Lifetime Prevalence of Emotional/Psychological Abuse among Qualified Female Healthcare Providers

The purpose of this study was to determine the lifetime prevalence of emotional/psychological abuse among married female healthcare providers in tertiary care hospitals in Karachi, Pakistan. A descriptive cross-sectional study was conducted in a sample of 350 married female nurses and doctors, recruited from three tertiary healthcare hospitals (one public and two private). This study used the self administered modified truncated WHO multi-country questionnaire. Descriptive and univariate analysis was performed. Of the total sample of 350 female married healthcare providers, 97.7% (n = 342) were reported with one or more forms of domestic violence at some point in their married life, whereby 62.6% (n = 214) lifetime prevalence of emotional abuse was found due to any forms of violence. The univariate analysis showed that those female healthcare providers who had done their diploma were more prone to emotional abuse 46.7% (n = 100). And, nurses experienced more emotional abuse 57.9% (n = 124) in their life than doctors. Moreover, there was a significant difference of emotional abuse among those participants’ husband who used and do not use alcohol (p = .009). The most common study participants responses against emotional abuse were: 62% (n = 212), verbally fighting back, 15.2% (n = 52) keeping quiet, 27.2% (n = 93) talking to husband, family/friends, 7% (n = 24) returning to parents’ home and 5.8% (n = 20) attempting suicide. Domestic violence leads to emotional scars and should be considered as an inhuman act. However, its prevalence exists in every culture and more so in underdeveloped, economically challenged cultures. Emotional abuse is frequent among nurses and doctors. Socio-demographic factors of women have been identified as one of the determinants of emotional abuse among healthcare professionals. Future research should investigate emotional abuse patterns not only for professional women but also for housewives.


Introduction
Emotional/psychological abuse is one of the considerable abused which usually followed by other form of domestic violence, including verbal, physical, and sexual. Domestic violence (DV) is not a new phenomenon in a married woman's life. It is exist around the world the WHO (2005) report identified that worldwide life time prevalence of domestic violence ranged between 15% -71% and was particularly high in male dominated societies. In Pakistan 70% -90% women are experiencing some form of domestic violence (Ali & Bustamante-Gavino, 2007;Ali & Gavino, 2008;Karmaliani, Irfan, Bann, McClure, Moss, Pasha et al., 2008).
However, emotional abuse is given less attention than other forms of abuse, such as physical abuse (O'Leary, 1999). Emotional/Psychological or non-verbal abuse, can be defined as intentional use of power, including the threat of physical force, against another person or group that can result in harm to physical, mental, spiritual, moral, or social development (Krug, Mercy, Dahlberg, & Zwi, 2002). Yelling, name-calling, blaming, shaming, isolation, intimidation, and controlling behavior also fall under emotional abuse (Ali & Bustamante-Gavino, 2007;Fikree, Jafarey, Korejo, Khan, & Durocher, 2004). Additionally, abusers who use emotional or psychological abuse often throw in threats of physical abuse (Sami & Ali, 2006). The UNICEF report (2000) highlights that "emotional torture and living under terror is often more unbearable than physical brutality, with mental stress leading to a high incidence of suicide and suicidal attempts" (p. 4).
Studies indicate that women who are emotionally/psychologically abused may get mental health consequences such as depression, fear, anxiety, low self esteem, sexual dysfunction, stress disorder with dissociation, eating disorder, obsessive compulsive disorder, classic post-traumatic, flashbacks, self harm, and even the development of multiple personality disorders and the outcome may be suicide or homicide (Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008;Herman-Lewis, 1992;Humphreys & Thiara, 2003;WHO, 2002). Emotional abuse embraces feeling anxious, depressed, or upset due to conflicts with husband and/or in-laws. Taket, Nurse, Smith, Watson, Shakespeare, Lavis et al. (2003) highlighted that different forms of abuse may occur together or on their own, although always in the context of coercion control of one partner over the other, and most of the time that was the male partner. Interestingly Mega, Mega, Mega, and Harris (2000) considered psychological abuse as "brainwashing tactics" by the perpetrator, which has five common features: isolation, unpredictable attacks, accusation, humiliation, and threats (p. 206).
This paper determined the lifetime prevalence of emotional/psychological abuse among married female healthcare providers working in tertiary care hospitals in Karachi, Pakistan.

Methods
A descriptive cross-sectional study design was used to fulfill the objective of the study. The inclusion criteria was: (1) female nurses and doctors, (2) currently or previously married (divorced, widowed, and separated), (3) working in selected departments of the selected one public and two private hospitals, (4) and willing to participate voluntarily and sign a consent form. The multi-stage sampling technique was used to collected data. Sample size calculation was done by using epi info version 16.0. For the current study, a structured modified truncated version of WHO Multi-country Study on Women's Health and Life Experiences tool (2005) was used. In Pakistan, this tool has already been modified in few research studies with divers' population (Ali, Asad, Mogren, & Krantz, 2011). The WHO (2005) tool has already been tested in 10 different countries, and in these studies the Cronbach alpha were .81, .66, and .73, for physical, sexual abuse, and controlling behavior respectively. Moreover, the tool has already been tested in the Pakistani context, after translation into Urdu (the national language), and the Cronbach alpha for physical, sexual, and psychological violence were .87, .79, and .93, respectively (Ali et al., 2011). Epi info 3.5.1 was used to enter the data and which was later transferred to SPSS version 19 for analysis purpose. Ethical approval was taken from the institutional ethical review committee (ERC).

Response Rate
Initially, 500 nurses and doctors were contacted for the required 400 sample size; among them five nurses and doctors refused to participate from the beginning. Hence, 495 research questionnaires were dispatched, out of which 375 research questionnaires were received back; therefore, the response rate for the study was 75%. However, 25 research questionnaires were excluded as they were incomplete. Finally, altogether, 350 nurses and doctors participated in the study.

Result
The present study analysis showed that participants who were exposed to all forms of abuse were hurt emotionally, as shown in Table 1. Table 1 showed that of the 342 participants, two thirds (n = 214, 62.6%) reported exposure to emotional and psychological abuse at some point in their married life in response to any form of violence. Mostly, they were emotionally hurt after exposure to physical abuse (n = 203, 98.5%), and verbal abuse (n = 332, 96.1%), followed by sexual abuse by an in-law (n = 36, 75%) and sexual abuse by husband (n = 193, 27.5%). Table 2 shows the controlling behavior used by husband and/ or in-laws, 69.2% (n = 148) of the participants reported "tried to prevent from seeing friends", 67.8% (n = 145) reported "restricted contact with their family members", 67.3% (n = 144) "insisted on knowing where they were at all times", 65.4% (n = 140) of the participants exposed to emotional abuse when "they speak to another man", and 51.9% (n = 111) "often suspicious that they were unfaithful". Table 3 shows that the most common perpetrator of emotional/psychological abuse is husband 84.6% (n = 181), followed by mother in-laws 12.1% (n = 26). Father and Brother In-laws were reported as the least common (.9%) perpetrators of emotional/psychological violence. Table 3 also finds various emotional disturbances related to all types of violence; more than eighty percent (82.7%, n = 283) of the participants reported that they had been made sad or depressed in their life with respect to all or some form of abuse, followed by 44.7% (n = 153) participants who had thought about ending their life, whereas, 6.7% (n = 23) had actually tried to take their life. Table 4 The victims of all forms of abuse responded in six ways (see Table 4). The findings of this study highlight that, out of total, 62.2% (n = 214) emotional abuse participants, 62% (n = 212) participants were  The percentages do not add up to 100, due to multiple responses possible. Ever attempted suicide (n = 342) 23 (6.7) The percentages do not add up to 100, due to multiple responses possible. 'verbally fought back; against emotional abuse. 27.2% (n = 93) participants reported that they "talked to husband, family/friend" when they were exposed to emotional abuse, however, more than fifteen percent of the participants reported that they "remain quiet". Seven percent (n = 24) participants reported that they returned to their parents' home' after exposure to emotional abuse. Furthermore a few participants reported that they "attempted suicide" in response to emotional abuse (5.8%, n = 20) and only two participants reported that they "took legal action" for emotional abuse (.6%). Table 5 showed that there were total ten reasons for keeping quiet in response to emotional abuse and two thirds (68.4%, n = 234) of the participants kept quiet in response of all form of domestic violence. Of those, 30.4% (n = 65) participants used silence due to "fear of escalating of violence". More than twenty percent (23.4%, n = 50) reported that they remained quiet as it "would not make any difference or they felt helpless" and the problem would still persist. Followed by 8.4% (n = 18) remained quiet out of respect of elders/in-laws. Few (5.6%, n = 12; 3.3%, n = 7) used silent "for the sake of children" and "Husband will leave/ make her leave" respectively.

Domestic Violence by Socio-Demographic
The following demographic characteristics were compared in relation to the presence of domestic violence, through chi square or fisher exact test type of family, household socio-economic status (SES), professional qualifications, profession, husband's employment status, use of alcohol and substance abuse by husband. Table 6 showed that, SES, professional qualifications, profession, use of alcohol by husband were assessed with respect to emotional abuse. Table 6 findings showed a significant difference was found between households in varying SES categories (lower, lower middle, upper middle and upper SES) with respect to emotional abuse (p = .048). Those participants who belonged to the upper middle SES were more exposed to emotional abuse (58.9%, n = 126). Another significant difference was professional qualification (diploma, undergraduates and graduate) (p = .028). Those females who had done their diploma were more exposed to emotional abuse (46.7%, n = 100). Among the two groups of professionals (nurses and doctors) a significant difference was found (p = .017); nurses were more vulnerable to experience emotional abuse (57.9%, n = 124).  Overall, as far as husbands data is concerned, statistically chi square stayed significantly different with respect to the use of alcohol by the husbands (p = .009); those who used alcohol carried out more emotional violence (15.9%, n = 34).

Discussion
Present study reported high prevalence rates of domestic then other study; overall 97.7% reported a lifetime prevalence of any forms of violence, whereby 62.6% emotional abuse were reported by participants. According to WHO, the prevalence of overall domestic violence, worldwide, is 15% -71% (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2006), while in Bangladesh and rural India it is 20% -50% (Schuler, Hashemi, Riley, & Akhter, 1996;Jejeebhoy, 1998) and in Pakistan it is 70% -90% (Human Rights Watch Report, 2006). The present study reveals a higher prevalence rate of domestic violence. This might be because the majority of the research projects focus on community based settings where the majority of the participants do not know about the exact definition of violence and consider husband exercising violence as a normative cultural norm (Khawaja, Linos, & El-Roueiheb, 2008). However, this study has been carried out amongst the educated strata (doctors & nurses), who are well aware about violence identification and demarcation. Being educated, and especially being educated professionals, has helped women to perceive violence in a better way and to articulate their rights against any inhumane activity.
In the present study the prevalence of the emotional/psychological abuse was 62.6%. A study conducted in three South African provinces revealed that those women who were the victims of physical abuse also experience emotional abuse (Jewkes, Penn-Kekana, Levin, Ratsaka, & Schrieber, 2001). The identifies prevalence of the current study was much higher than the studies conducted in Iran 33.8% (Ardabily, Moghadam, Salsali, Ramezanzadeh, & Nedjat, 2011) and Saudi Arabia 35.9% (Afifi, Al-Muhaideb, Hadish, Ismail, & Al-Qeamy, 2011). The finding of the current study was lesser than the prevalence of previous study conducted in Pakistan 83.6% Ali et al. (2011). The study was conducted among poor socio-economic women who experienced emotional/psychological abuse.

Household and Personal SES and Emotional Abuse
A majority (57.7%) of the participants in this study belonged to the upper middle socio-economic class. An article by Haq (2010) reported that a majority of the Pakistani population belonged to the upper middle socio-economic class in the urban areas. The present study findings highlighted that emotional abuse was found to be more prevalent in upper-middle SES.
As mentioned above, half of the study participants belonged to the upper middle socio-economic strata but they did not have anything in their own name because of which their individual property index appeared to be poor or low. In spite of the fact that one of the studies with male youths of Pakistan suggested a favorable perception among 87% of them, who favored women's ownership of property and economical resources (Naz, Ullah, Naveed, Farooq, & Nisar, 2010). According to Naz et al. (2010) a majority (84%) of the participants considered that giving women ownership of property is their Islamic and legal right. This indicates that people belonging to an Islamic culture favor the ownership of property by women. However, women in Pakistan have limited access to economic resources (Bari, 2000;Jejeebhoy & Sathar, 2001). According to one study on women's autonomy, the majority of women in Pakistan have very limited ownership of land or property, with no power to sell that property. Despite women's legal rights to own and inherit property from their families, there are very few women, who have the right to use and control these resources (Bari, 2000). Moreover, it has been observed in the Pakistani culture, that instead of women saving money for themselves they usually prefer to spend it on their house or give it to their husbands or in-laws. Hence, may be for these reasons, Figure 1 showed that in spite of living in the upper middle or upper SES, the study participants were victims of many forms of violence.

Educational Level and Emotional Abuse
According to a Pakistan Labor force survey during 2009-2010, the overall literacy rate in Pakistan is 57.7%, out of which the male literacy rate is 69.5% and the female rate is 45.2% (Farooq, 2011). If we compare the findings of this study with the overall Pakistan literacy rate, in this study's context, the female literacy rate was higher (100%) as compared to their husbands (99.7%).
In the present study, one of the highlighted findings identified the prevalence of different forms of violence among married female nurses and doctors with different educational backgrounds (graduates 14.3%, 41.1% undergraduate, and diploma 44.6%). An in-depth analysis of findings shows that emotional abuse is mostly prevalent among diploma and undergraduate participants.
In the present study, by profession, nurses were more prone to experience emotional abuse as compare to doctors, so it can be said that higher education is a protective factor as educated persons have awareness and can stand up for their rights. Similar findings have also been reported in India, Bangladesh, and in American studies, that the higher the education, the lesser will be the exposure to abuse. These studies also emphasize that increasing education within society will empower women and that this is one of the preventive actions for ending abuse (Dalal, 2011;Koenig, Ahmed, Hossain, & Mozumer, 2003;Kalaca & Dundar, 2010;Kyriacou, Anglin, Taliaferro, Stone, Tubb, Linden et al., 1999).

Husbands' Use of Alcohol
The present study identified a unique finding, which has not been identified yet, that alcoholic husbands are more prone to emotional abuse. Overall, only 12.3% participants agreed to the fact that their husbands drank alcohol. However, in reality this percentage could be higher. As Pakistan is a Muslim country, alcohol is prohibited for all Muslims because of which most participants, might considering it as a social stigma, may possibly have preferred not to report their husband as a drinker of alcohol (Michalak & Trocki, 2006;Hurcombe, Bayley, & Goodman, 2010). In addition, there is a law known as Hudood Ordinance, which was passed in 1979 under General Zia-ul Haq (1977-1988, which claimed Pakistan to be based on Muslim Sharia and the punishment for alcohol consumption is 80 lashes (Mehdi, 1997). Most participants from the present study reported alcohol consumption as being associated with the risk of domestic violence. Studies from the USA, Russia, and South Africa also identify alcohol as a risk factor in domestic violence (Zhan, Shaboltas, Skochilov, Kozlov, Krasnoselskikh, & Abdala, 2011;Abrahams, Jewkes, Hoffman, & Laubsher, 2004;Koenig et al., 2003).

Conclusion
Globally it exists in all religion, culture, and society, however, under developing countries women experiencing more than developed countries women. The study identified that domestic violence always leads to emotional abuse among female nurses and doctors. There were significant differences among socio-demographic characteristics and emotional abuse. The most frequent controlling behavior by the husband/in-laws was restricted to seeing friends and the main perpetrators are husband and mother in-laws. In response to emotional abuse, health professionals tried to verbally fight back or remained quiet. The most important reason for being quiet was fear of increasing violence. Moreover, the study concluded that women who are educated and professional were confronting domestic violence to the same extent as those who are uneducated and poor.