https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Risk Of Suicide among Women Survived Domestic Violence In Erbil Governorate ABSTRACT INTRODUCTION Violence against women is a serious human rights abuse and global public health issue. Women around the world are facing differ- ent forms of violence, such as physical, psy- chological, and sexual. The perpetrators could be strangers and/or family members who are known as domestic violence and intimate partner abuse *1+. Domestic vio- lence is defined according to the depart- ment of justice of United States of America (USA) as “a pattern of abusive be- havior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner”. The act of violence could be physical, sexu- al, emotional, economic, or psychological actions or threats of actions that put a di- rect or indirect risk on the safety and secu- rity of another family member. This in- cludes any behaviors that intimidate, ma- nipulate, humiliate, isolate, frighten, Background and objectives: Domestic violence is a global issue leading to many medical and mental health consequences. A stable family relationship is mandatory for physical and mental health. The current study aimed at assessing the risk of suicide as a conse- quence of domestic violence among the survived women in Erbil governorate. Methods: A cross-sectional study was conducted from 1st January 2018 to 31st December 2018. A sample of 105 women survived from domestic violence was recruited through a non-probability snowball sampling technique. Data were collected through direct inter- view with survivals using an adapted version of the ready-made questionnaire format of Columbia-Suicide Severity Rating Scale. The questionnaire was used for interviewing the women about (socio-demographic, violence, and risk of suicide). The validity and reliability of the instrument was checked. Data were analyzed by using the frequency, percentage and fisher exact test from the Statistical Package for Social Science version 23. Results: The results of the study revealed that, the mean age of the study sample was 33.16 years old. 62.9% were married, and 63.8% were housewives. 33.3% of violence con- ducted was marital rape, in 26.2% of the cases; the violence was continuous throughout the past year. 76.2% of women wished for death and 57.1% thought of suicide. The suicid- al risk was mostly linked to rape and sexual violence, were 100% of raped cases wished for death, and 62.5% of them had set a suicidal plan. Conclusion: Domestic violence has a direct relation to the risk of suicide among women survived domestic violence. Keywords: Suicide, Domestic-violence, Human, Female, Mental Health Diana Aprem Kako; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Abdulqadir Hussen Gardi; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: diana.kako@yahoo.com ) 34 Erbil Journal of Nursing & Midwifery Received: 10/9/2018 Accepted: 17/12/2018 Published: 30/5/2019 mailto:diana.kako@yahoo.com https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article terrorize, threaten, blame, hurt, injure, or wound someone within the context of fam- ily *2+. Throughout the history, violence against women was a private indoor matter. In fact, women beating were legal to some extent under the justification of disciplin- ing. It wasn’t until 1911 when the first court in the USA was established with the goal of solving domestic problems, that wife beating was made illegal in all states of the United States by 1920. The women’s movement of the 1960’s and the anti-rape movement of the 1970’s en- couraged survivors of domestic violence to report, which led to the formation of wom- en’s crisis centers and hotlines *3+. In the Kurdistan Region of Iraq (KRG) the parliament passed the act of combating domestic violence in 2011 *4+. Such act of violence increases the risk for mental health disorder among survivals. Multiple studies have been conducted about domestic violence and its effect on mental and physical health, in all of the studies, results indicated that intimate partner violence is a factor contributing to mental disorders *5+. “Mental disorder is a syndrome character- ized by a clinically significant disturbance in an individual's cognition, emotion regula- tion, or behavior that reflects a dysfunction in the psychological, biological, or develop- mental processes underlying mental func- tioning” *6+. Women who survive domestic violence in- cur $4.1 billion per year in direct costs for medical and mental health services *7+. Globally domestic violence is also contrib- uting to women’s mortality through suicide including in Egypt (61%), Brazil (48%), India (64%), Indonesia (11%), and in the Philip- pines (28%) of women had a significant correlation between domestic violence and suicidal ideation *8+. In the Kurdistan Re- gion of Iraq (KRG) in the first 10 months of 2017, 20 suicide cases were reported which had a direct link to domestic vio- lence *9+. Mental disorders are usually associated with significant distress in social, occupa- tional, and other important activities *10+. According to World Health Organization (WHO), women survived from domestic violence are suffering from emotional dis- tress, and survivals are in a higher risk for suicide comparing to other women *11+. WHO also reported that women are more victims of domestic violence then strangers’ violence, and the lifetime preva- lence of physical or sexual partner vio- lence, or both, varied from (15%) to (71%) *1+. The main objective of this study was to as- sess the risk of suicide as a consequence of domestic violence among the survived women. A cross-sectional study was conducted among women survived from domestic violence to find the risk of suicide as a con- sequence of domestic violence among the survived women. Duration of the study was from 1st January 2018 to 31st December 2018 in different locations in Erbil governorate. The study sample were 105 women survived from domestic violence, they were selected via using the snowball sampling technique to establish a representative sample of the targeted population, according to the study’s inclusion and exclusion criteria; women and girls who aged equal and more than 18 years old were included based on their informed consent. Data were collected from women safe spaces which are specialized for providing psychological support for women, and also part of data were collected from women shelter. Selected women were not diag- nosed with any mental disorders before METHODS 35 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article and occupation. The second part assessed the types and forms of violence, were participants been asked about the form of violence whether it is physical violence which includes beating, burning, hair pulling, and any oth- er violent act that have a negative impact on the body; Or sexual violence which is defined by WHO as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work” *1+. The psychological and emotional violence, which includes the acts or threats of acts resulting in emotional and psychological disturbance of the survivals. Marital rape which is a rape conducted by the intimate partner. And the last type of violence which is financial abuse was the violence is been conducted by preventing the survivals to access their financial rights, or when the survival financial income is taken off by the perpetrator. The frequency of violence act was assessed during the last year, either is contentious or been in certain point of time such as weekly or monthly, or whether the vio- lence occurred only once during the previ- ous year. The last part of the questionnaire assessed the level and severity of suicide risk, which has been adopted from the Columbia- Suicide Severity Rating Scale (C-SSRS). The scale contains six questions about par- ticipant’s thoughts, action, and feeling in the past month, with yes or no answer for each question, determining the stage of suicide risk that may be suicidal wishes, thoughts, intentions, plans, and suicidal behaviors *15+. The questionnaire was validated through a panel of experts from different scientific the occurrence of violence, and they had not been through any other accidents such as fire, traffic, terrorist, and robbery attack. The sample size was estimated based on the formula of. In which is standard normal variety at 5% type one error when propor- tion with a 95% level of confidence and a margin of error of 5%, = 1.96. p-value <0.05. The d is the absolute error and it’s equal to 0.05. And p stands for the ex- pected portion of population based on published data, in the current study, as there is no formal published percentage of domestic violence cases in Erbil, the inves- tigator calculated percentage of domestic violence cases based on report of WHO were they stated that 1 in 3 women are affected by domestic violence, thus refer- ring to proportion of women in Erbil popu- lation, which is 466803 *12+, and assuming that 1 in 3 women are affected by violence, Thus the p= 33.3%. Referring to this equa- tion; the total estimated study sample was (339) cases *14+, *13+. Referring to the sensitivity and social stig- ma of domestic violence, lack of reporting, and time limitation; the investigator could reach only to 105 cases. A pilot study on 15 cases was carried out for obtaining the "inter-rater reliability test. Internal consistency of the study was obtained through applying Pearson correla- tion (r) which was (0.92); it indicates that there is a strong positive correlation. Direct face to face interview through question- naire was conducted by the authors, after obtaining verbal consent from the study sample. The data collection tool was modified from the ready-made questionnaire and expert recommendation. The questionnaire con- sisted of three parts. The first part was on socio-demographic characteristics of Study Sample. This part composed questions about the age of the participants, the mari- tal status, and level of education, location, 36 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article backgrounds related to nursing and medi- cine. The expert responses were based on agreement or disagreement with items of the questionnaire. The experts agreed to the contents of the questionnaire with some modifications regarding the bio- graphic part and the expert also added more detail in the violence part. The inves- tigator took into consideration their com- ments and prepared the final version of the questionnaire accordingly. Prior to data collection, the formal permis- sion was obtained from the ethical com- mittee at the College of Nursing, Hawler Medical University. Furthermore, the in- formed oral consent was taken from the candidate who participated in the study, after confirmation of confidentiality, ano- nymity and participants self-determination by the researcher. Formal permission was also obtained from the Directorate of labor and social affairs and Directorate of wom- en correctional center. After data collection, the Statistical Pack- age for Social Science (SPSS, Version 23) was used for data processing and statistical analysis. The statistical analysis included descriptive statistical analysis such as fre- quency and percentage to describe the basic features of the data in a study and provide simple summaries about the sam- ple and the measures. Inferential statistical analyses as Chi-square and fisher exact test were implemented to make judgment about inferences from our data to more general conditions. The confidence interval was 95%. The P-value of each test ≤ 0.05 considered as statistically significant. Table 1 shows the general socio- demographic characteristics of the study sample, the age of participants ranged from 18-59 years old, with the mean age of 33.16 years old. Regarding the marital sta- tus of the survivals, the highest percentage (62.9%) were married, while divorced and single were 14.3% and 13.3% respectively. The education level of participants showed that the highest percentage (40%) was sec- ondary school graduated and the percent- age of the institute and/or college graduat- ed was 30.5%. As for the occupation, the highest percentages of the women (63.8%) were housewives and 13.3% had semi- skilled manual occupations. For the resi- dency of participants; the results showed that 80% of survivals were living in urban areas. 37 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Socio-demographic characteris- tics of the survived females of domestic violence Characteristics (n=105) Frequency Distribution Age (year) Range: 18-59 Mean ± St. Deviation 33.16 ± 9.28 F (%) Marital Status Single Married Divorced Widowed Separated 14 (13.3) 66 (62.9) 15 (14.3) 7 (6.7) 3 (2.9) Education Illiterate Read and write Primary school graduate Secondary school graduate Institute/college Postgraduate 7 (6.7) 12 (11.4) 8 (7.6) 42 (40) 32 (30.5) 4 (3.8) Occupation Associate professional occupations Skilled manual and non-manual occupation Semi-skilled manual occupations Unskilled manual occupations House wife Student 4 (3.8) 3 (2.9) 14 (13.3) 5 (4.8) 67 (63.8) 12 (11.4) Residential area Urban Rural 84 (80) 21 (20) https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Regarding the type of violence; as it shows in the table 2; the result shows that most common type of violence conducted (33.3%) was marital rape. Physical violence and emotional violence come in the second and third place with the percentage of 26.7% and 21.9%. The study results of re- currence of violence in past year indicated that the violent act was continuous in 36.2% of the cases while 20% of partici- pants were subjected to violence once per month. Regarding the perpetrator; the vio- lent act was conducted by the intimate partner in the most of cases (70.5%). Table 3 shows different level of suicide risk; were the results indicated that, most of the participants (76.2%) wished for death, while 57.1% of participants had sui- cidal thoughts without any suicidal plans. 35.2% of the study, sample thought of sui- cide in addition to setting a special suicidal plan meanwhile more than half of the par- ticipants (64.8%) did not plan for the sui- cide. Suicide attempt was positive in 17.1% of the participants. Regarding the association between the perpetrator and risk of suicide, as it shown in the table 4, result revealed that majority of cases (71.3%) who survived from vio- lence conducted by their intimate partner, wished for death; the results were statisti- cally significant with p-value= 0.01. Results also demonstrate a significant relationship between perpetrator and suicidal thoughts, were 70% of survivors from 38 Erbil Journal of Nursing & Midwifery Table 2: Forms of domestic violence among survived females of violence. Violence characteristics (n=105) Frequency Distribu- tion F (%) Violence type Physical violence Sexual Violence Emotional Violence Rape Marital rape Financial abuse 28 (26.7) 6 (5.7) 23 (21.9) 8 (7.6) 35 (33.3) 5 (4.8) Frequency of violence Continuous once per week 1/month 1/3months 1 / 6 months 1/ year 38 (36.2) 20 (19) 21 (20) 5 (4.8) 6 (5.7) 15 (14.3) Violence Perpetrator Intimate partner Brother Father Second degree relative Children 74 (70.5) 5 (4.8) 10 (9.5) 11 (10.5) 5 (4.8) Table 3: Suicide risk assessment among women survived domestic violence Depressive disorders Frequency Distribution F (%) Death wish Yes No 80 (76.2) 25 (23.8) 60 (57.1) 45 (42.9) 37 (35.2) 68 (64.8) 18 (17.1) 87 (82.9) Suicidal Thought Yes No Thought Plan Yes No Suicidal Behavior Yes No https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article intimate partner violence had active suicid- al thoughts, with p-value= 0.01. Regarding active suicidal thought with suicidal plan, however generally most of the cases didn’t have specific suicidal plan, yet 62.2% of As for the association between risk of sui- cide and type of violence, result showed that 40% of women who were raped by their spouse, wished for death and also had thought of suicide, the result was high- ly significant with p-value = 0.001. Regard- ing the active suicidal thoughts with plans, table 5 revealed that, 37.8% of women cases who faced violence from their inti- mate partner had set a specific suicidal plan, the relation were statistically signifi- cant with p-value= 0.01. who survived marital rape and 24.3% of physical violence survivals had set suicidal plan. Results were considered statistically significant with p-value= 0.03. Regarding suicidal behaviors, while 50% marital raped women had suicidal behavior, the relation- ship was statistically non-significant. 39 Erbil Journal of Nursing & Midwifery Table 4: Association between perpetrator and risk of suicide Risk of suicide Intimate partner F (%) Brother F (%) Father F (%) Second degree relative F (%) P-value * Dead Wish Yes No 57 (71.3) 17 (68) 1 (1.3) 4 (16) 7 (8.8) 3 (12) 15 (18.8) 1 (4) 0.013** Suicidal though Yes No 42 (70) 32 (71.1) 0 (0.0) 5 (11.1) 6 (10) 4 (8.9) 12 (20) 4 (8.9) 0.013** Suicidal Plan Yes No 23 (62.2) 51 (75) 0 (0.0) 5 (7.4) 4 (10.8) 6 (8.8) 10 (27) 6 (8.8) 0.019** Suicidal Behavior Yes No 12 (66.7) 62 (71.3) 0 (0.0) 5 (5.7) 4 (22.2) 6 (6.9) 2 (11.1) 14 (16.1) 0.165*** Risk of suicide Violence Types P-value * Physical violence F (%) Sexual Violence F (%) Emotional Violence F (%) Rape F (%) Marital rape F (%) Financial abuse F (%) Death Wish Yes No 15 (18.7) 13 (52) 6 (7.5) 0 (0.0) 16 (20) 7 (28) 8 (10) 0 (0.0) 32 (40) 3 (12) 3 (3.8) 2 (8) 0.001** Suicidal thoughts Yes No 11 (18.2) 17 (37.8) 6 (10) 0 (0.0) 14 (23.3) 9 (20) 5 (8.3) 3 (6.7) 24 (40) 11 (24.4) 0 (0.0) 5 (11.1) 0.001** Suicidal Plan Yes No 9 (24.3) 19 (27.9) 4 (10.8) 2 (2.9) 5 (13.5) 18 (26.5) 5 (13.5) 3 (4.4) 14 (37.8) 21 (30.9) 0 (0.0) 5 (7.4) 0.039*** Suicidal behavior Yes No 3 (16.7) 25 (26.7) 0 (0.0) 6 (6.9) 4 (22.2) 19 (21.8) 2 (11.1) 6 (6.9) 9 (50) 26 (29.9) 0 (0.0) 5 (5.7) 0.222**** Table 5: Association between different types of domestic violence and risk of suicide *Fishers’ Exact test was performed for statistical analysis, ** significant, *** non-significant *Fishers’ Exact test was performed for statistical analyses. ** highly significant **** significant **** non-significant https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Regarding the type of violence conducted against the study sample, the heights per- centage (33.3%) was marital rape which is forcing the partner on sexual intercourse. Similar findings of sexual violence by the intimate partner were reported in Erbil 12.1% *16+, 42.2% in Iran *19+, 16.4% in Spain *20+, and 12% in China *21+. Such a high percentage of intimate partner sexual violence could be linked to the social and cultural norms were in most contexts mari- tal rape is not recognized as a violation of women rights. Men and to some extent women believe that the intimate partner has the right of sexual intercourse at any time, and the wife is not to refuse or ob- ject. In most of the cases (36.2%) the violence was continuous in the past year, which means the survived women were living in a stressful situation most of their time, and also the violence could happen during pregnancy and in front of their children. Regarding the perpetrator; violence was mostly conducted by an intimate partner (70%), these results were also reported by WHO, as they found that most of the vio- lence faced by women are committed by their intimate partner, WHO also reported that; worldwide, almost one third (30%) of women who have been in a relationship report that they have experienced some form of physical and/or sexual violence by their intimate partner in their lifetime *13+. Regarding the risk of suicide; results of this study revealed that generally there is a high risk of suicide among women survived from domestic violence, the majority of the study sample (76.2 %) wished that they were dead. 57.1% of them randomly thought of suicide and imagined their death, but they had no actual suicidal plan. Meanwhile 35.2% of survivals thought of suicide and had a suicidal plan and they were thinking of implementing the suicidal plan, among them 17.1% attempted for The aim of the current study was to assess the risk of suicide among women survived domestic violence. Regarding the socio- demographic characteristics, the highest percentage of the study sample was in their age of thirties, Mean ± SD of partici- pant’s age was 33.16 ± 9.28, minimum age 18 years old and maximum age 59 years old. Most of them were married, and they were mostly secondary school graduated, and the majority of the study samples were housewives and they were living in urban areas. These results were similar to the findings of a study conducted in KRG by Al- Atrushi et al, as they also found that major- ity of women suffering from domestic vio- lence are in between 25-34 years old *16+, and also according to the WHO multi- country study on women’s health and do- mestic violence, results showed that (13%) to (61%) of women who reported on do- mestic violence are between 15 and 49 years old *11+. Regarding educational back- ground, the results indicated that the vio- lence has mostly occurred among women who had less degree of formal education. Results of the current study were similar to a study conducted in Erbil by Namir Al- Tawil, about the association of violence against women with religion and culture in Erbil Iraq, were only half of the participants (50.4%) had more than 12 years of formal education *17+. Women who are less edu- cated usually have less knowledge about the law, and they are less independent fi- nancially as most of them are housewives, thus it’s make them an easier target of vio- lence because they don’t ask for their rights. Results were also supported by a study conducted in USA, on the risk factors for Intimate Partner Violence (IPV), were they reported that having a school degree of less than high school will increase the risk of IPV *18+. 40 Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article contemplated suicide, and rape victims were also 13 times more likely to have attempted suicide *23+. Domestic violence has a direct link to the deterioration of mental health; women survived from domestic violence are at high risk of suicide due to the violence that they face. Domestic violence is always seen as a private family issue, were re- porting against violence act will put the survival in risk of social stigma and also the risk of honor killing by family members, which increase the stress on the survivals, leading to depression and eventually put the survivals at a higher risk of suicide. The authors have no any conflict of inter- est *1+ Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH, WHO Multi-country Study on Women’s Health and Domestic Violence against Women. Lancet London England. 2006 7;368 (9543):1260_9. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/17027732 *Accessed 19th July 2018+. *2+ The United States department of justices. Domestic Violence. 2017. Available from: https://www.justice.gov/ovw/domestic- violence*Accessed 19th May 2018+. *3+ Orloff LE, Feldman P. Domestic Violence and Sexual Assault Public Policy Timeline High- lighting Accomplishments on Behalf Of Im- migrants and Women of Color. National Im- migrant Women’s Advocacy Project; 2017. Available from: http://library.niwap.org/wp- content/uploads/Herstory-2016.pdf *Accessed 23th Feb 2018+. *4+ Parliament of Kurdistan. The act of com- bating domestic violence in Kurdistan region -Iraq 2011. Available from: http:// www.ekrg.org/files/pdf/ combat_domestic_violence_english.pdf *Accessed 10th October 2017+. suicide or arranged everything for suicide but changed their mind in the last minute before acting the plan. Globally domestic violence was found to be a risk factor for suicide in women. In KRG in the first 10 months of 2017, 20 suicide cases were re- ported which had a direct link to domestic violence *9+. Referring to a study published in Indian Journal of Psychiatry in 2015; results showed a significant relationship between domestic violence and suicidal ideations, in Egypt 61%, Brazil 48%, India 64%, Indone- sia 11%, and in the Philippines 28% of women who had suicide ideation, it was due to domestic violence problems *8+. Da- vis (2010), reported that approximately 30% of suicides in 16 states of the USA in 2005 were precipitated by intimate partner problems *22+. As for the association between type of vio- lence and different level of suicide, results demonstrate that wishing for death were mostly associated with survivors who expe- rienced marital rape, and this is usually re- lated to the social stigma that women and girls are facing when they goes through such experience, as marital rape is not rec- ognized as violence; in some cases the sur- vivors are looking at as the main guilty per- son and they may face the risk of divorce or physical violence if they reject such vio- lence by their spouse, were women are expecting protection and affection from their intimate partner, such act of violence by the intimate partner will cause extreme depression and emotional disturbance to the women leading to suicidal thoughts. Living in an environment where same vio- lence act is repeated many times is very likely to create frustration leading to suicid- al plan as it occurred in 37.8% of marital rape survived women. Kilpatrick (2000), found that 33% of the rape survivals have thought of suicide, and they were 4.1 times more likely than non-crime victims to have 41 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICTS OF INTEREST REFERENCES https://doi.org/10.15218/ejnm.2019.05 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article *13+ World Health Organization. Violence against women. 2017. Available from: http:// www.who.int/news-room/fact-sheets/ detail/violence-against-women *Accessed 27th Aug 2018+. *14+ Charan J, Biswas T. How to Calculate Sample Size for Different Study Designs in Medical Research? Indian Journal of Psychological Medicine. 2013;35 (2):121–6. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3775042/ *Accessed 12th Oct 2017+. *15+ Posner K, Brent D, Lucas C, Gould M, Stanley B, Brown G, et al. Columbia-suicide severity rating scale (C-SSRS). 2008. 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