying psychological disorders, delinquency, infertility of victim, family and cultural differences, inability to create emotional relationships, low educational level, low monthly income, high-risk sexual relationships, and ignoring moral codes are among the causes of domestic violence. Conclusion: It is obvious that the exact number of victims is hard to be estimated. It seems that lack of the legal, social, cultural, and economic supports results in persistence of violence creator factors at both family and society levels. It seems that performing legal solutions, strengthening social services, and paying more attention to violence creators are necessary when considering domestic violence.


Introduction
Violence, in two forms of domestic and public, is considered as a deep concern in both developed and developing countries. Various forms of violence have been introduced based on the cultural and local contexts (Ardabily et al., 2011). Violence is referred to as the intentional use or misuse of the force or physical power to threaten other individuals, which results in injury, psychological harm, mal development, various types of deprivation, and even death (Garcia-Moreno & Watts, 2011). In 2015, the World Health Organization (WHO) considered domestic violence as a health crisis (Buzawa & Buzawa, 2017). Experts asserted that the physical violence encompasses all forms of physical injury driven by being hurt by rigid objects, hand, and other actions that lead to broken bones or burn. Sexual violence includes all unmoral and unusual types of sexual activities such as indifference and forced sexual intercourses (Ghahari et al., 2005) Psychological violence is defined as subjecting or exposing someone to anxiety, blame, affront, accusation, deprivation, and social deprivation. Finally, economic violence is depriving individuals from their economic needs, forced mendacity, and income confiscation (Krahé, 2018). Although both males and females may be faced with violence, studies have shown that the domestic violence is more common for males. Firouzjaeean et al., for instance, demonstrated the incidence of different forms of violence among men (Firouzjayaan et al., 2016). Furthermore, several lines of evidence have revealed that a variety of factors can play roles in domestic violence, including patriarchy (Zare Shahabadi & Nadarpoor, 2016) personal characteristics, cultural anomalies, family values, structure of both family and society, poverty, (Jura & Bukaliya, 2015) supporting men"s violence against women, moral crisis, social injustice, unemployment, (Aliverdinia et al., 2013) job and low income of family, childhood neighborhoods, (Marshall & Furr, 2010) addiction and criminal conviction of husband (Sheikhan et al., 2014) insufficient support of women in family, lack of dowry, and religious beliefs of husband (Kamal, 2013). Based on the above-mentioned ideas, it seems that violence is a critical issue that requires further research in order to offer new effective solutions in tune with the needs and context of the societies. The current study aimed to explore the influential factors for the incidence of domestic violence.

Methods
This qualitative study was conducted to identify the effective factors on the incidence of violence in a hospital in Tehran, Iran, in 2018. Study population included all patients admitted in the hospital to receive healthcare services from September 2018 to March 2019. The sampling was performed by interviewing with 50% of the hospitalized patients to assess their primary status, which was followed by selection of those who were faced with violence. The inclusion criteria for this study included those patients who were under domestic violence. Finally, 40 patients were selected for the study. Semi-structured interviews and open-ended questions were used to collect data. Each interview took 20 to 25 minutes in average.
Interviews continued to the saturation point and to evaluate validity, accuracy, and reliability of the qualitative data were measured by four criteria: credibility, transferability, dependability, and confirm ability. Content analysis was also used to analyze the data. In this regard, coding and categorizing were under taken. All interviews were analyzed using MAXQDA 10 software; all interviews were initially transcribed and then two separate researchers reviewed them, and then the primary codes were extracted. Ultimately, categories were developed. Prior to the interviews, participants filled out the informed consent forms and were informed about the data collection methods, confidentially terms, and the recording procedure of the interviews. Overall, moral factors and the participants' satisfactions were respected. This study was approved with the code BH-MEC-

Results
Our findings showed that the all participants were women with an age average of 34 years old. Of all participants, 15 were housewives, 3 were unemployed, 1 was homeless, 1 was labor-child, 6 were daily workers (blue-collar workers from lower levels of the society), 3 were employee, 7 were student, 1 was retired, and 3 were unemployed. With regard to education, 3 of the participants held the upper-diploma degree, 3 were students, and 5 were illiterate. Others had diploma or lower degrees. According to the findings, violence was most significantly committed by husbands. Among participants, 20 noted that they were aware of the committed violence, while 20 were unaware of it. Eight interviewees tried to change the situation and started to resist as they noticed violence. However, 32 unaware participants did not resist against violence due to the cultural and social issues. Violence cases were mostly committed by husband, partner, father, mother, and children, respectively. Moreover, victims failed to cope with or prevent from the persistence of violence toward them. In the current study, domestic violence was divided into four categories and some of its examples are demonstrated in Table 2.
According to the findings, causes of violence were classified into 10 categories. Analysing interviews revealed presence of poverty, addiction, underlying psychological disorders, delinquency, infertility of victim, family and cultural differences, inability to create emotional relationships, low educational level, low monthly income, high risk sexual relationships, and ignoring moral codes.

Poverty
Poverty was the most frequent influential factor. Poor financial status and its consequences not only result in aggressive behaviours but also have serious adverse effects on the society. Poverty can cause incidence of a variety of violent behaviours at the society level. Lack of considering physical health of the individual and family members, which results in psychological and physical violence, is among the most conspicuous examples of the domestic violence.
For example, a 42 years old man, who could not afford treatment costs for her wife said: "my wife was pregnant unwillingly with her fourth child. Last week she became sick and we went to visit a doctor who said that she had to be hospitalized, but I could not afford the costs of hospitalization. She took some pill at home and suddenly became unconscious. Ambulance brought her here, but both mother and child died." Furthermore, child labour phenomenon can be mentioned in this regard. "It was in the morning that my father told me: you have to go to your workplace, the crossroad. The weather was cold and I did not want to go out. He throws a pot toward my head and I then I could not remember anything. He used to hit me with his belt several times" (P1).
Another consequence of poverty resulting in economic and psychological violence was early marriage (also called child marriage) and forced leave of school. "In our house, the only person who works is my nineteen-year old brother and other four children are consumers. My father is old and cannot work. As the family could not afford the costs, he did not let me go to school. I will get married in the next week and there will be one less mouth to eat (P19)." Another participant mentioned a story about physical and economic violence: "my husband never accepts the responsibility of our living costs. Initially, I was making money for myself by sewing, but now he asks me to provide his drugs. If I refuse to do so, he starts hurting me" (P10).

Addiction
The second important cause of violence in the current study was addiction. Addiction results in aggressive behaviours such as physical aggression.A participant noted that: "he was using drugs; suddenly, he stood up and threw me at the door. The glass was broken and he attacked me again with broken glasses. I did not notice how I was taken to the hospital!" (P21). Additionally, anxiety and concerns, arisen from lack of physical security at home, were among the examples of psychological violence. In this line, a participant who has experienced physical and psychological violence noted that: "my husband is always angry (using drugs or not) and beats me and even our daughter. Recently, he burned her with boiled water! Whenever, he comes home, we both get scared!" (P4).

Underlying psychological disorders
Apparently, psychosomatic diseases can result in aggressive behaviours and physical violence. One of the participants said: "when my son was 16, I noticed that his behaviours had become odd and aggressive. Psychologist said that the boy had schizophrenia. Now, we are living together. He forced his father to leave us due to his hating of him. He had a good relationship with me, but he sometimes threatened me to death. Finally, he attacked me with a knife! Neighbours saved me; unless, I do not know what would happen!!!" (P22).
Another participant explained a story about physical and mental violence: "my husband has mental problem; for a while he did not use any medicines. He gets annoyed with our children with no reason. My daughter"s university exam was finished, he hit her and said that she must be a physician in the future, but she could not. She took pills to commit suicide!!!"(P26).
Another participant told a story about sexual and psychological violence: "my husband has mental problems. He always thinks that I cheat on him. He always forces me to have sex with him, during which he uses vulgar words" (P7).

Delinquency
Findings illustrated that delinquency could be the cause of violence. For example, one patient who suffered from domestic violence said: "my father forced me to buy drugs for him, one day I was playing with my friends, he asked me to buy drugs and I refused; then, he hit me and broke my hand". (P18)

Victim of infertility
In the current study, lack of physical health brought out domestic violence. One of the participants said: "after three years of marriage, I found that I could not deliver a child, after some years my husband told me that he wanted to marry with another person who could bring children for him.

Create emotional relationships
Findings of the current study showed that the most common reasons for problems between couples wee inability to create emotional relationships as well as family and cultural differences. Severe dependency of the man or woman to her/his family and lack of independence can result in different types of violence. As one of the psychological violence victims said: "we lived together for sixteen years and my husband had enough money to buy a house, but he did not accept to leave the building, because his brother was living there. He always used to compare me with his brother"s wife and blamed me. Now, it is about ten years that I have been taking psychological medicine, he calls me mad" (P16). This participant had depression because of years of psychological violence.
On the other hand, being faced with emotional indifference and physical health ignorance can result in both physical (physical violence) and psychological harms (psychological violence). A participant said: "My spouse never pays attention to me. Whenever I told him that I had stomach ache, he ignored until the doctor told me that I was sick. I had a surgery and they removed my uterus" (P24).

Low educational level
Findings demonstrate that most people who suffered from violence had low levels of education. Table 1 show the educational degrees of those who suffered from violence.

Sudden decline of family income
Based on our findings, parents' income oscillation and unemployment were other factors that created tension. It seems that anxiety resulted from sudden income drop can significantly increase the domestic violence. An interviewee mentioned the important factors about psychological violence: "my father was bankrupt for several times and started his business with perseverance. Because of that, my mom is continuously repeating that she will leave us. I cannot get accustomed with this!!!"(P30). In this case, income oscillation led to further damages such as divorce, which has its own social consequences.
Another participant explained about the physical and psychological violence: "after he lost his job, he started insulting us (his family), smoking, and hitting my children. I know he is sorry about that, but I cannot tolerate this situation anymore" (P15)

High risk sexual relationships
Further investigations over the participants' living conditions revealed that respecting moral codes was another important criterion that could strengthen the family and increased its welfare. In terms of physical and psychological violence, an interviewee noted that: "for a long time, I knew that my mother had a boyfriend. Once, I saw them together, we had a severe discussion, which ultimately led to a physical dispute. After that, I left our home. Now that my parents got divorced, she levelled up her relationship with that man, who makes me nervous and crazy" (P37).

Ignoring moral codes
Commitment to moral codes can secure people from some types of violence mentioned above. One of the participants said: "my boyfriend was insisting on sexual intercourse. He promised that we would get married, which convinced me to continue having sex with him. When I told him that I was pregnant, he said "only God knows who else you had sexual intercourse with!!!" (P27). In this case, the victim accepted to have sexual intercourse, but after pregnancy, she was blamed, which is an example of psychological violence.

Discussion
Findings of this study showed that women were more subjected to domestic violence than men. Based on Iran"s social context, it seems that violence against men is a taboo and may be men do not like to talk about it. Hunter et al. also reported that women were at a higher risk of violence than men. Since majority of participants were living in poor conditions, they were forced to work with a low salary to afford living expenditures (Hunter et al., 2016). Furthermore, the highest rate of violence was committed by husbands. A large number of studies proved acceptance of patriarchy by women (Alhabib et al., 2010;Kiani, 2014 (Hunter et al., 2016). Another study also noted that men"s violence was a serious problem in marital relations, which surely had substantial physical and psychological impacts on the wife, family, and the society (Jahromi et al., 2016). In the current study, psychological, physical, economic, and sexual violence had the highest prevalence rates, respectively. The sexual issues are a taboo in Iranian society and no enough space exists to increase awareness of the youth appropriately and efficiently. So, it can be concluded that the society either is not aware of the violence or refuses to accept it. Various studies indicated that psychological-verbal violence had the highest prevalence ( Narimani & Aqamohamadian, 2005;Sheikhbardsiri et al., 2018). On the contrary, Shrestha in a study on pregnant women revealed that sexual violence had the highest prevalence (Shrestha et al., 2016).
In the current study, the following factors were identified as the main causative factors of violence: economic problems and poverty, addiction, previous psychological disorders, delinquency, victim of infertility, insufficient attention toward the children, family and cultural differences, and inability to create emotional relationships, low educational level, low monthly income, and addiction of victim, dangerous sexual relationships, and ignoring moral codes.
Överlien emphasized that a history of psychological disorders, lack of commitment and ignoring moral codes, and addiction (both narcotics and alcohol) were the main violence creators (Överlien, 2017). In addition, Montero et al. referred to having a history of psychological disorders in the family of the person who conducted violence, as the main causative factor of violence (Montero et al., 2011). Furthermore, a study conducted by White showed that the patriarchy, poverty, unemployment, ignoring family's problems, and alcohol addiction were the leading factors that gave rise to violence (White, 2004).
Comparing international and Iranian studies showed that poverty had a more important role in incidence of domestic violence in Iranian population; (Arjmand Siapoush & Ajam Dashtinezhad, 2010;Bagrezaei et al., 2017;Hassan et al., 2010). It seems that the current economic problems cause a huge impact.
Meanwhile, international studies represented that the poverty was among the minor factors with lowest impact on violence. For instance, a study conducted by the WHO reported that in the USA and European countries, families with high income represented lower rates of violence (World Health Organization, 2002). According to the findings of our research, lower literacy level caused higher chance of violence commitment. Narimani showed that increased levels of education among women decreased commitment of violence against them (Narimani & Aqamohamadian, 2005).
With these findings in mind, having a job is considered as an important factor for preventing violence commitment; in other words, unemployed men or sudden decreased levels of income increased the frequency of violence. In this regard, blue collar workers committed the most cases of the registered violence. A study conducted in Iran showed that blue collar workers and unemployed people committed the highest levels of violence, respectively. Comparing these two studies shows that economic status of the man, his income, and generally his social status influence his violence commitment (Arefi, 2003). Participants' trust was not easily achieved. Initially, most of them resisted to answer our questions. In most cases, participant"s families were not interested to participate, which was another important limitation.

Conclusion
The current study was conducted in six months and the findings showed that lack of legal, social, cultural, and economic supports were highly probable to result in persistence of violence creating factors at both family and society levels. Violence by father, mother, husband, children, and the others results in physical and psychological harms along with a plethora of psychological consequences of violence, including humiliation, menace, mocking, and ignorance, which in turn lead to or exacerbate physical diseases such as cardiovascular diseases, diabetes, neurologic disorders and even hospitalization. Therefore, it can be concluded that no clear distinction was observed between these two types of violence (physical and psychological). It seems that performing legal solutions, strengthening social services, as well as paying more attention to violence creators are necessary in considering domestic violence.