The effect of educational intervention based on the health belief model on the domestic violence coping skills in women referring to comprehensive rural health service centers

Abstract

Background

Domestic violence, in addition to the destructive effects it brings to the mother of the family, also has a strong impact on the children. According to the evidence obtained, coping strategies have been successful in tackling this issue. The purpose of this study was to investigate the effect of education on coping skills with domestic violence based on the health belief model (HBM) in women referring to comprehensive rural health service centers in Marvdasht City, Iran.

Methods

This semi-experimental study was conducted on 120 women affected by domestic violence who were referred to rural health centers in Marvdasht City in 2022. The multi-stage cluster sampling method was used for assigning people to two experimental and control groups (60 people in each group). The data collection tool was a questionnaire based on the HBM and a coping strategies questionnaire that was completed before and two months after the intervention by both groups. After entering SPSS 24, the data were analyzed by paired t, independent t, and chi-square statistical tests.

Results

Before the intervention between the two groups in terms of the constructs of awareness (P = 0.45), attitude (P = 0.23), behavior (P = 0.67), perceived sensitivity (P = 0.10), perceived severity (P = 0.84), perceived barriers (P = 0.31), perceived benefits (P = 0.21), perceived self-efficacy (P = 0.10), and cues to action (P = 0.19), no significant difference was observed, while after the intervention, a significant difference was observed between the two groups in terms of the structures expressed (P < 0.05). Likewise, before the intervention between the two experimental and control groups in terms of the ability to receive and send messages (P = 0.73), emotional control (P = 0.22), listening skills (P = 0.65), insight into the communication process (P = 0.15), communication combined with assertiveness (P = 0.98), and coping skills (P = 0.21), no significant difference was observed, while after the educational intervention, there was a significant difference between the two groups in terms of skill components (P = 0.001).

Conclusion

In the current study, education based on the HBM with a focus on coping skills led to the improvement of the skills of women who have experienced violence, their attitude and awareness, perceived sensitivity and perceived severity, and finally the benefits and barriers they receive from using coping skills.

Introduction

One of the important issues and harms in the field of family in Iran is domestic violence, which is indicative of social issues at the individual and family level as well as at the macro level in society [1]. Domestic violence, which is the most prevalent form of violence against women, is defined as any gender-based violence that causes physical, sexual, or psychological harm to women or raises the risk that it will occur in them. It also includes actions that inflict pain on women or compel them to give up their personal or social freedoms against their will [2,3,4]. Despite the fact that these forms of violence typically take place in the privacy of the home, they have a negative impact on women’s life in all public and social spheres and have detrimental effects on families, society, and the advancement of social and economic conditions [5]. According to the report of the World Health Organization in 2021, one out of every three women will experience domestic violence from their husbands [6]; this rate has been reported in Asian countries at around 37.7% [7]. The results of a national study that was conducted in 28 provinces of Iran showed that in 66% of the investigated families, women experienced violence at least once since the beginning of their life together, 30% of the families experienced serious and acute violence, and 10% of the families experienced violence leading to temporary injury [8].

The occurrence and impact of spousal violence are substantially influenced by cultural influences, economic dependency, and societal attitudes towards gender roles in patriarchal nations [9]. Various factors play a role in the occurrence of domestic violence. Among these factors are physiological and biological issues, addiction, personality disorders, and traits, as well as family factors such as differentiation, family structure, building power in the family, and inappropriate family experiences [10, 11]. Economic factors, occupational and organizational factors, social and cultural factors, differences between men and women, and marital myths can also have an influence on the occurrence of domestic violence [12]. Regarding the importance of domestic violence, it can be mentioned that domestic violence has many consequences, which, in addition to the destructive effects it brings to the mother, also strongly affect the children [13]. Therefore, preventing domestic violence is necessary. According to the evidence, one of the measures to prevent domestic violence is coping strategies, which mean behavioral and psychological efforts to control pressures and face stressful situations in order to prevent, regulate, and suppress tension [11]. People can be divided based on their problem-oriented, emotion-oriented, and avoidance coping styles [14]. Herrero-Arias et al. (2021) found that women use two strategies: silence or leaving to face violence by their partners. Resigning is a difficult tactic since you require other people’s backing. Moving through complex structural disparities can be challenging for women in patriarchal systems because of the social stigma attached to divorce and the normalization of violence in personal relationships [2]. One strategy used by these women is to remain silent.

Mahapatro and Singh (2020) showed that women with an informal support system have a better outcome in coping in their marriage, and intervention in the formal system leads to an improvement in their coping strategies and, at the same time, a reduction in their psychological distress [3]. In some other studies, the use of educational interventions in increasing women’s awareness, self-efficacy, and behavioral skills in preventing domestic violence has been mentioned; for example, Mahmoudian et al. (2019) reported the effectiveness of anger and stress management training according to the Ministry of Health program of Iran, women’s and leads to a reduction in violence [15]. Yazdanpanah Dolatabadi et al. (2021) showed the positive effect of using the educational package on reducing men’s violence and increasing children’s academic enthusiasm [16]. However, in the conducted studies, the use of educational models in increasing coping skills against violence in women is less mentioned, while, for a better and deeper understanding of behavior and its promotion, the use of evidence-based theories and models in education seems necessary [17]. Based on scientific documents, education is one of the most basic tools and methods of preventing violence against women [18].

Among the many health education models and patterns, the health belief model (HBM) is an effective one [19]. The HBM is a psychological model that tries to explain and predict health behaviors. It focuses on people’s attitudes and beliefs and shows the relationship between beliefs and behavior; in fact, the HBM allows us to examine possible psychological factors affecting people’s decisions [20]. The constructs of this model are perceived sensitivity, perceived intensity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Domestic violence against women in the family is one of the main obstacles to the health and consolidation of the family because men and women are the elements and the basis of family stability, and the continued existence of the family depends on them. Investigating husbands’ violence against women in the family is not only important from an individual and family point of view but also from a social point of view, since the effects of husbands’ violence against women are not limited to women but also affect husbands and children, the family, and society in general. Women who are victims of violence, when they have run out of patience, may find themselves running away from home because of child abuse, moral corruption, suicide, spousal murder, etc.

Considering the widespread occurrence and significant consequences of domestic violence in Iran, specifically among traditional and ethnic communities like Marvdasht City, it is imperative to tackle this problem at the grassroots level. Domestic violence has detrimental effects on both the physical and mental well-being of women, as well as significant repercussions on children and society as a whole. Despite the economic, social, and cultural changes that have occurred in recent decades, traditional ideas still hold sway in Marvdasht City, making it necessary to implement interventions that are specific to the local context. Thus, this study seeks to examine the impact of educational interventions grounded in the Health Belief Model (HBM) on enhancing coping abilities among women who are facing domestic violence within this particular demographic. Gaining insight into and actively engaging with the distinct cultural and socioeconomic intricacies of Marvdasht City can result in more efficient and enduring solutions. The emphasis on the local context is crucial for customizing the educational programs to address the distinct requirements and situations of women in this community, ultimately leading to improved results and the mitigation of domestic violence.

Methods

Study design

This quasi-experimental study was conducted in 2022 on 120 women who had been referred to health centers in Marvdasht City, Iran, with complaints of domestic violence during the past 12 months. Women who met the inclusion criteria—diagnosed with domestic violence (physical, sexual, mental, verbal, and economic) within the last 12 months by their relatives (husband, child, family members such as mother or father-in-law)—were invited to participate. Participants were required to express willingness to participate in the study and attend the training sessions. Exclusion criteria included unwillingness to cooperate at any time during the study and failure to attend at least two training sessions. The study involved pre- and post-intervention assessments to measure the effectiveness of the educational intervention.

Sample formula and sampling

The sample size was determined based on a similar study by Yazdanpanah Dolatabadi et al. (2021), using the formula for comparing two means with an alpha level of 0.05 and a study power of 80% [16]. The initial calculation estimated that 53 participants were needed for each group. To account for an anticipated attrition rate of 20%, the final sample size was set at 60 participants per group, resulting in a total sample size of 120 women. A multi-stage cluster sampling method was employed. Each health center in Marvdasht City was considered a cluster. Four health houses were randomly selected from these clusters. Two centers (Persepolis and Persian Gulf centers) were designated as control groups, while two centers (Konareh and Hajiabad centers) were designated as experimental groups. Participants were then selected from these centers using convenience sampling. If participants dropped out, replacements were made by selecting additional eligible women from the same health centers to maintain the sample size.

Data gathering tools

To collect information, a questionnaire containing personal information about people, a researcher-made questionnaire based on the HBM, and a communication skills questionnaire were used.

Questionnaire for demographic information

This part included demographic characteristics (age, education, spouse’s education, occupation, and spouse’s occupation).

The HBM questionnaire

This section measured awareness, attitude, behavior, and the components of the HBM towards domestic violence.

Initially, awareness towards domestic violence had 18 questions (such as: I am a religious person; the opinions of younger parents are closer to their children; I have learned the necessary training on how to deal with violence from my textbooks; ). These questions were designed as three options (correct score 3, I don’t know score 2, and false score 1). The range of scores was between 18 and 54, and a higher score indicated higher awareness of domestic violence.

Attitude had 18 questions (such as: My relatives have violent behavior; My family problems affect the way I deal with others; My family members understand me). These questions were designed as five options (totally agree score 5, agree score 4, do not have an opinion score 3, disagree score 2, and completely disagree score 1). The range of scores was between 18 and 90, and higher scores indicated a higher attitude towards domestic violence.

Behavior had eight questions, such as the definition of physical violence (hitting, slapping, throwing objects at others, pushing) and verbal violence (obscenity, disrespect, insulting, threatening, etc.). These questions were designed as three options (correct score 3, don’t know score 2, and false score 1). The range of scores was between 8 and 24, and higher scores indicated higher behavior towards domestic violence.

Perceived sensitivity had seven questions (such as: I have learned the necessary training on how to deal with violence from television; I have read novels with violent characters; I feel uncomfortable when people pry into my private life.); Perceived intensity had 10 questions (such as: My mother visits me regularly to check my life situation; My father visits me regularly to check my life situation and my condition; My wife pays enough attention to my children’s education).

Perceived benefits had six questions (such as: the food that is cooked at home should be according to the man’s taste; the type of makeup and clothing of the woman outside the house should be according to the man’s wishes and opinion). Perceived barriers had eight questions (such as: A woman should have a full hearing from her husband; if a woman disobeys her husband, the man has the right to beat her; and the most important duty of a woman is to take care of her husband).

Self-efficacy had eight questions (such as: If a married man has a relationship with another woman, there is no problem if he makes her a concubine; determining the place of residence is with the husband, and the wife should be subordinate to him; and the man has the right to have marital relations with his wife even if his wife is not inclined to do so). Cues to action had five questions (questions like: The book of the rules of marriage is effective in controlling domestic violence; seeking help and guidance from a family member has an effect on controlling domestic violence; exercising and relaxing the soul has an effect on controlling domestic violence).

These questions were designed as 5 options (totally agree score 5, agree score 4, don’t know score 3, disagree score 2, and completely disagree score 1). The range of scores was as follows: perceived intensity 10–50, perceived sensitivity 7–35, perceived barriers 8–40, perceived benefits 6–30, and self-efficacy 8–40. The range of cues to action was from 5 to 25. Higher scores indicated a better situation regarding domestic violence against women.

This questionnaire has already been used in Garmaroudi et al.‘s study and its validity and reliability have been confirmed. Cronbach’s alpha was 0.74 for awareness, 0.75 for perceived intensity, 0.82 for perceived sensitivity, 0.84 for perceived benefits, 0.76 for perceived barriers, 0.82 for self-efficacy, and 0.81 for behavior [20].

The communication skills questionnaire (confrontational)

Queen Dam created the communication skills questionnaire in 2004. The purpose of this questionnaire was to assess people’ communication abilities. There are 34 items on it that discuss communication abilities. After reading each item, the respondent must indicate on a five-point Likert scale from never to always how much their current state conforms with its content. The score range is 1 (never) to 5 (always) [21].

This scale looks at a variety of communication abilities, such as assertive communication, emotional management, listening comprehension, message sending and receiving skills, and communication insight [21].

The ability to receive and send messages has nine questions: 4-5-6-12-21-22-23-24-29), emotional control has nine questions: 7-8-9-11-13-16-28 32 − 30), listening skills has six questions: 3-25-26-27-31-34), insight into the communication process includes five questions: 1-2-17-18-20), and assertive communication has five questions: 10-14-15-19-33)

A separate score is calculated for each respondent in each of the aforementioned skills, which are presented in the form of sub-tests including a different number of items. In addition, the sum of the scores of each of the 34 statements gives a total score for the respondent, which indicates the subject’s communication skills. Thus, the possible score range for each person is between 34 and 170. It should be noted that some expressions are graded inversely in the calculation of the grade due to their nature and content [21]. Sharifi Nia et al. determined the validity and reliability of this questionnaire (2022). The test’s internal consistency was found to be adequate, with a total validity calculation of 0.69. For college students, this figure was 0.71, while for high school students, it was 0.66. Additionally, it was determined that the test’s overall reliability was 0.71 [22].

Educational program

To design the intervention, first the questionnaires were collected from the participants, and then, after finding the weaknesses and strengths of the participants, the education was designed based on the weak points of the respondents. The program included five sessions of 50 to 60 min and was carried out in the form of three teaching methods (speech, question and answer, and group discussion) in health centers in order to improve coping skills and prevent the occurrence of violence in the intervention group (Table 1). Then, two months after the completion of the program, the data was obtained again from both groups and compared with before the education.

In the session, training videos were prepared using the Ministry of Health training book and illustrated using a video projector. To prepare the educational content, the Domestic Violence Prevention Manual provided to the centers by the Ministry of Health, the Network Management Center, the Non-Communicable Diseases Management Office, and the Psychosocial Health Office under the supervision of the Deputy Health Minister were used.

Table 1 Educational program

Data analysis

With SPSS 24, the data was examined. First, the Kolmogorov-Smirnov test was used to determine whether the data were normal. Frequency indices, mean, standard deviation, and independent t-tests were used to summarize the data. The chi-square test, paired t-test, and the independent t-test were used to compare the average data in the two groups before and after the intervention. For all tests, 0.05 was taken as the significant level.

Results

The respondents’ demographic data is displayed in Table 2. The experimental and control groups did not significantly differ in their education (P = 0.48), spouse’s education (P = 0.23), occupation (P = 0.45), or spouse’s occupation (P = 0.32), according to the results of the chi-square test. Additionally, the t-test revealed that there was no discernible age difference between the two groups (P = 0.79).

Table 2 Comparison of the frequency distribution of the primary variables of the respondents in the study according to their groups

Before the intervention, there was no discernible difference between the two groups’ awareness (P = 0.45), attitude (P = 0.23), behavior (P = 0.67), perceived sensitivity (P = 0.10), perceived severity (P = 0.84), perceived barriers (P = 0.31), perceived benefits (P = 0.21), perceived self-efficacy (P = 0.10), and chess to action (P = 0.19, according to the independent t-test. After the intervention, there was a substantial difference (P < 0.05) between the two groups’ awareness, attitude, behavior, perceived sensitivity, perceived intensity, perceived hurdles, perceived advantages, perceived self-efficacy, and cues to action (Table 3).

Table 3 Comparison of awareness, attitude, behavior, and the constructs of the HBM before and after the intervention in the two study groups

The independent t-test found no considerable differences between the two study groups before the intervention in terms of the ability to receive and send messages (P = 0.73), emotional control (P = 0.22), listening skills (P = 0.65), insight into the communication process (P = 0.15), relationship with determination (P = 0.98), and coping skills (P = 0.21). While, after the intervention there was a notable difference in the aforementioned variables among the two studied groups (P = 0.001) (Table 4).

Table 4 Comparison of mean and standard deviation of the components of coping skills before and after the intervention in the two groups

Discussion

From a social, economic, and cultural point of view, Marodasht City has an almost traditional and ethnic texture, and despite the economic, social, and cultural changes made in recent decades in the whole country, it seems that traditional beliefs are still more dominant in this city. Violence against women in its various dimensions endangers women’s physical and mental health and violates their human rights, while many women do not have the necessary ability to deal with violence, which leads to more unpleasant experiences for them. Conclusively, the present study was designed and implemented with the aim of investigating the effect of an education based on the HBM on improving coping skills in a group of abused women in Marvdasht City, Iran. The focus of the training was on coping skills, not meant to deal with violence, but the goal was to improve listening skills, communication with assertiveness, and emotional control, which we will interpret as positive results in the following.

In the present study, the intervention led to an enhancement in awareness towards coping skills in the experimental group compared to the control group. In many cases, women are not aware of the appropriate behavior in times of violence and show an inappropriate reaction to it unintentionally, but with training based on coping skills, women can improve their knowledge of how to deal with violence. The improvement in women’s awareness of coping skills can be attributed to the application of the HBM. This finding is consistent with the findings of Forcadell-Díez et al. (2023) [23], Silverman et al. (2023) [24], and Allison et al. (2023) [25].

In this study, the intervention led to an increase in the attitude towards coping skills in the experimental group compared to the control group. In general, performing health interventions when they are focused on the desired structure leads to the improvement of that structure in the trained person and makes the person gain a better attitude towards their skills and become more determined to put aside inappropriate attitudes. It seems that training coping skills could effectively contribute to diminishing some outdated attitudes towards women, such as patriarchy and women’s silence in arguments. This finding is consistent with the results of the studies by Serrano-Montilla et al. (2023) [26], Keith et al. (2023) [27], and Mittal et al.‘s study (2023) [28].

After the intervention, a sharp rise was seen in the behavior of coping skills in the experimental group compared to the control group. It seems that the training increased the performance and health beliefs of the trained women in the field of coping skills, and this led to an increase in coping behaviors in them compared to the control group. This finding is consistent with the results of studies by Farmer et al. (2023) with the aim of school-based interventions to prevent violent relationships [29], and Carlisle et al. with the aim of conducting psychological interventions in survivors of domestic violence by partners [30].

Following the intervention, the perceived sensitivity towards coping skills in the experimental group was noticeably enhanced compared to the control group. In justifying this finding, it can be stated that the HBM includes efforts seeking to understand variables affecting behaviors and their related processes. This model reveals health interventions and is considered a valuable tool in the research process. This pattern increases a person’s sensitivity to the category of violence and the use of coping skills, leading to an increase in sensitivity and the use of coping skills. This finding is in agreement with the results of the studies of Dolev-Cohen et al. (2023) [31], Jack et al. (2023) [32], and Seinfeld et al. (2023) [33].

In this study, the experimental group’s perceived severity of coping abilities showed a significant increase following the intervention when compared to the control group. The HBM is a cognitive model that, in general, assesses how individuals react to a factor that poses a threat to their health and produces improvements in the perceived severity of the illness. This conclusion is in line with the findings of research conducted by Sultana et al. (2023) [34] and Wong et al. (2023) [35].

Following the intervention, the experimental group’s perceived barriers to coping abilities significantly decreased in comparison to the control group. Identifying the obstacles in coping strategies for women allows us to remove these barriers and enables us to take actions to transform obstacles into benefits. In this study, according to the women’s own expression, the prevailing culture in this region made women live and accept domestic violence, which emphasizes the implementation of interventions to encourage them to defend their rights to prevent domestic violence. This finding was consistent with the results of Henriksen et al.‘s (2023), Arora et al.‘s (2023), and Lederer et al.‘s (2023) studies [36,37,38].

After implementing the training program, the perceived benefits of coping skills in the experimental group improved dramatically compared to the control group. Education based on the HBM contributes to the evaluation of benefits and costs, and for this reason, the patient is trained in a way that by following some items (such as compliance with treatment or the drug regimen), they can reduce costs, prevent complications, and finally, it leads to increasing the benefits of self-regulation behavior in the patient. This finding is in line with the results of Koohboomi et al. (2023) [39] and the study of Mohammadi et al. (2023) [40].

The component of perceived self-efficacy of coping skills in the experimental group greatly improved in the experimental group compared to the control group. The term self-efficacy means empowering a person to do their work and prevent complications. In interventions based on coping skills, when the intervention is based on components such as listening skills and emotional control, a person will find the ability to receive and send messages, and finally, they can have a relationship with determination, which means self-efficacy in a person. This finding is consistent with the results of Webermann et al.‘s (2022) [41], Porter et al.‘s (2022) [42], and the study of Darvishnia et al. (2022) [43].

Lastly, education based on the HBM increased the coping skills and behavior of the experimental group compared to the control group. In other words, the interventions focused on the HBM ultimately led to the change and improvement of the coping skills of the women participating in this study, and this improvement can lead to the improvement of their mental health status. This finding is in agreement with the results of the studies of Galdo-Castiñeiras et al. (2023) with the aim of educational intervention on adolescents subjected to domestic violence [44], Pérez-Martínez et al. (2023) [45], and Villardón-Gallego et al. (2022) [46].

Strengths and limitations

One of the strengths of this study was the involvement of health centers in the implementation of the study, the design of the educational intervention, the use of different educational methods in the meetings, and the novelty of the plan.

Short-term follow-up of the effect of the implemented program and the lack of generalization of the results due to the direct effect of cultural attitudes regarding domestic violence could be mentioned as the limitations of this study.

Conclusion

In the current study, education based on the HBM with a focus on coping skills led to the improvement of the skills of women who have experienced violence, an improvement in their awareness, attitude, perceived sensitivity, perceived intensity, and finally, the benefits and obstacles they receive from using coping skills.

Considering the importance of the role of health education in promoting behaviors such as coping skills in violent women, as well as preventing the occurrence of inappropriate reactions and the possibility of more problems, the necessity of education on a wider scale and with different tools is felt more and more in society, and it should be one of the health priorities. Therefore, it is suggested to have longer interventions with the aim of focusing on women’s attitudes towards violence and conducting qualitative studies to determine the causes of violence and eliminate them.