qualitative research methods domestic violence

• Open access
• Published: 20 June 2023

A qualitative quantitative mixed methods study of domestic violence against women

• Mina Shayestefar 1 ,
• Mohadese Saffari 1 ,
• Razieh Gholamhosseinzadeh 2 ,
• Monir Nobahar 3 , 4 ,
• Majid Mirmohammadkhani 4 ,
• Seyed Hossein Shahcheragh 5 &
• Zahra Khosravi 6  

BMC Women's Health volume  23 , Article number:  322 ( 2023 ) Cite this article

7341 Accesses

1 Altmetric

Metrics details

Violence against women is one of the most widespread, persistent and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication. Domestic violence against women harms individuals, families, and society. The objective of this study was to investigate the prevalence and experiences of domestic violence against women in Semnan.

This study was conducted as mixed research (cross-sectional descriptive and phenomenological qualitative methods) to investigate domestic violence against women, and some related factors (quantitative) and experiences of such violence (qualitative) simultaneously in Semnan. In quantitative study, cluster sampling was conducted based on the areas covered by health centers from married women living in Semnan since March 2021 to March 2022 using Domestic Violence Questionnaire. Then, the obtained data were analyzed by descriptive and inferential statistics. In qualitative study by phenomenological approach and purposive sampling until data saturation, 9 women were selected who had referred to the counseling units of Semnan health centers due to domestic violence, since March 2021 to March 2022 and in-depth and semi-structured interviews were conducted. The conducted interviews were analyzed using Colaizzi’s 7-step method.

In qualitative study, seven themes were found including “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems”. In quantitative study, the variables of age, age difference and number of years of marriage had a positive and significant relationship, and the variable of the number of children had a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). Also, increasing the level of female education and income both independently showed a significant relationship with increasing the score of violence.

Conclusions

Some of the variables of violence against women are known and the need for prevention and plans to take action before their occurrence is well felt. Also, supportive mechanisms with objective and taboo-breaking results should be implemented to minimize harm to women, and their children and families seriously.

Peer Review reports

Violence against women by husbands (physical, sexual and psychological violence) is one of the basic problems of public health and violation of women’s human rights. It is estimated that 35% of women and almost one out of every three women aged 15–49 experience physical or sexual violence by their spouse or non-spouse sexual violence in their lifetime [ 1 ]. This is a nationwide public health issue, and nearly every healthcare worker will encounter a patient who has suffered from some type of domestic or family violence. Unfortunately, different forms of family violence are often interconnected. The “cycle of abuse” frequently persists from children who witness it to their adult relationships, and ultimately to the care of the elderly [ 2 ]. This violence includes a range of physical, sexual and psychological actions, control, threats, aggression, abuse, and rape [ 3 ].

Violence against women is one of the most widespread, persistent, and detrimental violations of human rights in today’s world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication [ 3 ]. In the United States of America, more than one in three women (35.6%) experience rape, physical violence, and intimate partner violence (IPV) during their lifetime. Compared to men, women are nearly twice as likely (13.8% vs. 24.3%) to experience severe physical violence such as choking, burns, and threats with knives or guns [ 4 ]. The higher prevalence of violence against women can be due to the situational deprivation of women in patriarchal societies [ 5 ]. The prevalence of domestic violence in Iran reported 22.9%. The maximum of prevalence estimated in Tehran and Zahedan, respectively [ 6 ]. Currently, Iran has high levels of violence against women, and the provinces with the highest rates of unemployment and poverty also have the highest levels of violence against women [ 7 ].

Domestic violence against women harms individuals, families, and society [ 8 ]. Violence against women leads to physical, sexual, psychological harm or suffering, including threats, coercion and arbitrary deprivation of their freedom in public and private life. Also, such violence is associated with harmful effects on women’s sexual reproductive health, including sexually transmitted infection such as Human Immunodeficiency Virus (HIV), abortion, unsafe childbirth, and risky sexual behaviors [ 9 ]. There are high levels of psychological, sexual and physical domestic abuse among pregnant women [ 10 ]. Also, women with postpartum depression are significantly more likely to experience domestic violence during pregnancy [ 11 ].

Prompt attention to women’s health and rights at all levels is necessary, which reduces this problem and its risk factors [ 12 ]. Because women prefer to remain silent about domestic violence and there is a need to introduce immediate prevention programs to end domestic violence [ 13 ]. violence against women, which is an important public health problem, and concerns about human rights require careful study and the application of appropriate policies [ 14 ]. Also, the efforts to change the circumstances in which women face domestic violence remain significantly insufficient [ 15 ]. Given that few clear studies on violence against women and at the same time interviews with these people regarding their life experiences are available, the authors attempted to planning this research aims to investigate the prevalence and experiences of domestic violence against women in Semnan with the research question of “What is the prevalence of domestic violence against women in Semnan, and what are their experiences of such violence?”, so that their results can be used in part of the future planning in the health system of the society.

This study is a combination of cross-sectional and phenomenology studies in order to investigate the amount of domestic violence against women and some related factors (quantitative) and their experience of this violence (qualitative) simultaneously in the Semnan city. This study has been approved by the ethics committee of Semnan University of Medical Sciences with ethic code of IR.SEMUMS.REC.1397.182. The researcher introduced herself to the research participants, explained the purpose of the study, and then obtained informed written consent. It was assured to the research units that the collected information will be anonymous and kept confidential. The participants were informed that participation in the study was entirely voluntary, so they can withdraw from the study at any time with confidence. The participants were notified that more than one interview session may be necessary. To increase the trustworthiness of the study, Guba and Lincoln’s criteria for rigor, including credibility, transferability, dependability, and confirmability [ 16 ], were applied throughout the research process. The COREQ checklist was used to assess the present study quality. The researchers used observational notes for reflexivity and it preserved in all phases of this qualitative research process.

Qualitative method

Based on the phenomenological approach and with the purposeful sampling method, nine women who had referred to the counseling units of healthcare centers in Semnan city due to domestic violence in February 2021 to March 2022 were participated in the present study. The inclusion criteria for the study included marriage, a history of visiting a health center consultant due to domestic violence, and consent to participate in the study and unwillingness to participate in the study was the exclusion criteria. Each participant invited to the study by a telephone conversation about study aims and researcher information. The interviews place selected through agreement of the participant and the researcher and a place with the least environmental disturbance. Before starting each interview, the informed consent and all of the ethical considerations, including the purpose of the research, voluntary participation, confidentiality of the information were completely explained and they were asked to sign the written consent form. The participants were interviewed by depth, semi-structured and face-to-face interviews based on the main research question. Interviews were conducted by a female health services researcher with a background in nursing (M.Sh.). Data collection was continued until the data saturation and no new data appeared. Only the participants and the researcher were present during the interviews. All interviews were recorded by a MP3 Player by permission of the participants before starting. Interviews were not repeated. No additional field notes were taken during or after the interview.

The age range of the participants was from 38 to 55 years and their average age was 40 years. The sociodemographic characteristics of the participants are summarized in table below (Table  1 ).

Five interviews in the courtyards of healthcare centers, 2 interviews in the park, and 2 interviews at the participants’ homes were conducted. The duration of the interviews varied from 45 min to one hour. The main research question was “What is your experience about domestic violence?“. According to the research progress some other questions were asked in line with the main question of the research.

The conducted interviews were analyzed by using the 7 steps Colizzi’s method [ 17 ]. In order to empathize with the participants, each interview was read several times and transcribed. Then two researchers (M.Sh. and M.N.) extracted the phrases that were directly related to the phenomenon of domestic violence against women independently and distinguished from other sentences by underlining them. Then these codes were organized into thematic clusters and the formulated concepts were sorted into specific thematic categories.

In the final stage, in order to make the data reliable, the researcher again referred to 2 participants and checked their agreement with their perceptions of the content. Also, possible important contents were discussed and clarified, and in this way, agreement and approval of the samples was obtained.

Quantitative method

The cross-sectional study was implemented from February 2021 to March 2022 with cluster sampling of married women in areas of 3 healthcare centers in Semnan city. Those participants who were married and agreed with the written and verbal informed consent about the ethical considerations were included to the study. The questionnaire was completed by the participants in paper and online form.

The instrument was the standard questionnaire of domestic violence against women by Mohseni Tabrizi et al. [ 18 ]. In the questionnaire, questions 1–10, 11–36, 37–65 and 66–71 related to sociodemographic information, types of spousal abuse (psychological, economical, physical and sexual violence), patriarchal beliefs and traditions and family upbringing and learning violence, respectively. In total, this questionnaire has 71 items.

The scoring of the questionnaire has two parts and the answers to them are based on the Likert scale. Questions 11–36 and 66–71 are answered with always [ 4 ] to never (0) and questions 37–65 with completely agree [ 4 ] to completely disagree (0). The minimum and maximum score is 0 and 300, respectively. The total score of 0–60, 61–120 and higher than 121 demonstrates low, moderate and severe domestic violence against women, respectively [ 18 ].

In the study by Tabrizi et al., to evaluate the validity and reliability of this questionnaire, researchers tried to measure the face validity of the scale by the previous research. Those items and questions which their accuracies were confirmed by social science professors and experts used in the research, finally. The total Cronbach’s alpha coefficient was 0.183, which confirmed that the reliability of the questions and items of the questionnaire is sufficient [ 18 ].

Descriptive data were reported using mean, standard deviation, frequency and percentage. Then, to measure the relationship between the variables, χ2 and Pearson tests also variance and regression analysis were performed. All analysis were performed by using SPSS version 26 and the significance level was considered as p < 0.05.

Qualitative results

According to the third step of Colaizzi’s 7-step method, the researcher attempted to conceptualize and formulate the extracted meanings. In this step, the primary codes were extracted from the important sentences related to the phenomenon of violence against women, which were marked by underlining, which are shown below as examples of this stage and coding.

The primary code of indifference to the father’s role was extracted from the following sentences. This is indifference in the role of the father in front of the children.

“Some time ago, I told him that our daughter is single-sided deaf. She has a doctor’s appointment; I have to take her to the doctor. He said that I don’t have money to give you. He doesn’t force himself to make money anyway” (p 2, 33 yrs).

“He didn’t value his own children. He didn’t think about his older children” (p 4, 54 yrs).

The primary code extracted here included lack of commitment in the role of head of the household. This is irresponsibility towards the family and meeting their needs.

“My husband was fired from work after 10 years due to disorder and laziness. Since then, he has not found a suitable job. Every time he went to work, he was fired after a month because of laziness” (p 7, 55 yrs).

“In the evening, he used to get dressed and go out, and he didn’t come back until late. Some nights, I was so afraid of being alone that I put a knife under my pillow when I slept” (p 2, 33 yrs).

A total of 246 primary codes were extracted from the interviews in the third step. In the fourth step, the researchers put the formulated concepts (primary codes) into 85 specific sub-categories.

Twenty-three categories were extracted from 85 sub-categories. In the sixth step, the concepts of the fifth step were integrated and formed seven themes (Table  2 ).

These themes included “Facilitators”, “Role failure”, “Repressors”, “Efforts to preserve the family”, “Inappropriate solving of family conflicts”, “Consequences”, and “Inefficient supportive systems” (Fig.  1 ).

Themes of domestic violence against women

Some of the statements of the participants on the theme of “ Facilitators” are listed below:

Husband’s criminal record

“He got his death sentence for drugs. But, at last it was ended for 10 years” (p 4, 54 yrs).

Inappropriate age for marriage

“At the age of thirteen, I married a boy who was 25 years old” (p 8, 25 yrs).

“My first husband obeyed her parents. I was 12–13 years old” (p 3, 32 yrs).

“I couldn’t do anything. I was humiliated” (p 1, 38 yrs).

“A bridegroom came. The mother was against. She said, I am young. My older sister is not married yet, but I was eager to get married. I don’t know, maybe my father’s house was boring for me” (p 2, 33 yrs).

“My parents used to argue badly. They blamed each other and I always wanted to run away from these arguments. I didn’t have the patience to talk to mom or dad and calm them down” (p 5, 39 yrs).

Overdependence

“My husband’s parents don’t stop interfering, but my husband doesn’t say anything because he is a student of his father. My husband is self-employed and works with his father on a truck” (p 8, 25 yrs).

“Every time I argue with my husband because of lack of money, my mother-in-law supported her son and brought him up very spoiled and lazy” (p 7, 55 yrs).

Bitter memories

“After three years, my mother married her friend with my uncle’s insistence and went to Shiraz. But, his condition was that she did not have the right to bring his daughter with her. In fact, my mother also got married out of necessity” (p 8, 25 yrs).

Some of their other statements related to “ Role failure” are mentioned below:

Lack of commitment to different roles

“I got angry several times and went to my father’s house because of my husband’s bad financial status and the fact that he doesn’t feel responsible to work and always says that he cannot find a job” (p 6, 48 yrs).

“I saw that he does not want to change in any way” (p 4, 54 yrs).

“No matter how kind I am, it does not work” (p 1, 38 yrs).

Some of their other statements regarding “ Repressors” are listed below:

Fear and silence

“My mother always forced me to continue living with my husband. Finally, my father had been poor. She all said that you didn’t listen to me when you wanted to get married, so you don’t have the right to get angry and come to me, I’m miserable enough” (p 2, 33 yrs).

“Because I suffered a lot in my first marital life. I was very humiliated. I said I would be fine with that. To be kind” (p1, 38 yrs).

“Well, I tell myself that he gets angry sometimes” (p 3, 32 yrs).

Shame from society

“I don’t want my daughter-in-law to know. She is not a relative” (p 4, 54 yrs).

Some of the statements of the participants regarding the theme of “ Efforts to preserve the family” are listed below:

Hope and trust

“I always hope in God and I am patient” (p 2, 33 yrs).

Efforts for children

“My divorce took a month. We got a divorce. I forgave my dowry and took my children instead” (p 2, 33 yrs).

Some of their other statements regarding the “ Inappropriate solving of family conflicts” are listed below:

Child-bearing thoughts

“My husband wanted to take me to a doctor to treat me. But my father-in-law refused and said that instead of doing this and spending money, marry again. Marriage in the clans was much easier than any other work” (p 8, 25 yrs).

Lack of effective communication

“I was nervous about him, but I didn’t say anything” (p 5, 39 yrs).

“Now I am satisfied with my life and thank God it is better to listen to people’s words. Now there is someone above me so that people don’t talk behind me” (p 2, 33 yrs).

Some of their other statements regarding the “ Consequences” are listed below:

Harm to children

“My eldest daughter, who was about 7–8 years old, behaved differently. Oh, I was angry. My children are mentally depressed and argue” (p 5, 39 yrs).

After divorce

“Even though I got a divorce, my mother and I came to a remote area due to the fear of what my family would say” (p 2, 33 yrs).

Social harm

“I work at a retirement center for living expenses” (p 2, 33 yrs).

“I had to go to clean the houses” (p 5, 39 yrs).

Non-acceptance in the family

“The children’s relationship with their father became bad. Because every time they saw their father sitting at home smoking, they got angry” (p 7, 55 yrs).

Emotional harm

“When I look back, I regret why I was not careful in my choice” (p 7, 55 yrs).

“I felt very bad. For being married to a man who is not bound by the family and is capricious” (p 9, 36 yrs).

Some of their other statements regarding “ Inefficient supportive systems” are listed below:

Inappropriate family support

“We didn’t have children. I was at my father’s house for about a month. After a month, when I came home, I saw that my husband had married again. I cried a lot that day. He said, God, I had to. I love you. My heart is broken, I have no one to share my words” (p 8, 25 yrs).

“My brother-in-law was like himself. His parents had also died. His sister did not listen at all” (p 4, 54 yrs).

“I didn’t have anyone and I was alone” (p 1, 38 yrs).

Inefficiency of social systems

“That day he argued with me, picked me up and threw me down some stairs in the middle of the yard. He came closer, sat on my stomach, grabbed my neck with both of his hands and wanted to strangle me. Until a long time later, I had kidney problems and my neck was bruised by her hand. Given that my aunt and her family were with us in a building, but she had no desire to testify and was afraid” (p 3, 32 yrs).

Undesired training and advice

“I told my mother, you just said no, how old I was? You never insisted on me and you didn’t listen to me that this man is not good for you” (p 9, 36 yrs).

Quantitative results

In the present study, 376 married women living in Semnan city participated in this study. The mean age of participants was 38.52 ± 10.38 years. The youngest participant was 18 and the oldest was 73 years old. The maximum age difference was 16 years. The years of marriage varied from one year to 40 years. Also, the number of children varied from no children to 7. The majority of them had 2 children (109, 29%). The sociodemographic characteristics of the participants are summarized in the table below (Table  3 ).

The frequency distribution (number and percentage) of the participants in terms of the level of violence was as follows. 89 participants (23.7%) had experienced low violence, 59 participants (15.7%) had experienced moderate violence, and 228 participants (60.6%) had experienced severe violence.

Cronbach’s alpha for the reliability of the questionnaire was 0.988. The mean and standard deviation of the total score of the questionnaire was 143.60 ± 74.70 with a range of 3-244. The relationship between the total score of the questionnaire and its fields, and some demographic variables is summarized in the table below (Table  4 ).

As shown in the table above, the variables of age, age difference and number of years of marriage have a positive and significant relationship, and the variable of number of children has a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). However, the variable of education level difference showed no significant relationship with the total score and any of the fields. Also, the highest average score is related to patriarchal beliefs compared to other fields.

The comparison of the average total scores separately according to each variable showed the significant average difference in the variables of the previous marriage history of the woman, the result of the previous marriage of the woman, the education of the woman, the education of the man, the income of the woman, the income of the man, and the physical disease of the man (p < 0.05).

In the regression model, two variables remained in the final model, indicating the relationship between the variables and violence score and the importance of these two variables. An increase in women’s education and income level both independently show a significant relationship with an increase in violence score (Table  5 ).

The results of analysis of variance to compare the scores of each field of violence in the subgroups of the participants also showed that the experience and result of the woman’s previous marriage has a significant relationship with physical violence and tradition and family upbringing, the experience of the man’s previous marriage has a significant relationship with patriarchal belief, the education level of the woman has a significant relationship with all fields and the level of education of the man has a significant relationship with all fields except tradition and family upbringing (p < 0.05).

According to the results of both quantitative and qualitative studies, variables such as the young age of the woman and a large age difference are very important factors leading to an increase in violence. At a younger age, girls are afraid of the stigma of society and family, and being forced to remain silent can lead to an increase in domestic violence. As Gandhi et al. (2021) stated in their study in the same field, a lower marriage age leads to many vulnerabilities in women. Early marriage is a global problem associated with a wide range of health and social consequences, including violence for adolescent girls and women [ 12 ]. Also, Ahmadi et al. (2017) found similar findings, reporting a significant association among IPV and women age ≤ 40 years [ 19 ].

Two others categories of “Facilitators” in the present study were “Husband’s criminal record” and “Overdependence” which had a sub-category of “Forced cohabitation”. Ahmadi et al. (2017) reported in their population-based study in Iran that husband’s addiction and rented-householders have a significant association with IPV [ 19 ].

The patriarchal beliefs, which are rooted in the tradition and culture of society and family upbringing, scored the highest in relation to domestic violence in this study. On the other hand, in qualitative study, “Normalcy” of men’s anger and harassment of women in society is one of the “Repressors” of women to express violence. In the quantitative study, the increase in the women’s education and income level were predictors of the increase in violence. Although domestic violence is more common in some sections of society, women with a wide range of ages, different levels of education, and at different levels of society face this problem, most of which are not reported. Bukuluki et al. (2021) showed that women who agreed that it is good for a man to control his partner were more likely to experience physical violence [ 20 ].

Domestic violence leads to “Consequences” such as “Harm to children”, “Emotional harm”, “Social harm” to women and even “Non-acceptance in their own family”. Because divorce is a taboo in Iranian culture and the fear of humiliating women forces them to remain silent against domestic violence. Balsarkar (2021) stated that the fear of violence can prevent women from continuing their studies, working or exercising their political rights [ 8 ]. Also, Walker-Descarte et al. (2021) recognized domestic violence as a type of child maltreatment, and these abusive behaviors are associated with mental and physical health consequences [ 21 ].

On the other hand and based on the “Lack of effective communication” category, ignoring the role of the counselor in solving family conflicts and challenges in the life of couples in the present study was expressed by women with reasons such as lack of knowledge and family resistance to counseling. Several pathologies are needed to investigate increased domestic violence in situations such as during women’s pregnancy or infertility. Because the use of counseling for couples as a suitable solution should be considered along with their life challenges. Lin et al. (2022) stated that pregnant women were exposed to domestic violence for low birth weight in full term delivery. Spouse violence screening in the perinatal health care system should be considered important, especially for women who have had full-term low birth weight infants [ 22 ].

Also, lack of knowledge and low level of education have been found as other factors of violence in this study, which is very prominent in both qualitative and quantitative studies. Because the social systems and information about the existing laws should be followed properly in society to act as a deterrent. Psychological training and especially anger control and resilience skills during education at a younger age for girls and boys should be included in educational materials to determine the positive results in society in the long term. Manouchehri et al. (2022) stated that it seems necessary to train men about the negative impact of domestic violence on the current and future status of the family [ 23 ]. Balsarkar (2021) also stated that men and women who have not had the opportunity to question gender roles, attitudes and beliefs cannot change such things. Women who are unaware of their rights cannot claim. Governments and organizations cannot adequately address these issues without access to standards, guidelines and tools [ 8 ]. Machado et al. (2021) also stated that gender socialization reinforces gender inequalities and affects the behavior of men and women. So, highlighting this problem in different fields, especially in primary health care services, is a way to prevent IPV against women [ 24 ].

There was a sub-category of “Inefficiency of social systems” in the participants experiences. Perhaps the reason for this is due to insufficient education and knowledge, or fear of seeking help. Holmes et al. (2022) suggested the importance of ascertaining strategies to improve victims’ experiences with the court, especially when victims’ requests are not met, to increase future engagement with the system [ 25 ]. Sigurdsson (2019) revealed that despite high prevalence numbers, IPV is still a hidden and underdiagnosed problem and neither general practitioner nor our communities are as well prepared as they should be [ 26 ]. Moreira and Pinto da Costa (2021) found that while victims of domestic violence often agree with mandatory reporting, various concerns are still expressed by both victims and healthcare professionals that require further attention and resolution [ 27 ]. It appears that legal and ethical issues in this regard require comprehensive evaluation from the perspectives of victims, their families, healthcare workers, and legal experts. By doing so, better practical solutions can be found to address domestic violence, leading to a downward trend in its occurrence.

Some of the variables of violence against women have been identified and emphasized in many studies, highlighting the necessity of policymaking and social pathology in society to prevent and use operational plans to take action before their occurrence. Breaking the taboo of domestic violence and promoting divorce as a viable solution after counseling to receive objective results should be implemented seriously to minimize harm to women, children, and their families.

Limitations

Domestic violence against women is an important issue in Iranian society that women resist showing and expressing, making researchers take a long-term process of sampling in both qualitative and quantitative studies. The location of the interview and the women’s fear of their husbands finding out about their participation in this study have been other challenges of the researchers, which, of course, they attempted to minimize by fully respecting ethical considerations. Despite the researchers’ efforts, their personal and professional experiences, as well as the studies reviewed in the literature review section, may have influenced the study results.

Data Availability

Data and materials will be available upon email to the corresponding author.

Abbreviations

Intimate Partner Violence

Human Immunodeficiency Virus

Organization WH. Violence against women prevalence estimates, 2018: global, regional and national prevalence estimates for intimate partner violence against women and global and regional prevalence estimates for non-partner sexual violence against women. World Health Organization; 2021.

Huecker MR, Malik A, King KC, Smock W. Kentucky Domestic Violence. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Ahmad Malik declares no relevant financial relationships with ineligible companies. Disclosure: Kevin King declares no relevant financial relationships with ineligible companies. Disclosure: William Smock declares no relevant financial relationships with ineligible companies.: StatPearls Publishing Copyright © 2023, StatPearls Publishing LLC.; 2023.

Gandhi A, Bhojani P, Balkawade N, Goswami S, Kotecha Munde B, Chugh A. Analysis of survey on violence against women and early marriage: Gyneaecologists’ perspective. J Obstet Gynecol India. 2021;71(Suppl 2):76–83.

Article   Google Scholar  

Sugg N. Intimate partner violence: prevalence, health consequences, and intervention. Med Clin. 2015;99(3):629–49.

Google Scholar  

Abebe Abate B, Admassu Wossen B, Tilahun Degfie T. Determinants of intimate partner violence during pregnancy among married women in Abay Chomen district, western Ethiopia: a community based cross sectional study. BMC Womens Health. 2016;16(1):1–8.

Adineh H, Almasi Z, Rad M, Zareban I, Moghaddam A. Prevalence of domestic violence against women in Iran: a systematic review. Epidemiol (Sunnyvale). 2016;6(276):2161–11651000276.

Pirnia B, Pirnia F, Pirnia K. Honour killings and violence against women in Iran during the COVID-19 pandemic. The Lancet Psychiatry. 2020;7(10):e60.

Article   PubMed   PubMed Central   Google Scholar  

Balsarkar G. Summary of four recent studies on violence against women which obstetrician and gynaecologists should know. J Obstet Gynecol India. 2021;71:64–7.

Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. The lancet. 2008;371(9619):1165–72.

Chasweka R, Chimwaza A, Maluwa A. Isn’t pregnancy supposed to be a joyful time? A cross-sectional study on the types of domestic violence women experience during pregnancy in Malawi. Malawi Med journal: J Med Association Malawi. 2018;30(3):191–6.

Afshari P, Tadayon M, Abedi P, Yazdizadeh S. Prevalence and related factors of postpartum depression among reproductive aged women in Ahvaz. Iran Health care women Int. 2020;41(3):255–65.

Article   PubMed   Google Scholar  

Gebrezgi BH, Badi MB, Cherkose EA, Weldehaweria NB. Factors associated with intimate partner physical violence among women attending antenatal care in Shire Endaselassie town, Tigray, northern Ethiopia: a cross-sectional study, July 2015. Reproductive health. 2017;14:1–10.

Duran S, Eraslan ST. Violence against women: affecting factors and coping methods for women. J Pak Med Assoc. 2019;69(1):53–7.

PubMed   Google Scholar  

Devries KM, Mak JY, Garcia-Moreno C, Petzold M, Child JC, Falder G, et al. The global prevalence of intimate partner violence against women. Science. 2013;340(6140):1527–8.

Article   CAS   PubMed   Google Scholar  

Mahapatro M, Kumar A. Domestic violence, women’s health, and the sustainable development goals: integrating global targets, India’s national policies, and local responses. J Public Health Policy. 2021;42(2):298–309.

Lincoln YS, Guba EG. Naturalistic inquiry: sage; 1985.

Colaizzi PF. Psychological research as the phenomenologist views it. 1978.

Mohseni Tabrizi A, Kaldi A, Javadianzadeh M. The study of domestic violence in Marrid Women Addmitted to Yazd Legal Medicine Organization and Welfare Organization. Tolooebehdasht. 2013;11(3):11–24.

Ahmadi R, Soleimani R, Jalali MM, Yousefnezhad A, Roshandel Rad M, Eskandari A. Association of intimate partner violence with sociodemographic factors in married women: a population-based study in Iran. Psychol Health Med. 2017;22(7):834–44.

Bukuluki P, Kisaakye P, Wandiembe SP, Musuya T, Letiyo E, Bazira D. An examination of physical violence against women and its justification in development settings in Uganda. PLoS ONE. 2021;16(9):e0255281.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Walker-Descartes I, Mineo M, Condado LV, Agrawal N. Domestic violence and its Effects on Women, Children, and families. Pediatr Clin North Am. 2021;68(2):455–64.

Lin C-H, Lin W-S, Chang H-Y, Wu S-I. Domestic violence against pregnant women is a potential risk factor for low birthweight in full-term neonates: a population-based retrospective cohort study. PLoS ONE. 2022;17(12):e0279469.

Manouchehri E, Ghavami V, Larki M, Saeidi M, Latifnejad Roudsari R. Domestic violence experienced by women with multiple sclerosis: a study from the North-East of Iran. BMC Womens Health. 2022;22(1):1–14.

Machado DF, Castanheira ERL, Almeida MASd. Intersections between gender socialization and violence against women by the intimate partner. Ciência & Saúde Coletiva. 2021;26:5003–12.

Holmes SC, Maxwell CD, Cattaneo LB, Bellucci BA, Sullivan TP. Criminal Protection orders among women victims of intimate Partner violence: Women’s Experiences of Court decisions, processes, and their willingness to Engage with the system in the future. J interpers Violence. 2022;37(17–18):Np16253–np76.

Sigurdsson EL. Domestic violence-are we up to the task? Scand J Prim Health Care. 2019;37(2):143–4.

Moreira DN, Pinto da Costa M. Should domestic violence be or not a public crime? J Public Health. 2021;43(4):833–8.

Download references

Acknowledgements

The authors of this study appreciate the Deputy for Research and Technology of Semnan University of Medical Sciences, Social Determinants of Health Research Center of Semnan University of Medical Sciences and all the participants in this study.

Research deputy of Semnan University of Medical Sciences financially supported this project.

Author information

Authors and affiliations.

School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran

Mina Shayestefar & Mohadese Saffari

Amir Al Momenin Hospital, Social Security Organization, Ahvaz, Iran

Razieh Gholamhosseinzadeh

Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran

Monir Nobahar

Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran

Monir Nobahar & Majid Mirmohammadkhani

Clinical Research Development Unit, Kowsar Educational, Research and Therapeutic Hospital, Semnan University of Medical Sciences, Semnan, Iran

Seyed Hossein Shahcheragh

Student Research Committee, School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran

Zahra Khosravi

You can also search for this author in PubMed   Google Scholar

Contributions

M.Sh. contributed to the first conception and design of this research; M.Sh., Z.Kh., M.S., R.Gh. and S.H.Sh. contributed to collect data; M.N. and M.Sh. contributed to the analysis of the qualitative data; M.M. and M.Sh. contributed to the analysis of the quantitative data; M.SH., M.N. and M.M. contributed to the interpretation of the data; M.Sh., M.S. and S.H.Sh. wrote the manuscript. M.Sh. prepared the final version of manuscript for submission. All authors reviewed the manuscript meticulously and approved it. All names of the authors were listed in the title page.

Corresponding author

Correspondence to Mina Shayestefar .

Ethics declarations

Ethics approval and consent to participate.

This article is resulted from a research approved by the Vice Chancellor for Research of Semnan University of Medical Sciences with ethics code of IR.SEMUMS.REC.1397.182 in the Social Determinants of Health Research Center. The authors confirmed that all methods were performed in accordance with the relevant guidelines and regulations. All participants accepted the participation in the present study. The researchers introduced themselves to the research units, explained the purpose of the research to them and then all participants signed the written informed consent. The research units were assured that the collected information was anonymous. The participant was informed that participating in the study was completely voluntary so that they can safely withdraw from the study at any time and also the availability of results upon their request.

Consent for publication

Not applicable.

Competing interests

All authors declare that there are no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Shayestefar, M., Saffari, M., Gholamhosseinzadeh, R. et al. A qualitative quantitative mixed methods study of domestic violence against women. BMC Women's Health 23 , 322 (2023). https://doi.org/10.1186/s12905-023-02483-0

Download citation

Received : 28 April 2023

Accepted : 14 June 2023

Published : 20 June 2023

DOI : https://doi.org/10.1186/s12905-023-02483-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Domestic violence
• Cross-sectional studies
• Qualitative research

BMC Women's Health

ISSN: 1472-6874

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Male perspectives on intimate partner violence: A qualitative analysis from South Africa

Roles Formal analysis, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations School of Public Health, Brown University, Providence, Rhode Island, United States of America, Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States of America

Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Affiliations School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, UN Women Nigeria, Abuja, Nigeria

Roles Writing – review & editing

Affiliations Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island, United States of America, Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa

Roles Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing

Affiliations School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, Department of Health Behavior, School of Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America

Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Affiliation Sonke Gender Justice, Johannesburg, South Africa

Roles Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Affiliation School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Roles Formal analysis, Writing – review & editing

Affiliations Center for Global Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America

• Krysta A. Pelowich, 
• Tosin Akibu, 
• Jennifer Pellowski, 
• Abigail Hatcher, 
• Dumisani Rebombo, 
• Nicola Christofides, 
• Karen Hampanda

• Published: April 16, 2024
• https://doi.org/10.1371/journal.pone.0298198
• Reader Comments

Intimate partner violence (IPV) affects one in four women globally and is more commonly enacted by men than women. Rates of IPV in South Africa exceed the global average. Exploring the background and context regarding why men use violence can help future efforts to prevent IPV.

We explored adult men’s perspectives of IPV, livelihoods, alcohol use, gender beliefs, and childhood exposure to abuse through a secondary analysis of qualitative interviews that were conducted in South Africa. The setting was a peri-urban township characterized by high unemployment, immigration from rural areas, and low service provision. We utilized thematic qualitative analysis that was guided by the social ecological framework.

Of 30 participants, 20 were residents in the neighborhood, 7 were trained community members, and 3 were program staff. Men reported consumption of alcohol and lack of employment as being triggers for IPV and community violence in general. Multiple participants recounted childhood exposure to abuse. These themes, in addition to culturally prescribed gender norms and constructs of manhood, seemed to influence the use of violence.

Interventions aimed at reducing IPV should consider the cultural and social impact on men’s use of IPV in low-resource, high-IPV prevalence settings, such as peri-urban South Africa. This work highlights the persistent need for the implementation of effective primary prevention strategies that address contextual and economic factors in an effort to reduce IPV that is primarily utilized by men directed at women.

Citation: Pelowich KA, Akibu T, Pellowski J, Hatcher A, Rebombo D, Christofides N, et al. (2024) Male perspectives on intimate partner violence: A qualitative analysis from South Africa. PLoS ONE 19(4): e0298198. https://doi.org/10.1371/journal.pone.0298198

Editor: Dorina Onoya, University of the Witwatersrand, SOUTH AFRICA

Received: May 1, 2022; Accepted: January 21, 2024; Published: April 16, 2024

Copyright: © 2024 Pelowich et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant qualitative data are within the paper. Additional questionnaires and data files are available from the SAMRC MEDAT Data Repository ( https://medat.samrc.ac.za/index.php/catalog/24 ).

Funding: This research was funded through What Works To Prevent Violence? A Global Programme on Violence Against Women and Girls (VAWG) funded by the UK Government’s Department for International Development (now called the UK Foreign, Commonwealth and Development Office). However, the views expressed do not necessarily reflect the department’s official policies and the funders had no role in study design, collection, management, analysis, interpretation of data, writing of the report, or the decision to submit the paper for publication.

Competing interests: The authors have declared that no competing interests exist.

Introduction

South Africa has one of the highest rates of intimate partner violence (IPV) globally [ 1 ]. IPV, as defined by the Centers for Disease Control and Prevention (CDC), refers to “physical violence, sexual violence, stalking and psychological aggression, including coercive tactics, by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner)” [ 2 ]. In most heterosexual relationships in South Africa, men are the users (i.e., perpetrators) of violence rather than the ones experiencing it [ 3 ]. The impact that IPV has on women and girls in South Africa are numerous. IPV can cause immediate and direct health consequences such as acquisition of sexually transmitted infections (STIs), including HIV [ 4 ]. Physical injury is also commonly reported. Other adverse effects of IPV can be seen through diverse mental health outcomes including depression, post-traumatic stress disorder (PTSD), substance use, and diminished self-esteem [ 5 ]. If a woman is pregnant at the time of IPV exposure, indirect health issues, such as low birth weight of child and premature birth of a baby are also possible [ 1 ]. Death is another potential outcome of IPV. The WHO estimates between 40–70 percent of female murders that occur globally are committed by a husband or boyfriend, often in the context of an abusive relationship [ 6 ].

Data collected in South Africa highlights the varying prevalence of IPV. Some of the underlying causes that impact IPV prevalence can be attributed to geographic location, age, gender, and by study [ 7 ]. For example, the most recent Demographic and Health Survey reported that over 25 percent of ever-partnered adult women have experienced IPV during their lifetime with 13 percent reported experiencing IPV in the last year [ 8 ]. Among non-representative samples, Selin et al. (2019) reported a 37 percent prevalence of IPV in adolescent girls aged 13–20 years living in rural South Africa [ 9 ]. Zembe et al. found a much higher prevalence of IPV, 86 percent, among young women aged 16–24 years residing in the urban city of Cape Town, South Africa [ 10 ].

While the majority of research that is conducted on IPV–both globally and in South Africa–focuses on women’s perspective, some data have been collected among men. In a study by Dunkle et al., quantitative surveys with 1275 young men in rural South Africa found 31.8 percent of the participants self-reported using violence against their female partner [ 11 ]. Of these, the primary type of violence used was solely physical (71.9 percent). The next common form of violence reported was both physical and sexual violence (16.8 percent) [ 11 ]. The use of only sexual violence was the least common (11.3 percent). In a study conducted by Jewkes et al. (2008) across three South African districts, men self-reported a prevalence of using physical IPV at 30.7 percent [ 12 ]. Within this study, disclosure of men who raped their partner was 29.6 percent [ 12 ]. In peri-urban township settings near Johannesburg and eThekwini (Durban), roughly half of men reported using some form of IPV within the last year [ 12 , 13 ]. Integral to providing effective primary prevention is understanding the male perspective of IPV, particularly in a context where violence is used more than the global average [ 1 ].

Despite the high prevalence of men’s use of IPV in South Africa, much less is known about the key factors contributing to male violent behavior in this geographic context. Some men may consider violence as a way to maintain power and dominance over women, and enact hegemonic masculinity [ 14 ]. According to the Theory of Gender and Power, social norms can exacerbate men’s use of IPV in settings where male dominance tends to be acceptable [ 15 ]. Recent literature on hegemonic masculinity, however, argues that masculinities are configurations of behaviors developed over time and that understanding men’s life histories is critical to interpret the role of masculinity in IPV [ 16 ]. Unfortunately, there is a paucity of research establishing which exposures at various levels of the social ecology across the life-course lead to South African men’s use of IPV and men’s interpretation of their experiences. Further, it is rare that interventions are able to effectively reduce the use of IPV utilized by men [ 17 ]. The primary aim and objective of this research is to explore adult male perceptions of IPV in a peri-urban township setting in South Africa by conducting a secondary analysis of a pre-collected qualitative data set. This information will be used to further understand why men use violence and provide a framework to developing acceptable, effective interventions. The secondary aim is to explore key aspects of early life trauma and what impact that has on adult relationships.

Data source

The data was collected in 2015 as part of formative research for a community-level intervention that focused on preventing IPV use among adult males. The study was approved through the human research ethics committee (HREC) of the University of Witwatersrand, South Africa (HREC M160361). The interviews helped the research team make important refinements to an existing gender-transformative program developed by Sonke Gender Justice, an organization focused on combatting gender-based violence, HIV/AIDS, and child abuse. Sonke Gender Justice is part of the Violence Prevention Alliance (VPA) which is a network of WHO members, international agencies, and civil society organizations working to prevent violence while increasing awareness of human rights and promoting healthy attitudes towards masculinity [ 18 ].

Purposive sampling was completed by two key informants that worked at Sonke Gender Justice and had strong ties to the local community. The key informants identified, approached, and invited men to participate. Individuals that were interested in the study were then contacted by a trained researcher to schedule a time for their interview (n = 30). Inclusion criteria required that men be over 18 to participate so they could legally consent, and they must have been living in the same peri-urban township during 2015.

Twenty of the men were from the general population of community members, 7 were community action team members that were local volunteers who received a stipend from the program and additional training. The final 3 were Sonke Gender Justice staff members who received training, ongoing supervision, and a monthly salary. The three groups of men had homogeneous characteristics and were asked similar semi-structured interviews, therefore, we examined all 30 men’s responses together. This allowed for a larger sample size and breadth of perspectives to be analyzed.

The interviews took place in a peri-urban setting near Johannesburg, South Africa, and focused on the topics of employment, fatherhood, IPV interventions, perceptions of IPV, and gender norms. Written informed consent was obtained from the men who opted to participate. The qualitative researcher conducted the interviews in the participants chosen language of isiZulu or Sesotho and, with permission, audio recorded the conversation using a digital application. A trained transcriptionist translated the interview from isiZulu or Sesotho to English and typed English transcripts verbatim, with italics for important phrases that were spoken in the local language. Interviews took approximately 60 minutes and were held wherever the interviewee was comfortable [ 19 ]. This meant that for some participants, interviews were conducted in their homes while for others, they were conducted in a church or community hall as long as privacy was maintained [ 19 ].

Data analysis

To follow best practices in qualitative methodology, the research team thoroughly read and re-read the transcripts to familiarize themselves with the text prior to any coding. After this process, the team began to apply structured coding to the transcripts utilizing Atlas.ti. A priori codes were created based off of the parent study’s interview guide and codes that were identified in a previous analysis (see S1 Appendix ). This was used as a framework when the team began to read and set up an initial codebook.

To establish interrater reliability, two authors (KP & KH) used the same codebook to independently code the same interviews. They then discussed any discrepancies they found and came to consensus. This was done for 10% of the interviews. After this subset of interviews was coded, any necessary revisions were made, and the final codebook was established. The final codebook contained thematic code names and definitions which the research team used to complete data analysis by applying codes to varying text (see S2 Appendix ).

The full analysis team (KP, JP, AH, AK) reviewed the initial results and interrogated the findings, which resulted in additional queries and validity checks of the analyses. Utilizing the final data that had been coded, the analysis team wrote qualitative analytical reports on each major thematic code.

Participant characteristics

Participants had been residing in the area between 4 months to 20 years. The majority were either unemployed or self-employed as day laborers. Ages of participants ranged from 18 to 57 years and most individuals lived with a romantic partner. Roughly half of the participants spoke about having children of their own, though we did not collect demographic data on this aspect of their lives. None of the participants were screened or assessed for use of IPV prior to the qualitative interviews.

In the following sections, we present the main themes from the qualitative interviews related to men’s experiences and perceptions of IPV.

1. Alcohol usage is linked to violence.

Participants described that the use of violence, including IPV, was often linked to alcohol consumption. It was common for men and women to gather at bars, or shebeens (i.e. local, informal, and unlicensed drinking areas), and begin drinking in the afternoons. As the evening continued, violence in the streets would break out between community members, gang members, and between partners. When one participant stated that “ …people around [here] actually like violence…” ( CAT07) the interviewer asked him what might be the reason. The participant replied, “ we drink too much ” (CAT07).

Another participant described often hearing his neighbors fight and he perceived them as being in an abusive relationship. He explained that when a fight erupted between the couple, he could hear it. When the participant was asked what he thought might cause the fights, he also felt that alcohol played a role.

“I think sometimes it [use of violence] is alcohol . When they are sober they are okay [not using violence] . When they start drinking everything goes wrong . ” (FORM11)

This connection is further supported by participants’ observations of the lack of violence during the day when people are less likely to be drinking. A conversation between an interviewer and participant illustrated this:

I : I have observed that now in the afternoon we do not hear any cries for help or shouting [ due to violence] . R : No , no cries at all . I : Because people are sober ? R : Exactly , because people are sober… . when [the clock] strikes 12 at night there will be no peace . (FORM20)

These three excerpts describe how there is a perceived direct link between alcohol consumption and violence. The violence described by participants included both community violence and IPV.

2. Socioeconomic context of violence.

While many participants noted in their interviews that they moved to the peri-urban settlement in hopes of finding an occupation, several were still unemployed. Having no income to support one’s family and living in an impoverished area created significant stress for men. Some participants, such as CM02, described how they perceived the connection between economic hardship and violence:

“…maybe there is no electricity and there is no water and others—they are not even working—that kind of thing can pile up into stress whereby someone he took his frustration out to his partner because he is not working , he can’t afford to buy food , the kids don’t have shoes to go to schools . ” (CM02)

Alternatively, those that were able to obtain employment and financial means sometimes used their economic status as leverage over their partner, thus creating a situation for violence to start. CAT04 expressed how the male “provider” role, based on the social construction of gender norms, allowed men to provoke fear in their partner and prevent them from reporting IPV to the police as it could inhibit household wellbeing:

“… men think they have power over a woman … because maybe I’m a breadwinner . If you fight me back , I will stop buying food , I will stop paying rent if I’m renting … If my wife wants something , I’m the one who’s going to buy , so if my wife fights me back , she’ll be afraid . And if she goes to the police station and reports , she will think about if she reports her man … they’re going to arrest him and he’ll lose his job . ” (CAT04)

Even though the economic status of participants fluctuated, violence remained a continuous issue. The narratives above describe how both economic hardship and men earning money can be related to their use of IPV.

3. Perception of gender and constrained views around manhood.

The participants perceived gender roles in a variety of ways. For some, it meant the differences in household responsibilities. Participant CAT01 explained that men would be made fun of if they were seen “ doing washing and just cooking and cleaning around ” because it was “ women’s work ” (CAT01).

Some of the participants described women as being more passive compared to men when characterizing the perceived behavior differences.

“The role of a woman in the house is supposed to be submissive , that’s all . She doesn’t have a say whether in finance or anything in the house—you guys don’t have to share some responsibility in the house . ” (CM02)

In this example, the participant illustrates the perceived culturally prescribed power dynamics that differ between men and women. Women are not to question what men are doing with the household decision making. Similarly, some participants discussed gender power dynamics in relation to how they felt women should act in society. CM06 explained,

“It’s kind of normal for me to be seen smoking and then two minutes it’s a lady smoking , it’s kind of weird to people . They don’t expect a woman smoking and then if she’s smoking , obviously she’s going [to] be called names…It’s also becoming normal for ladies to wear trousers…can’t you see they’re undermining us men ? ” (CM06)

In this quote, the participant is sharing their perception of gender differences in relation to smoking behavior, as well as clothing. Within the community, smoking is considered a masculine behavior. Additionally, the simple act of a woman wearing trousers, which is perceived as a standard item of clothing for men, begins to encroach on men’s masculinity. When both genders exhibit equal behaviors, it can be perceived as threatening for some men. It is postulated that during social transitions, such as changes in gender roles, IPV may temporarily increase due to men’s backlash against women assuming more equitable roles [ 20 ].

To clarify what the male participants perceived as masculine behavior, they were specifically asked to provide examples on what masculinity meant to them. Nearly every participant described masculinity as being synonymous with pride, responsibility, and coming-of-age. Some participants described going through a ceremony within their tribe, during which they became a man. Others described masculinity as providing for their family. FORM14 explained, “ in this area , being a man means having money , you cannot live here if you don’t have it ”.

Another form of masculinity was described as asserting sexual dominance. CAT01 stated that masculinity meant having “ one-night stands ,” while CAT02 described it as “ having lots of girlfriends ”. CAT02 further expanded on the meaning.

“Just to brag that I’ve slept with–let me say–[I made 15 kids with] 15 ladies this weekend . ” (CAT02)

This example of young men in the community boasting about having multiple sexual partners was not singular. It was a common theme among the men due to hegemonic masculinity fostered by the perceived power and expected subordination of women. Women’s subordination can be additionally justified in a marriage if the man paid “lobola” (i.e., bride price paid by the man to the woman’s family). Gender norms, combined with the lobola custom, can have implications on men’s justification for the use of IPV, as illustrated by the following quote:

“I think the men , that is why they used to abuse their wives . They think they are strong or they think no one can tell them what is right , so that is why they are abusing the women . They have that thing… . so he has to do that because he paid lobola [bride price] and everything so I have to abuse…it is good I can beat her…because I paid for her , it’s like having a car . ” (CM01)

The quote above highlights how hegemonic masculinity is exerted through violence and control. Men’s perspective that violence and control over women are acceptable behaviors was further exacerbated by paying lobola, which gave them a sense of ownership over women.

4. Familial violence across generations.

A final theme that was salient in the interviews was generational violence. For example, some participants described experiencing violence in their childhood from their own father, referencing “the stick” as a tool in which they were struck with. FORM05 explained that during his own childhood, “ the stick was highly functional . If you made a mistake , they [parents] did not talk too much , you knew you were going to be beaten . Those were the ways in those days . Even at school , if you did not perform well , you were beaten so you could go and read .” Several participants described the continued use of violence as a method to teach and discipline their own children.

“He [son] knows , when he is naughty , he knows . When he gets naughty , I spank him with a belt just a little bit . I then talk to him and tell him that what he did was wrong and that I did not like it . I also warn him that if he repeats what he did I will spank him again . ” (FORM02)

Alternatively, other participants in our sample described how violence exposure in their childhood made them hesitant to use the same force with their own children. When asked about the differences between their own childhood and how they parent currently, one participant responded that he used words rather than physical violence to teach his children, which was in sharp contrast to his experience as a child:

“It’s not the same , I grew up in a household where I would occasionally get spanked . I think long and hard before spanking my kids because children of today are very sensitive and will take physical discipline as not being loved by their parents . I would rather sit down and speak to my children with their mother . We used to be hit all the time . ” (FORM18)

There is a difference in how the participants described using violence towards their partner as opposed to using it towards their children. Some participants reflected on their childhood experiences and chose to use different methods for disciplining their own children, yet it is unclear why violence used by participants towards their partner continued. While participants may have intended to create a better future for their children by the reduction in violence directly used on them, the imprinting that occurred to their children when violence took place between parents was just as significant.

“This thing , it comes from generation from generation , when we say I might want to do what my dad does at home , you know , problems start at home . Because , you find out that both parents are drinking and then they fight , you know , so they keep close up , seeing everything , experiencing this . Now you just want to show off . My dad beats my mom like this and that , my dad smokes in front of me , so sometimes , I even drink with him . ” (CAT02)

In the above quote, the participant acknowledged the intergenerational transmission of both violence and alcohol use. Engaging in similar behaviors as male role models in the home (e.g., fathers), even if problematic, may allow boys social opportunities to connect with their fathers. This quote illustrates the tension between healthful behaviors and finding forms of connectedness, particularly as a child in constrained environments.

This qualitative study investigated the complexities behind IPV from the male perspective in a low resource setting with high community violence and IPV in South Africa. While there is a vast literature on gender power dynamics and IPV, there is a gap in research on men’s perceptions of factors that influence the use of IPV, particularly in global settings [ 21 ]. At each level of the social ecology (sociocultural, economic, interpersonal and familial, and individual), male participants in the present study provided examples of influential factors connected to the use of IPV against women, supporting prior research on the usefulness of applying the social ecological model to the study of IPV [ 12 , 13 , 22 ]. Unfortunately, our participants emphasized the high levels of various types of violence in the community, which created an atmosphere where violence, including IPV, became normalized.

This study revealed the importance of the life course perspective and social learning on adult men’s perceptions and behaviors, including the use of IPV. The findings of the present study are in line with the Intergenerational Transmission of Violence Theory and social learning theory, which both posit that individuals will imitate the behaviors of influential role models, including interpersonal violence they may have witnessed in their household as children [ 23 , 24 ]. Our participants explicitly described how men in this setting often engage in behaviors that they observed from male role models (“[I] do what my dad does”). This included the use of violence as a form of discipline for children, the use of IPV against women, and substance use. Prior research from multiple global settings has similarly reported that experiencing childhood abuse and growing up with domestic violence are risk factors for IPV [ 25 , 26 ]. Our findings highlight that the men in the present study are consciously aware of this connection and viewed the violence they witnessed or experienced as problematic. Despite this recognition, none of the participants described explicit attempts to stop the intergenerational cycle of IPV against women. Conversely, some participants did describe active attempts to stop the cycle of physical violence against children (e.g., talking instead of spanking). More research is needed to explore how men in different contexts understand the consequences of experiencing violence as a child (direct victimization) compared to witnessing violence against women (indirect/vicarious victimization), which could be leveraged in future prevention efforts.

Our participants continuously highlighted the complexities of how Black South African men are expected to attain dominant cultural standards of masculinity within the constraints of post-colonial/post-apartheid economic marginalization [ 27 , 28 ]. In our interviews, men consistently endorsed the notion that to fulfil masculine gender norms, they are expected to work outside the home and be the main financial providers of the family. Most participants described coming to the peri-urban township setting in hopes of finding employment, yet they remained jobless. Finding employment was extremely difficult in this setting due to high levels of unemployment and economic precarity. When men could not adequately fulfill their expected masculine role as the breadwinner, men often experienced a high level of stress, which was subsequently exhibited in the form of violence, including IPV. Prior research has also noted that income loss and an increased time at home are both drivers of IPV [ 29 ]. We concur with other scholars who argue that IPV researchers need to consider how constructions of masculinity in Sub-Saharan African settings are entangled in complex heteropatriarchal-capitalist configurations based on a unique historical political economy that has disenfranchised certain groups of men [ 27 , 30 ].

Yet, our participants reported a somewhat contradictory observation that men’s greater access to economic resources compared to women, when combined with gender norms legitimizing violence, can also exacerbate IPV. This finding supports prior research indicating that in societies where there is unequal access to economic or political resources by gender, the likelihood of IPV against women increases [ 31 , 32 ]. In our interviews, participants described that when men were successfully able to fulfil their role as the financial provider, women could be in a situation where they are forced to endure IPV because of their economic dependence on the male partner. Prior research has similarly reported that when women are dependent on men for economic and social capital, a potential consequence can be the acceptance of IPV and staying in violent relationships [ 33 ]. While some gender norms differed by participant, men typically emphasized hegemonic masculine ideals, including entitlement over women [ 34 ]. Further, within the context of the study location, it is not uncommon for lobola, or bride price, to be paid from the man to the bride’s family prior to marriage, which may additionally increase men’s level of entitlement and acceptance of IPV because they “own women” [ 35 ].

Alcohol use, the most prominent theme we discovered, has been associated with violent crimes, anger and IPV [ 36 ]. This, however, is not a new finding. Researchers have been looking for a causal link between alcohol and violence for over thirty years [ 37 ]. While it is hard to pinpoint the mechanism, it is clear that excessive alcohol exacerbates violence. Further, the primary form of social networking in the peri-urban township took place at bars, or shebeens, where alcohol consumption occured. Participants described IPV to either start at the bar, if the male brought his female partner with him, or it began when he went back home.

Current programs, such as Sonke Gender Justice, exist to help implement gender transformative interventions. Sonke Gender Justice holds trainings that aim to reduce gender inequality, and engage men in IPV prevention efforts [ 38 ]. Equimundo, founded in Brazil, is another organization that works globally to engage men in gender equality. Their programs include breaking down traditional gender norms, empowering women in the economy, and combating homophobia [ 39 ]. Other gender transformative programs include the qualitative evaluation by Gibbs et al. on the Stepping Stone’s intervention, which worked to transform men’s gender norms, build gender equality, and enhance men’s economic opportunities [ 40 ].

The use of qualitative research in this topic area is important because it allows for the community members to describe their own experiences with IPV and greater clarity surrounding the topic can be acquired. This research helps to fill the gap as it highlights areas in which our attention could be focused on, particularly alcohol use, economic opportunities for men, gender norms, and breaking the cycle for family violence. The findings from this study will be used in the future as formative work for creating culturally appropriate primary prevention strategies. Further research should focus on developing and implementing acceptable and effective intervention approaches to prevent men from ever using IPV. In addition to the more common interventions aimed at assisting women experiencing IPV, work should also focus on assisting men to cease their use of IPV.

Limitations

A few limitations of this study should be highlighted. This study utilized secondary data analysis and thus, interview questions were not created a priori with regards to this specific research question and the Theory of Gender and Power was not used to frame the initial interview questions. This posed some challenges during analysis as we could not probe further to illustrate the associations of identified perceptions to use of violence. With this particular data set, we aimed to explore topics related to gender norms and early life experiences but also found significant information regarding alcohol use and employment status. Due to the qualitative nature and in person interviews, social desirability bias and recall bias were also possible. While we utilized team coding to strengthen the findings, it is important to note the positionality of the primary researcher. The secondary data analysis was led by a white, Global North female with limited time in the community of focus. Co-authors who led primary data collection, ethnographic, and trial data collection over the course of several years offered contextual insights to overcome this limitation. Finally, few demographic information was collected on the participants which limited our ability to comprehensively understand the sample population and be able to compare participants within the sample.

In this study with 30 men living in a peri-urban township of South Africa, we exploried their perceptions of IPV. The main themes were that gender power dynamics, early life trauma, alcohol consumption, and lack of economic opportunities were perceived to fuel IPV enacted by men towards women. This highlighted the various levels of the social ecology that need to be addressed in order to prevent men’s use of IPV. Integral to providing effective primary prevention is understanding the male perspective of IPV, particularly in a context where violence is used more than the global average. While IPV interventions overall are lacking, those that exist primarily focus on limiting the harmful effects that women experience after an IPV event rather than promoting primary or secondary prevention strategies among those who use violence.

Supporting information

S1 appendix. a priori themes..

https://doi.org/10.1371/journal.pone.0298198.s001

S2 Appendix. Codebook and definitions.

https://doi.org/10.1371/journal.pone.0298198.s002

Acknowledgments

The authors would like to thank the reviewers, as well as Ruari McBride, Shehnaz Munshi, and Nkululeko Ndlovu who led primary data collection.

• View Article
• Google Scholar
• PubMed/NCBI
• 9. Selin A, Delong S. M., Julien A., MacPhail C., Twine R., Hughes J. P, et al. Prevalence and Associations, by Age Group, of IPV Among AGYW in Rural South Africa. SAGE. 2019:1–12.
• 14. Connell RW. Gender and Power: Society, the Person, and Sexual Politics. Stanford: Stanford University Press; 1987.
• 33. Travers M, Bennett L. AIDS, Women, and Power. In: Sherr L, Hankins C, Bennett L, editors. AIDS as a Gender Issues: Psychosocial Perspectives. Bristol, PA: Taylor & Francis, Ltd.; 1996. p. 64–77.

Advertisement

“I’ll be Okay”: Survivors’ Perspectives on Participation in Domestic Violence Research

• Original Article
• Open access
• Published: 08 March 2023
• Volume 38 , pages 1139–1150, ( 2023 )

Cite this article

You have full access to this open access article

• Molly Dragiewicz   ORCID: orcid.org/0000-0002-0275-2367 1 ,
• Delanie Woodlock   ORCID: orcid.org/0000-0002-9398-0890 2 ,
• Helen Easton   ORCID: orcid.org/0000-0002-8857-7300 3 ,
• Bridget Harris   ORCID: orcid.org/0000-0002-6618-9235 2 &
• Michael Salter   ORCID: orcid.org/0000-0001-6446-9498 4  

4538 Accesses

4 Citations

16 Altmetric

Explore all metrics

This article investigates survivors’ experiences participating in research interviews about technology-facilitated domestic violence. University research ethics committees often assume that participating in research on violence and abuse is distressing for survivors. Scholars have called for research testing this assumption. This article contributes to the evidence base on the benefits and risks of asking research participants about gender-based violence.

This article is based on semi-structured interviews with 20 Australian domestic violence survivors. Template analysis was used to code the interviews and develop key themes.

The five themes derived from the interviews include reflection on recovery and personal growth; helping other women; rejecting victim-shaming; empowerment; and the importance of timing.

All participants reported positive experiences taking part in the study. However, the authors noticed substantial differences in participant narratives across service cohorts. The implications of recruiting through channels associated with different points in trauma trajectories warrant attention.

Similar content being viewed by others

Doing Reflexive Thematic Analysis

Focus group methodology: some ethical challenges

Julius Sim & Jackie Waterfield

Promoting Gender Equality: A Systematic Review of Interventions

Michaela Guthridge, Maggie Kirkman, … Melita J. Giummarra

Avoid common mistakes on your manuscript.

Introduction

Research ethics guidelines were initially created in response to concerns about human rights violations in medical experimentation by Nazis during World War II. International ethics frameworks such as the Nuremberg Code and Helsinki Declaration were designed to promote informed consent and protect participant safety and privacy in biomedical experimentation (Gorman, 2011 ; Reverby, 2000 ; van den Hoonaard, 2002 ). Numerous countries have established standardized administrative procedures for governing research ethics, beginning with the Belmont Report in the US (Office of the Secretary, 1979 ). While continuing to rely on biomedical models, University Research Ethics Committees (RECs) “have unintentionally expanded their mandate to include a host of groups and practices that were undoubtedly not anticipated in the original research ethics formulations” (Haggerty, 2004 , p. 392). RECs have become increasingly interventionist over time, a phenomenon known as “ethics creep” (Haggerty, 2004 , p. 391; Wynn, 2011 , p. 95). RECs now make extensive demands concerning research design including the topics under investigation, participant pools, question item wording, theoretical frameworks, and research team composition that arguably extend beyond their mandates (Gorman, 2011 ; Haggerty, 2004 ). While a full discussion of the reasons for ethics creep are beyond the scope of this article (see Haggerty, 2004 ), these interventions have serious consequences, including preventing research with key populations on critical issues (De Vries et al., 2004 ; Langlois, 2011 ; Lincoln & Tierney, 2004 ; Mathews et al., 2022 ; Wynn, 2011 ; Yeater et al., 2012 ).

Scholars devote significant time to the creation, submission, review, and revision of research ethics applications (Pearce, 2002 ). REC conditions for approval “increasingly complicate, hamper, or censor certain forms of nontraditional, qualitative, or critical social scientific research” (Haggerty, 2004 , p. 393). Critiques include that RECs impose conditions based on assumptions about the likelihood of adverse participant experiences rather than evidence (Dazzi et al., 2014 ; Mathews et al., 2022 ; Yeater et al., 2012 ); are inappropriate to participants and study design (Schrag, 2011 ); and highly inconsistent across projects and institutions (Schrag, 2011 ; Wynn, 2011 ).

This study contributes to the growing body of research investigating the benefits and risks of participation in research on trauma, violence, and abuse. We present results from a thematic analysis of twenty Australian domestic violence survivors’ comments on their participation in a study on technology-facilitated abuse. First, we review the literature on feminist research ethics and the ethics of research on trauma, violence and abuse. Then, we explain the research methods used in the larger study upon which this article is based. Next, we present the themes we developed using template analysis. Study participants described multiple rewards of research engagement, including reflection on recovery and personal growth, helping other women, rejecting victim-shaming, and empowerment. We also discuss participants’ observations about the importance of the timing of participation in research. Finally, we conclude by presenting the implications of our findings, discussing study limitations, and presenting directions for future research and practice.

Literature Review

Feminist research ethics.

Feminist research includes diverse methodologies and conflicting theoretical orientations (e.g. Alcoff & Potter, 1993 ; Harnois, 2013 ; Schwartz, 1997 ; Stanley & Wise, 1993 ; Reinharz, 1992 ). However, feminist researchers share core methodological, substantive, and political commitments (Westmarland & Bows, 2019 ). Feminist scholars take gender as a central category of analysis (Rhode, 1990 ), reflecting a foundational interest and investment in efforts to promote gender equality. Ethical approaches to research design are a central part of feminist methodologies and epistemologies. As Stanley & Wise ( 1993 ) put it, “feminist social sciences must acknowledge the ethical and political issues involved in what we do, how we do it, and claims we make for it” (p. 7). Scholars who study violence against women have been at the forefront of efforts to attend to the well-being of research participants, linking ethics to the quality of knowledge produced (Reinharz, 1992 ; Stanley & Wise, 1993 ).

Research on men’s violence against women is a key area of feminist scholarship. This research has played an important role in making the prevalence and social and structural contributing factors to gender-based violence visible, calling for action to change the conditions that produce violence, and securing resources for abused women and other survivors (e.g. Dobash & Dobash, 1979 ; Dragiewicz, 2008 , 2011 ; Dragiewicz & Lindgren, 2009 ; Kelly, 1988 ). Feminist scholars have made significant contributions to promoting ethical engagement with research participants, including people who have experienced gender-based violence and abuse. This body of work addresses the risks and benefits of research in this area (e.g. Campbell, 2002 , Campbell et al., 2010 ; Downes et al., 2014 ; Schwartz, 1997 ; Westmarland & Bows, 2019 ).

Some of the first major studies on violence against women were by feminists, such as Russell and Howell’s interview study with 930 women about rape, conducted in part to counter efforts to discredit emerging research on rape prevalence. In Russell and Howell’s (1983) project, interviewers received 65 hours of training on rape, incest, and how to discuss sexual abuse sensitively. This commitment to the safety of participants in violence against women research was adapted from the approaches used in direct service work with survivors in rape crisis centres and women’s refuges (see also Kelly, 1988 ). While concerns for participants were central, Russell & Howell ( 1983 ) recognized that ethical approaches to research are linked to research quality. For example, their study was designed to remedy the under-reporting of rape endemic to previous surveys. More recently, UK Women’s Aid organizations developed the Research Integrity Framework for Domestic Violence and Abuse (Women’s Aid et al., 2020 ) to provide guidance on the full range of ethical considerations for research in this area. This work illustrates the broad range of ethical considerations involved in studying gender-based violence.

Research Ethics, Trauma, Violence, and Abuse

In Australia, research ethics guidelines are governed by the National Health and Medical Research Council (NHMRC) via The National Statement on Ethical Conduct in Human Research ( 2018 ), administered via a standardized Human Research Ethics Application. The National Statement (NHMRC, 2018 ) requires researchers and RECs to minimize the risks of “harms, discomforts and/or inconveniences for participants and/or others” and conduct a risk-benefit analysis of all research “conducted with or about people, or their data or tissue” (p. 13). While the NHMRC ( 2018 ) requires researchers and ethics boards to base their risk-benefit analysis on “the available evidence” (p. 13), research indicates that REC demands are often based on commonly held assumptions about the harmfulness of talking about sensitive issues rather than evidence (Becker-Blease & Freyd, 2006 ; Blades et al., 2018 ; Dazzi et al., 2014 ; DePrince & Freyd, 2006 ; Griffin et al., 2003 ; Mathews, 2022 ; Newman et al., 2006 ).

Ethics creep is a particular impediment to research on violence against women (Carter-Visscher et al., 2007 ; Jaffe et al., 2015 ; Yeater et al., 2012 ). RECs often approach research on gender-based violence as potentially traumatizing for participants. As a result, research on domestic and sexual violence is subject to obstructive intervention by RECs (Downes et al., 2014 ; Westmarland & Bows, 2019 ). For example, Jaffe et al.’s ( 2015 ) survey of 114 US-based researchers showed that 61.4% had RECs “raise concerns about asking participants questions about their prior trauma experiences” (p. 41). In addition, 13.3% said that RECs had “refused to approve a protocol due to concerns about the effects of asking participants about prior trauma experiences” (p.41). The most common concern expressed by RECs was that asking about prior trauma might cause harm by triggering negative emotions that could psychologically “shatter” participants (Jaffe et al., 2015 , p.41). Downes et al. ( 2014 ) and Gustafson & Brunger ( 2014 ) argue that in recent years, RECs have become fixated on women’s vulnerabilities when participating in violence research.

Although 51% of Australian women report sexual violence and 23% report domestic violence in their lifetime (Australian Bureau of Statistics, 2017 ; Townsend et al., 2022 ), survivors of violence and abuse are regularly presumed to be vulnerable subjects, similar to children and prisoners (Mulla & Hlavka, 2011 ). Westmarland and Bows ( 2019 ) remark that, “Paradoxically, excessive ethical scrutiny in this area can lead to greater harm, by limiting the amount of research that is carried out and making it more difficult for specialist abuse services to demonstrate the effectiveness of their services and approaches” (p. 23). The assumption that participating in research on sensitive issues is harmful is contradicted by extant research.

Downes et al. ( 2014 ) argue that RECs have an increasingly risk-averse approach to research with survivors of domestic violence. While careful considerations should be made when designing research on gender-based violence, framing survivors as uniquely vulnerable is problematic. Survivors of violence are the best source of information about their experiences. They can contribute valuable information about the dynamics and distribution of violence and abuse and how people and systems respond to reports. Downes et al. ( 2014 ) challenge the notion that research with survivors of domestic violence involves uniquely vulnerable participants. They argue that, given the high prevalence of sexual assault and domestic violence against women and girls worldwide, many female participants in any research will be survivors. They caution that positioning survivors as vulnerable is paternalistic, suggesting incapacity to comprehend risks and consequences.

A growing body of research indicates that few participants report distress from taking part in trauma research (Carter-Visscher et al., 2007 ; DePrince & Chu, 2008 ; DePrince & Freyd, 2006 ; Newman et al., 2001 ; Yeater et al., 2012 ). In a meta-analysis of trauma research, including studies with survivors of domestic violence, Jaffe et al. ( 2015 ) found that contrary to common REC concerns that “asking participants about prior traumatic experiences will induce extreme distress” (p. 40), the majority of research participants found the experience positive. The analysis, which included 70 studies with a total of 73,959 participants, showed that while some participants might have immediate psychological distress, this was not extreme. Participants also reported low levels of regret about being part of the research and low levels of concern about being coerced or that the research questions were too personal (Jaffe et al., 2015 ).

Significantly, emerging research evidence indicates that participation in research on traumatic experiences is usually experienced as less stressful than everyday events. Yeater et al. ( 2012 ) reported that all 504 participants in their study comparing student responses to surveys on trauma and sex and measures of cognitive ability rated each normal life stressor, such as getting a paper cut or taking a difficult math test, as more distressing than participating in a survey on topics commonly viewed as sensitive (Yeater et al., 2012 ). In a study comparing students’ reactions to completing a survey on trauma (N = 240) to other personal questions (N = 277), Cromer et al. ( 2006 ) found that “trauma questions cause relatively minimal distress and perceived greater importance and greater cost–benefit ratings compared to other kinds of psychological research in a human subjects pool population” (p. 359). Even the 24 of Cromer et al.’s 517 participants who reported the trauma research to be much more distressing than everyday life saw it as valuable (p. 360). Similarly, in a study of 899 students’ experiences completing a survey on gender-based sexual violence on campus, Gómez et al. ( 2015 ) found that “the majority of students (72.3%) rated the survey as neutral (56.7%), somewhat less distressing (6.5%), or much less distressing (9.1%) compared to day-to-day experiences” (p. 42). In addition, Legerski and Bunnell’s ( 2010 ) review of the risks and benefits of participating in trauma research notes that the small minority of participants who report distress indicate it dissipates quickly.

In addition to the low risk of harm from participating in research, there is growing evidence that participating in research on traumatic material is experienced as beneficial to participants and others. Most participants report benefits from participating in research on traumatic experiences and indicate that these outweigh the costs (Campbell et al., 2010 ; DePrince & Chu, 2008 ; DePrince & Freyd, 2006 ; Hamberger et al., 2020 ; Jaffe et al., 2015 ; Legerski & Bunnell, 2010 ; Newman et al., 2006 ; Newman & Kaloupek, 2004 ). In contrast to what RECS might assume, DePrince and Chu ( 2008 ) found that participants who took part in interviews rated the benefits of research participation even more highly than those who completed surveys.

Qualitative research provides insight into some of the reasons this might be and enumerates key benefits of research participation. Campbell et al. ( 2010 ) interviewed 92 rape survivors about their experiences participating in research. They found that 70 participants discussed only positive aspects of participation, 18 noted it was positive but difficult, and 4 discussed the negative aspects of thinking about traumatic experiences without discussing any benefits of participation (pp. 69–70). Participants valued talking about their experiences with a supportive, engaged listener who normalized their experiences and reactions, having control over what questions they answered, receiving referrals to support services, and reflecting on their past experiences. Hamberger et al. ( 2020 ) reported similar findings from interviews with 24 domestic violence survivors as part of a longitudinal study of screening and intervention in a healthcare setting. Participants described a range of benefits including making positive life changes, which the women attributed partly to participating in the research. Participants in this study expressed the value of discussing difficult experiences with non-judgemental listeners, understanding that they are not alone in experiencing abuse, and learning from being asked questions about different types of abuse and their use of safety strategies and support resources (pp.47–48).

In addition to the personal benefits of research participation outweighing costs, most research participants indicate that asking about issues like violence and abuse is important because it offers significant benefits to society. Frequently mentioned benefits include preventing future abuse and improving support services and researcher training (Campbell et al., 2010 ; DePrince & Freyd, 2006 ; Jaffe et al., 2015 ; Legerski & Bunnell, 2010 ; Newman et al., 2006 ). Overall, the research suggests that participation in research on trauma and abuse presents low risks, that the benefits outweigh the costs, and that participants perceive such research as personally and collectively important. The research consensus, then, indicates that REC assumptions that such research is exceptionally risky for participants are unfounded. In addition, the research indicates that the benefits of inviting survivors to participate in research on trauma and abuse are significant.

Our previous experiences with RECs provided the impetus to investigate participants’ experiences with domestic violence research. All of the authors have experienced RECS assuming that survivors are an exceptionally vulnerable population of research participants who may be traumatized by talking about their experiences. Authors one and three interviewed twenty women who identified as domestic violence survivors as part of a larger qualitative study on technology-facilitated domestic violence in Australia. All of their abusers were men (for full details see Dragiewicz et al., 2019 , 2021 , 2022 ; Woodlock et al., 2023 ). A convenience sample was used to recruit participants from Queensland (10) and New South Wales (10). Participants ranged from 21 to 65 years old, with an average age of 39. Half of the participants identified as Australian (9) or Aboriginal (1) and half reported being born overseas in Canada (1), China (2), India (2), Italy (1), Japan (1), New Zealand (1), Northern Ireland (1), and South Africa (1). The final segment of the interview schedule included questions about the women’s experiences participating in the study. Questions included: “How did you find the experience of talking with me today?” And “Would you recommend participating in research to other women who had experiences similar to yours?”

We employed what Downes et al. ( 2014 ) describe as a “positive empowerment” approach to this study. In this approach, researchers are “invested in both protecting and safeguarding survivors of domestic violence and maximizing their capacity for self-determination and autonomy within the research process” (p. 7). The positive empowerment approach balances efforts to ensure that the research process is not re-traumatizing for survivors with commitments to provide participants opportunities to tell their stories and share knowledge.

One of the critical steps we took was partnering with specialist domestic violence organizations. This collaboration allowed us to compensate the organizations for their assistance with the study and take advantage of the safety protocols they use when working with survivors. Our community partners assisted with the research design by providing feedback on the interview protocol and information and consent forms. They also played an essential role in the recruitment process, which is common and effective in domestic violence research (Bender, 2017 ). The partner organizations identified potential participants, contacted them to assess interest, reviewed informed consent materials with them to gauge whether they wanted to take part, screened for eligibility, and scheduled the interviews. The services also provided safe, private locations to conduct interviews and a safe, blocked phone number to conduct calls for participants who preferred to speak by phone. This approach offered multiple benefits. In addition to the partner organizations completing a substantial portion of the time-consuming recruitment, screening, and scheduling work, it ensured that support systems and safety were built into the process. We knew that participants were being supported by experienced professionals throughout the research process. This approach to recruitment also meant that participants had experience with technology-facilitated domestic violence so that they could make meaningful contributions to the study.

While both partner organizations offer specialist domestic violence services, one is a women’s legal service. The other is a women’s health service that runs a domestic violence court support program. The services recruited women at different stages of their recovery journeys. The court support program provides assistance to survivors at court. These survivors were in the early stages of seeking domestic violence orders, dealing with criminal charges, or leaving abusers. The legal service recruited women who were further along on pathways of separation.

The interview process included a preamble that explained why we were conducting the research, what the findings would be used for, and a discussion about participants’ preferences about what to do if they became upset during the interview. As is common in violence against women research, we compensated participants with $50 gift cards and transportation vouchers. Downes et al. ( 2014 ) state that compensation should be high enough to show respect for the participants’ contributions but not high enough to be coercive.

We used template analysis in this study (King, 1998 , 2012 ). Template analysis involves developing a coding template that can include themes identified prior to coding and accommodate new themes developed during coding (Woodlock et al., 2023 ). We re-coded all interviews to gain insight into participants’ experiences with the research. We developed five themes using template analysis: reflection on recovery and personal growth; helping other women; rejecting victim-shaming; empowerment; and the importance of timing.

Anecdotally, we noticed differences between the interviews across the services. Interviews with women recruited via the court support program had more fragmented narrative structures than those from the legal service. This is consistent with research on how trauma narratives cohere over time with recovery (Booker et al., 2020 ; Brosi & Rolling, 2010 ; Herman, 1998 ; van der Kolk, 1998 ). Despite these differences, all 20 participants described participation in the study as positive, which we discuss in more detail below.

We developed five themes based on our template coding of 20 interviews with women who were survivors of technology-facilitated domestic violence. The five themes centred on participants’ perceptions of the benefits of participation and their consideration of other survivors’ place in recovery. The first four themes reflect positive experiences participating in domestic violence research. The final theme highlights care and respect for other survivors whose needs and situations might differ from their own. All 20 participants reported that they found the interviews to be a positive experience overall and that they would recommend participating in similar research to other women. This aligns with the extant research on participation in studies on violence, abuse, and trauma, indicating that negative experiences are uncommon and that the benefits outweigh the costs (Carter-Visscher et al., 2007 ; DePrince & Chu, 2008 ; DePrince & Freyd, 2006 ; Jaffe et al., 2015 ; Newman et al., 2006 ; Yeater et al., 2012 ).

Reflection on Recovery and Personal Growth – “It was my Past”

Several participants in this study noted that the interview provided an opportunity to reflect on their experiences and how far they had come. Ajinder and Julia indicated that the interview enabled them to reflect on how much they had grown. Both noted that talking about their abuse experiences did not affect them as much as it would have in the past. Julia also remarked that participating in the interview helped build knowledge of how domestic violence perpetrators can use technology. Julia said:

It was like bringing up the past, but actually, it’s made me think how far I’ve grown as a person and how [much] stronger I am - leaving domestic violence and giving me some insight into this technology stuff as well.

Julia appears to be reflecting on her own recovery in the aftermath of abuse. Survivors describe this process as a spiral including “ups and downs,” “back and forth,” which is “never-ending” (Murphy et al., 2009 , p. 160). By answering the interview questions, Julia could trace her development through this process and also learn new information through the interview. Similarly, Ajinder noted how much she had grown over time. She said:

Now I’m okay with that, like, it was my past, so now I’m living happily. So, some things, so like women get very easily, you know, get emotional, or something like that. But I’m - now I’m a strong person, so it doesn’t impact me that much.

Developing a clear sense of what is past and what life is like now is a key part of trauma recovery (Herman, 1998 ). Ajinder and Julia distance themselves from who they were before, associating weakness with their experiences of domestic violence and reflecting that they are stronger now. These quotes support Hamberger et al. ( 2020 ) and Campbell et al. ( 2010 )’s earlier findings that interviews provide an opportunity for participants to reflect on their past experiences and glean new knowledge from the questions asked. These quotes also highlight how emotional reactions to discussing abuse are not necessarily negative and may simply be part of the recovery process. This may help to explain why surveys on trauma research find some participants report that it is challenging to discuss trauma but still worth it (Cromer et al., 2006 ; Jaffe et al., 2015 ).

Michelle also expressed that participating in the interview enabled her to see how much better she could cope with her experiences now. Michelle felt that participation brought up upsetting emotions, but being part of the interview gave those feelings a purpose. She said:

Yeah, look, it does bring up some emotions that are upsetting, but it’s okay because it is going to help other women. So doing this stuff is helping other women - because it’s awful. I would never wish it on anybody. Yeah, so but it’s much better now. So I know even though it’s hard bringing it up, I’ll be okay.

This comment illuminates the extant research showing that most participants in research on traumatic experiences indicate that the benefits outweigh the costs (Campbell et al., 2010 ; DePrince & Chu, 2008 ; DePrince & Freyd, 2006 ; Hamberger et al., 2020 ; Jaffe et al., 2015 ; Legerski & Bunnell, 2010 ; Newman et al., 2006 ; Newman & Kaloupek, 2004 ). Michelle’s comment above also aligns with the majority of participants’ experiences in another way. Being able to help other women by using their knowledge to create change was the most common benefit mentioned for participats in the study. We explore this next.

Helping Other Women – “I am Doing this for the Coming Generations”

Several survivors reported that contributing to the greater good was a reason that the benefits of research participation outweighed the costs. These women hoped they could use their experiences to help other women. Jessica said it was hard to talk about what happened to her, but she was motivated to help others, “It was tough to bring up stuff, you know? But at the same time, if it can help people in the future, to make it easier, I think that’s important.” Similarly, Anaya expressed that it was difficult to talk about her experiences of domestic violence, but she wanted to do this to benefit future generations of girls. She said:

Of course, it’s a big emotional - like overwhelming for me when you put your heart out and all those things, and it gives me an impact, but on the other hand that’s okay. I am doing this for the coming generations. I really wanted that kind of society when children, they don’t even imagine that okay, somebody can slap someone. I know it’s not possible in these coming years - five or ten years - but still, a time is coming when a male can’t stop a girl talking by just slapping her. Yeah, I really pray for that. I don’t want any girl, whatever I have been going through, I say that no girl should go through all this - whatever I have been.

Amahle discussed a similar motive for participating in the research. Empathizing with other survivors, Amahle reflected that having Post Traumatic Stress Disorder might make it difficult for some women to participate in research. Even then, feeling that they are preventing violence might make it worth the upset. She said:

It depends on the person and the level of like PTSD they may have. In my case, I don’t, and I just want to make it better for other people in the future. So I think that people who have been kind of abused actually are very supportive of each other, and so we would generally want to do something to help other people not have to go through these things. So even if someone does have PTSD or something it might, they might be able to get some value from feeling like they’re actually in some way contributing to someone else not having, or having it in the same way.

The above quotations reiterate that being upset or emotional when discussing abuse is not necessarily harmful. As Becker-Blease and Freyd ( 2006 ) argue, “Even if questions remind participants of upsetting events, the feelings that come up are not necessarily overwhelming or even completely undesirable” (p. 221). These women indicate that discussing abuse is worth it even if it is difficult or emotional. It is worth considering that REC and researchers’ fears about upsetting participants mirror some participants’ association of emotion with weakness. Perhaps normalising distress and high emotion as normal responses to trauma can reduce the stigma of women’s emotions.

Women who reported that the interviews did not upset them also expressed that helping others is empowering. Isabella explained:

I’m actually happy because if it’s going to help someone in future, I’m more than happy to speak up about it. Because I feel like I’m not a crying mess. It’s kind of empowering.

Rebecca also indicated that taking part in an interview was a positive experience. She said:

It’s actually been a bit of a relief to talk about it and know that the information that I give you is going to help somebody else who might be in my situation. So turning a negative into a positive is great.

Like Rebecca, Catalina also wanted to turn what had happened to her into something positive that she could use to help others. She said:

I feel as if my purpose in life, I’ve been looking to see how I can help others. That’s just what I’ve always wanted to do. I want to help another human being who is helpless and doesn’t know where to go for help... you know, or are scared. So I like the feeling of knowing that I can help someone in that situation.

Josie said that she did not feel upset by the interview. Like Catalina, she saw participating in research as a way to help others:

I’m one of those people that I like to help others. I did lots of volunteer work in my life because it is good that - if I can help somebody with my experience, why not. Yeah, I think it’s a great idea. I feel that this is a good cause and I think it’s great that someone is really caring about stuff like this. Yes, I’m really glad actually and I think a lot of people should help. That’s the only way that you can help others in the future.

The motivation to participate in research on violence against women to help other women has been connected to the feminist and anti-rape movements, where women sharing their individual experiences of male violence was used as part of consciousness-raising, building knowledge about the collective experiences of survivors and helping frame it as a social problem with structural roots (Downes et al., 2014 ). The interaction of survivors’ helping and advocacy work with their own healing is a new contribution of our research to the literature on ethics and trauma research.

Rejecting Victim-Shaming – “I have Nothing to Hide”

Several women mentioned that participating in the research was consistent with their belief in being open and honest about their experiences. At the same time, they expressed empathy for other women whose experiences may differ and respect for their agency in making that choice. When asked if she would recommend other survivors participate in research, Charlotte said:

It depends on their experience, I guess, and their tolerance for talking about it. I just talk about it to everyone and I’m just like, yeah, this is what’s happening. So yeah, it all just depends. I mean, if you’re a secret - if you’re like a secretive sort of quiet person, then maybe talking to someone is good and if you’re used to talking to people then do it, but if you don’t want to, then don’t.

Elizabeth and Georgia felt that participating in the interviews was about getting things out in the open. Elizabeth said, “I believe I’m quite an open person, I have nothing to hide and if it’s going to help anybody….” Georgia said, “I think it’s a good idea for them to be able to speak about it if they need to. Get it off their chest.” Research on disclosure of sexual abuse indicates that non-disclosure may have negative implications for victims. However, many survivors are afraid to disclose as they fear negative reactions (Gries et al., 2000 ; Morris et al., 2012 ; Ullman, 2002 ). Research can provide a safe opportunity to disclose abuse without judgment. We discuss this more in the next section.

Empowerment – “It’s Very Empowering”

Jade, Nicole, and Sarah said participating in the research was a positive experience because they felt heard and that the interviewer did not judge them. All three women spoke about how being a survivor of domestic violence is a silencing experience, so being able to talk to someone and feel their stories mattered was empowering for them. For Jade, the experience of being interviewed was challenging, but that was outweighed by having her story heard. She said:

I think talking about it is always - it’s hard to talk about but it’s kind of good to talk about it too because it’s nice to be able to tell my story and feel like somebody is not judging me.

Likewise, Nicole said that being a domestic abuse survivor was isolating, particularly the lack of understanding of technology-facilitated abuse, so being believed and heard as part of the interview process was important to her. Nicole explained:

It’s okay with me to talk about it. It’s nice to be heard about it. I think, like I said to you before, that I sometimes feel alone in the emotional abuse side of it and that nobody recognizes that they - very few people seem to recognize the abuse you can get still over your phone.

Sarah described her experience participating in the research as empowering. She also clarified that the abusers’ actions are what is upsetting rather than research about it. Sarah said:

It’s very empowering because when you’re a survivor of domestic violence, we’re silenced all the time, and a lot of the times you’re not believed, you have to constantly prove your story, give evidence. So it’s so important that survivors are given the opportunity to tell their stories, because it just keeps happening otherwise if we’re not given an opportunity to speak. So research like this is extremely important. And it certainly is not upsetting because asking these questions, if it’s upsetting, it’s because we’re living with it not the questions - it’s the situation again from the perpetrator, it’s not asking questions that I think would be ever upsetting.

The comments above support the extant research on the benefits of disclosing abuse to a supportive and non-judgmental listener (Campbell, 2002 ; Campbell et al., 2010 ; Gries et al., 2000 ; Lutgendorf & Antoni, 1999 ; Hamberger et al., 2020 ; Ullman & Filipas, 2005 ). Sarah’s comment refocusing our attention on the abusers as the source of distress is a useful reminder. There is a tendency of even well-meaning researchers and RECs to problematize survivors’ normal reactions to abuse rather than abusers’ behavior. The themes discussed above reveal survivors’ perceptions of the benefits of participating in research. The next section addresses the issue of research timing.

Importance of Timing “I Think the Timing’s Really Important”

Due to the nature of the services that assisted with recruitment, the two cohorts of participants were at different stages of their journeys. Participants reflected that timing and agency were critical to the decision to participate in research. Two women recruited via the women’s legal service thought that they might have felt it was too upsetting to be part of a research study if they had been asked earlier. For example, Jessica explained that while the interview brought up difficult things, she was ready to talk about these issues as she had had time to process these experiences. She explained:

I think something like this is important, as difficult as it is to talk about it. I think, you know, and people need to be encouraged, even if it is tough and brings some stuff up. I mean, obviously, I’ve been going through this for some time. If you were to contact me six months ago, eight months ago, it might have been a different situation, because I think I wouldn’t have dealt with certain stuff up until that point.

Jia agreed that timing was important. However, she was much closer to the period of separation than Jessica. It had only been about two months since leaving the man who abused her. She indicated that talking about her experiences with services had made her feel better. Jia said:

I think the timing’s really important. I think at the moment’s a good timing, because I cannot put this thing down, because it - it happened in September, so it’s already roughly about two months, so I get off - get out from this terrible thing, so I can sit down and to share my experience. Before, before I came today, and I have been to, like, several lawyers in the service here, and it’s another voluntary service, so I talk to them. So, it made me feel better. The more I talk, I feel okay. It’s like, get out of it.

These quotations point to the need to consider the timing of engaging in research. Survivors’ agency in determining whether or not to participate in research should be respected, as it is an individual decision and preference which may vary from woman to woman. While the available research indicates that even participating in trauma-related research immediately after an event carries a low risk of distress and primarily positive appraisal of research participation (Griffin et al., 1997 , 2003 ; Kassam-Adams & Newman, 2002 ; Ruzek & Zatzick, 2000 ), approaching survivors during a crisis or the immediate aftermath may be less fruitful for participants and researchers. As we noted earlier, the court support program participants produced shorter and more fragmented interviews. From a practical standpoint, this made it more difficult for the research team to code the interviews and identify example quotations to use in publications.

We contend that RECs’ focus on the potential harms of asking research participants about life experiences shared by a significant portion of the population, such as domestic violence, incorrectly assume that gender-based abuse is rare. This reinforces harmful stereotypes about abuse by suggesting that survivors (and perpetrators) are somehow unusual or different from the rest of the population. The prevalence of gender-based violence and other adverse life experiences should raise the question of whether research on these issues is more traumatic than participants’ everyday experiences.

Research on the implications of asking about violence and abuse raises questions about the costs of not asking about it (DePrince & Freyd, 2006 ). Failing to ask about violence and abuse in research where it is very likely to be relevant, such as studies that investigate outcomes of divorce, violence prevention, or mental health, omits valuable information that can help us understand sociological and psychological phenomena (Becker-Blease & Freyd, 2006 ; Mathews et al., 2022 ). As our findings show, asking participants about violence and abuse can significantly benefit them and the broader public. These findings can be used to inform future research and inform REC policy and practice.

Implications for Practice

Our findings have direct implications for RECs and researchers. As Newman et al. ( 2006 ) put it, “Ethical decision-making about trauma-related studies requires a flexible approach that counters assumptions and biases about victims, assures a favorable ethical cost-benefit ratio, and promotes advancement of knowledge that can benefit survivors of traumatic stress” (p. 29). We argue that research ethics committees should not presume that research on violence, abuse, or trauma is inherently risky for participants. Our findings indicate that treating survivors as a uniquely vulnerable population is unwarranted and may harm the very groups they’re intended to protect. Survivors are, as Sarah emphasizes, “silenced all the time.” As Jade remarked, being able to “tell my story” without judgement and “be heard” by researchers is important. REC recommendations that seek to protect survivors based on assumptions about their vulnerability rather than evidence can unintentionally replicate the silencing they encounter in other contexts.

Asking research participants about their experience with the study is good practice. It can provide valuable opportunities to improve research practice by identifying key skills and strategies for researchers and RECs (see for example Campbell et al., 2009 ). Researchers can take advantage of existing tools, such as Kassam-Adams and Newman’s ( 2002 ) Response to Research Participation Questionnaire,” to collect data about participant experiences and build on current knowledge. Qualitative research is also important to building an understanding of what survivors find beneficial and challenging about research participation and why. This is essential information to guide appropriate measures to minimize the risk of negative experiences with research while maximizing the benefits.

Despite requirements to meet REC conditions to receive institutional approval, researchers can push back against arbitrary and inappropriate demands when conducting research with survivors. It may be ethically necessary to do so. For example, some Australian RECs demand that interview transcripts be sent to participants for verification. In addition to adding to the labour burden imposed on participants, this practice introduces unnecessary safety and privacy risks that would not otherwise exist. Requiring the collection of identifying and correspondence information precludes anonymity and introduces an unnecessary risk of interception of sensitive communication. Researchers can refuse recommendations by explaining why they are inappropriate, asking for the research evidence that is the basis for the recommendation, or requesting the location of specific requirements in their national research ethics policies. We recommend that researchers who study gender-based violence share information and seek advice from their peers about ethics processes and challenges in order to learn from one another. In addition, we encourage others to incorporate questions about research participation in their studies and publish about their experiences with RECs.

This article investigated survivors’ perspectives on participating in an interview as part of a study about technology-facilitated domestic violence. In line with the prior research, some of the women reported feeling emotional when thinking and talking about the abuse they had experienced in a research interview yet experienced participation as positive. Participants described beneficial outcomes including having the opportunity to reflect on their experiences, help other women avoid violence and abuse, and have their experiences validated by a non-judgmental listener. Our findings align with the previous research and provide new insights about the importance of helping others to survivors. It is worth noting that while the research process itself may not be re-traumatizing, and participants perceive it as beneficial, participation in research may be more productive for all involved if survivors have more distance from the immediate crisis.

Limitations

Like all research, this study has limitations. The sample size for this study was small, so a limited number of responses were gathered, limiting the diversity of opinions represented. However, it is necessary to ask these questions in a range of research studies to understand participants’ needs and experiences. While recruitment in partnership with community organizations had many benefits, this approach excluded those who had not accessed formal support services and may have different experiences. As the interviewer asked the questions about participation, it is possible that participant responses were shaped by their desire to please the researcher. However, participants were quite open about the negative and positive implications of research participation for themselves and reflected on what others’ experiences might be. Several women discussed their experiences and mentioned that other women’s needs and perceptions might differ. As these participants observed, survivors’ autonomy and judgment about participation are paramount.

Future Research

This study suggests directions for additional research. Academics could build on this research by working collaboratively with survivors to design survivor-centered research topics, informed consent documents, research methods, and approaches to safely sharing findings. Future scholarship might investigate the content of REC guidance for research on violence and abuse to see whether it aligns with the Research Integrity Framework for Domestic Violence and Abuse (Women’s Aid et al., 2020 ) guidelines for best practice. Additionally, documentation of actual adverse effects (which is already collected by RECs in annual reviews and on project completion) could provide an evidence base to guide practice instead of relying on stereotypes about what effects might befall victims of violence who engage in research. Following Campbell et al. ( 2010 ), more research could investigate how intentionally adopting trauma-informed research methods can enhance the benefits of research participation for survivors and avoid harm. Finally, as Alaggia et al. ( 2012 ) argue, disclosure of domestic violence is an essential step in getting help, yet it is under-studied. Scholars could use longitudinal approaches to study survivors’ experiences participating in research and other disclosure sites to understand how survivor experiences and narratives change over time.

Given the substantial effects of domestic violence and abuse in women’s lives, failing to ask about abuse might be a more significant risk than asking about it, causing researchers to misinterpret or miss information directly pertinent to the phenomena under investigation (Becker-Blease & Freyd, 2006 ; Edwards et al., 2007 ). Thoughtfully developed and executed research on domestic violence can provide opportunities for survivors to share their insights about their life experiences. These insights are valuable to researchers and policymakers and can contribute to improved responses to domestic violence and abuse. Asking participants about experiences that might otherwise be hidden, and valuing survivors’ contribution to knowledge, can potentially promote positive outcomes for research, survivors, and women’s lives.

Alaggia, R., Regehr, C., & Jenney, A. (2012). Risky business: an ecological analysis of intimate partner violence disclosure. Research on Social Work Practice , 22 (3), 301–312. https://doi.org/10.1177/1049731511425503 .

Article   Google Scholar  

Alcoff, L., & Potter, E. (Eds.). (1993). Feminist Epistemologies . Routledge.

Australian Bureau of Statistics. (2017). Personal Safety, Australia, 2016 . Australian Bureau of Statistics.

Becker-Blease, K. A., & Freyd, J. J. (2006). Research participants telling the truth about their lives: the ethics of asking and not asking about abuse. American Psychologist , 61 (3), 218–226. https://doi.org/10.1037/0003-066X.61.3.218 .

Article   PubMed   Google Scholar  

Bender, A. K. (2017). Ethics, methods, and measures in intimate partner violence research: the current state of the field. Violence Against Women , 23 (11), 1382–1413. https://doi.org/10.1177/1077801216658977 .

Blades, C. A., Stritzke, W. G. K., Page, A. C., & Brown, J. D. (2018). The benefits and risks of asking research participants about suicide: a meta-analysis of the impact of exposure to suicide-related content. Clinical Psychology Review , 64 , 1–12. https://doi.org/10.1016/j.cpr.2018.07.001 .

Booker, J. A., Fivush, R., Graci, M. E., Heitz, H., Hudak, L. A., Jovanovic, T., Rothbaum, B. O., & Stevens, J. S. (2020). Longitudinal changes in trauma narratives over the first year and associations with coping and mental health. Journal of Affective Disorders , 272 , 116–124. https://doi.org/10.1016/j.jad.2020.04.009 .

Article   PubMed   PubMed Central   Google Scholar  

Brosi, M. W., & Rolling, E. S. (2010). A narrative journey for intimate partner violence: from victim to survivor. The American Journal of Family Therapy , 38 (3), 237–250. https://doi.org/10.1080/01926180902961761 .

Campbell, R. (2002). Emotionally involved: the impact of researching rape . Routledge.

Campbell, R., Adams, A. E., Wasco, S. M., Ahrens, C. E., & Sefl, T. (2009). Training interviewers for research on sexual violence: a qualitative study of rape survivors’ recommendations for interview practice. Violence Against Women , 15 (5), 595–617. https://doi.org/10.1177/1077801208331248 .

Campbell, R., Adams, A. E., Wasco, S. S., Ahrens, C. E., & Sefl, T. (2010). What has it been like for you to talk with me today?”: the impact of participating in interview research on rape survivors. Violence Against Women , 16 (1), 60–83.

Carter-Visscher, R. M., Naugle, A. E., Bell, K. M., & Suvak, M. K. (2007). Ethics of asking trauma-related questions and exposing participants to arousal-inducing stimuli. Journal of Trauma & Dissociation , 8 (3), 27–55. https://doi.org/10.1300/J229v08n03_03 .

Cromer, L. D., Freyd, J. J., Binder, A. K., DePrince, A. P., & Becker-Blease, K. (2006). What’s the risk in asking? Participant reaction to trauma history questions compared with response to other personal questions. Ethics & Behavior , 16 (4), 347–362. https://doi.org/10.1207/s15327019eb1604_5 .

Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine , 44 (16), 3361–3363. https://doi.org/10.1017/S0033291714001299 .

Article   CAS   PubMed   Google Scholar  

DePrince, A. P., & Chu, A. (2008). Perceived benefits in trauma research: examining methodological and individual difference factors in responses to research participation. Journal of Empirical Research on Human Research Ethics , 3 (1), 35–47. https://doi.org/10.1525/jer.2008.3.1.35 .

DePrince, A. P., & Freyd, J. J. (2006). Costs and benefits of being asked about trauma history. Journal of Trauma Practice , 3 (4), 23–35. https://doi.org/10.1300/J189v03n04_02 .

De Vries, R. D., DeBruin, A., & Goodgame, A. (2004). Ethics review of social, behavioral, and economic research: where should we go from here? Ethics & Behavior , 14 (4), 351–368.

Dobash, R. E., & Dobash, R. P. (1979). Violence against wives: a case against the patriarchy . Free Press.

Downes, J., Kelly, L., & Westmarland, N. (2014). Ethics in violence and abuse research: a positive empowerment approach. Sociological Research Online , 19 (1), 1–13. https://doi.org/10.5153/sro.3140 .

Dragiewicz, M. (2008). Patriarchy Reasserted. Feminist Criminology , 3 (2), 121–144. https://doi.org/10.1177/1557085108316731 .

Dragiewicz, M. (2011). Equality with a vengeance: Men’s rights groups, battered women, and antifeminist backlash . University Press of New England.

Dragiewicz, M., Harris, B., Woodlock, D. & Salter, M. (2021). Digital media and domestic violence in Australia: Essential contexts. Journal of Gender Based Violence , 5 (3), 377–393. https://doi.org/10.1332/239868021X1615378292397 .

Dragiewicz, M., Harris, B., Woodlock, D., Salter, M., Easton, H., Lynch, A., Campbell, H., Leach, J. & Milne, L. (2019). Domestic violence and communication technology: Survivor experiences of intrusion, surveillance, and identity crime . Australian Communications Consumer Action Network. https://accan.org.au/files/Grants/2017%20QUT%20DV/20190823%20Domestic%20violence%20and%20communication%20technology%20victim%20experiences%20of%20intrusion%20surveillance%20and%20identity%20theft.pdf

Dragiewicz, M., & Lindgren, Y. (2009). The gendered nature of domestic violence: Statistical data for lawyers considering equal protection analysis. American University Journal of Gender, Social Policy & the Law , 17 (2), 229–268.

Dragiewicz, M., Woodlock, D., Salter, M., & Harris, B. (2022). “What’s Mum’s Password?”: Australian mothers’ perceptions of children’s involvement in technology-facilitated coercive control. Journal of Family Violence , 37 , 137–149. https://doi.org/10.1007/s10896-021-00283-4 .

Edwards, V. J., Dube, S. R., Felitti, V. J., & Anda, R. F. (2007). It’s okay to ask about past abuse. The American Psychologist , 62 (4), 327–328. https://doi.org/10.1037/0003-066X62.4.327 . discussion 330–332.

Gómez, J. M., Smith, C. P., Rosenthal, M. N., & Freyd, J. J. (2015). Participant reactions to questions about gender-based sexual violence: implications for campus climate surveys. EJournal of Public Affairs , 4 (2), https://doi.org/10.21768/ejopa.v4i2.75 .

Gorman, S. M. (2011). Ethics creep or governance creep?: Challenges for Australian Human Research Ethics Committees (HRECS). Monash Bioethics Review , 29 (4), 23–38. https://doi.org/10.1007/BF03351328 .

Gries, L. T., Goh, D. S., Andrews, M. B., Gilbert, J., Praver, F., & Stelzer, D. N. (2000). Positive reaction to disclosure and recovery from child sexual abuse. Journal of Child Sexual Abuse , 9 (1), 29–51. https://doi.org/10.1300/J070v09n01_03 .

Griffin, M. G., Resick, P. A., Waldrop, A. E., & Mechanic, M. B. (2003). Participation in trauma research: is there evidence of harm? Journal of Traumatic Stress , 16 (3), 221–227. https://doi.org/10.1023/A:1023735821900 .

Griffin, M. G., Resnick, P. A., & Mechanic, M. B. (1997). Objective assessment of peritraumatic dissociation: psychophysiological indicators. American Journal of Psychiatry , 154 (8), 1081–1088. https://doi.org/10.1176/ajp.154.8.1081 .

Gustafson, D. L., & Brunger, F. (2014). Ethics, ‘vulnerability’, and feminist participatory research with a disability community. Qualitative Health Research , 24 (7), 875–1017. https://doi.org/10.1177/1049732314538122 .

Haggerty, K. D. (2004). Ethics creep: governing social science research in the name of ethics. Qualitative Sociology , 27 (4), 391–414. https://doi.org/10.1023/B:QUAS.0000049239.15922.a3 .

Hamberger, L. K., Larsen, S., & Ambuel, B. (2020). “It helped a lot to go over it”: intimate partner violence research risks and benefits from participating in an 18-month longitudinal study. Journal of Family Violence , 35 , 43–52. https://doi.org/10.1007/s10896-019-00075-x .

Harnois, C. E. (2013). Feminist measures in survey research . Sage.

Herman, J. L. (1998). Recovery from psychological trauma. Psychiatry and Clinical Neurosciences , 52 (S1), S98–S103. https://doi.org/10.1046/j.1440-1819.1998.0520s5S145.x .

Jaffe, A. E., DiLillo, D., Hoffman, L., Haikalis, M., & Dykstra, R. E. (2015). Does it hurt to ask? A meta-analysis of participant reactions to trauma research. Clinical Psychology Review , 40 , 40–56. https://doi.org/10.1016/j.cpr.2015.05.004 .

Kassam-Adams, N., & Newman, E. (2002). The reactions to research participation questionnaires for children and for parents (RRPQ-C and RRPQ-P). General Hospital Psychiatry , 24 (5), 336–342. https://doi.org/10.1016/s0163-8343(02)00200-1 .

Kelly, L. (1988). Surviving sexual violence . University of Minnesota Press.

King, N. (1998). Template analysis. In G. Symon, & C. Cassell (Eds.), Qualitative methods and analysis in organizational research: a practical guide (pp. 118–134). Sage.

King, N. (2012). Doing template analysis. Qualitative organizational research: Core methods and current challenges , 426 (10.4135), 9781526435620.

Google Scholar  

Langlois, A. J. (2011). Political research and human research ethics committees. Australian Journal of Political Science , 46 (1), 141–156. https://doi.org/10.1080/10361146.2010.544287 .

Legerski, J. P., & Bunnell, S. L. (2010). The risks, benefits, and ethics of trauma-focused research participation. Ethics & Behavior , 20 (6), 429–442. https://doi.org/10.1080/10508422.2010.521443 .

Lincoln, Y. S., & Tierney, W. G. (2004). Qualitative research and institutional review boards. Qualitative Inquiry , 10 (2), 219–234. https://doi.org/10.1177/1077800403262361 .

Lutgendorf, S. K., & Antoni, M. H. (1999). Emotional and cognitive processing in a trauma disclosure paradigm. Cognitive Therapy and Research , 23 (4), 423–440.

Mathews, B., MacMillan, H. L., Meinck, F., Finkelhor, D., Haslam, D., Tonmyr, L., Gonzalez, A., Afifi, T. O., Scott, J. G., Pacella, R. E., Higgins, D. J., Thomas, H., Collin-Vézina, D., & Walsh, K. (2022). The ethics of child maltreatment surveys in relation to participant distress: implications of social science evidence, ethical guidelines, and law. Child Abuse & Neglect , 123 , 105424. https://doi.org/10.1016/j.chiabu.2021.105424 .

Morris, A., Hegarty, K., & Humphreys, C. (2012). Ethical and safe: research with children about domestic violence. Research Ethics , 8 (2), 125–139. https://doi.org/10.1177/1747016112445420 .

Mulla, S., & Hlavka, H. (2011). Gendered violence and the ethics of social science research. Violence Against Women , 17 (12), 1509–1520. https://doi.org/10.1177/1077801211436169 .

Murphy, S. B., Moynihan, M. M., & Banyard, V. L. (2009). Moving within the spiral: the process of surviving. Affilia , 24 (2), 152–164. https://doi.org/10.1177/0886109909331702 .

National Health and Medical Research Council. (2018). National Statement on ethical Conduct in Human Research 2007 (updated 2018) . National Health and Medical Research Council.

Newman, E., & Kaloupek, D. G. (2004). The risks and benefits of participating in trauma-focused research studies. Journal of Traumatic Stress , 17 (5), 383–394. https://doi.org/10.1023/B:JOTS.0000048951.02568.3a .

Newman, E., Risch, E., & Kassam-Adams, N. (2006). Ethical issues in trauma-related research: a review. Journal of Empirical Research on Human Research Ethics , 1 (3), 29–46. https://doi.org/10.1525/jer.2006.1.3.29 .

Newman, E., Willard, T., Sinclair, R., & Kaloupek, D. (2001). Empirically supported ethical practice: the costs and benefits of research from the participants’ views. Accountability in Research , pp. 8 , 309–329.

Office of the Secretary. (1979). The Belmont report: ethical principles and guidelines for the protection of human subjects of research . The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, US Government Printing Office.

Pearce, M. (2002). Challenging the system: rethinking ethics review of social research in Britain’s national health service. In van den W. C. Hoonaard (Ed.), Walking the tightrope: ethical issues for qualitative researchers (pp. 43–58). University of Toronto Press.

Reinharz, S. (1992). Feminist methods in social research . Oxford University Press.

Reverby, S. M. (Ed.). (2000). Tuskegee’s truths: Rethinking the Tuskegee syphilis study (1st edition). The University of North Carolina Press.

Rhode, D. L. (1990). Feminist critical theories. Stanford Law Review , 42 (3), 617–638. https://doi.org/10.2307/1228887 .

Russell, D. E. H., & Howell, N. (1983). The prevalence of rape in the United States revisited. Signs: Journal of Women in Culture and Society , 8 (4), 688–695. https://doi.org/10.1086/494003 .

Ruzek, J. I., & Zatzick, D. F. (2000). Ethical considerations in research participation among acutely injured trauma survivors: an empirical investigation. General Hospital Psychiatry , 22 (1), 27–36. https://doi.org/10.1016/s0163-8343(99)00041-9 .

Schrag, Z. M. (2011). The case against ethics review in the social sciences. Research Ethics , 7 (4), 120–131. https://doi.org/10.1177/174701611100700402 .

Schwartz, M. D. (Ed.), (1997). Researching sexual violence against women . Sage.

Stanley, L., & Wise, S. (1993). Breaking out again: Feminist ontology and epistemology . Routledge.

Townsend, N., Loxton, D., Egan, N., Barnes, I., Byrnes, E., & Forder, P. (2022). A life course approach to determining the prevalence and impact of sexual violence in Australia. Findings from the australian Longitudinal Study on Women’s Health . ANROWS.

Ullman, S. E. (2002). Social reactions to child sexual abuse disclosures: a critical review. Journal of Child Sexual Abuse , 12 (1), 89–121. https://doi.org/10.1300/J070v12n01_05 .

Ullman, S. E., & Filipas, H. H. (2005). Gender differences in social reactions to abuse disclosures, post-abuse coping, and PTSD of child sexual abuse survivors. Child Abuse & Neglect , 29 (7), 767–782. https://doi.org/10.1016/j.chiabu.2005.01.005 .

van den Hoonaard, W. C. (2002). Introduction: Ethical norming and qualitative research. In W. C. van den Hoonaard (Ed.), Walking the tightrope: Ethical issues for qualitative researchers (pp. 3–16). Toronto.

van der Kolk, B. A. (1998). Trauma and memory. Psychiatry and Clinical Neurosciences , 52 (S1), S52–S64. https://doi.org/10.1046/j.1440-1819.1998.0520s5S97.x .

Westmarland, N., & Bows, H. (2019). Researching gender, violence and abuse: theory, methods, action . Routledge.

Women’s, & Aid (2020). Women’s Aid Federation Northern Ireland, Scottish Women’s Aid, Welsh Women’s aid. Research Integrity Framework (RIF) on domestic violence and abuse (DVA) . Women’s Aid, Women’s Aid Federation Northern Ireland, Scottish Women’s Aid, Welsh Women’s aid.

Woodlock, D., Salter, M., Dragiewicz, M., & Harris, B. (2023). “Living in the darkness”: Technology-facilitated coercive control, disenfranchised grief, and institutional betrayal. Violence Against Women , 29 (5), 987–1004. https://doi.org/10.1177/10778012221114920 .

Wynn, L. L. (2011). Ethnographers’ experiences of institutional ethics oversight: results from a quantitative and qualitative survey. Journal of Policy History , 23 (1), 94–114. https://doi.org/10.1017/S0898030610000333 .

Yeater, E., Miller, G., Rinehart, J., & Nason, E. (2012). Trauma and sex surveys meet minimal risk standards: implications for institutional review boards. Psychological Science , 23 (7), 780–787. https://doi.org/10.1177/0956797611435131 .

Download references

Open Access funding enabled and organized by CAUL and its Member Institutions

Author information

Authors and affiliations.

Griffith University, Southport, Australia

Molly Dragiewicz

Monash University, Melbourne, Australia

Delanie Woodlock & Bridget Harris

Macquarie University, Macquarie Park, Australia

Helen Easton

University of New South Wales, Sydney, Australia

Michael Salter

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Molly Dragiewicz .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Dragiewicz, M., Woodlock, D., Easton, H. et al. “I’ll be Okay”: Survivors’ Perspectives on Participation in Domestic Violence Research. J Fam Viol 38 , 1139–1150 (2023). https://doi.org/10.1007/s10896-023-00518-6

Download citation

Accepted : 21 February 2023

Published : 08 March 2023

Issue Date : August 2023

DOI : https://doi.org/10.1007/s10896-023-00518-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Methodology
• Domestic violence
• Find a journal
• Publish with us
• Track your research

A qualitative quantitative mixed methods study of domestic violence against women

Affiliations.

• 1 School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran. [email protected].
• 2 School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran.
• 3 Amir Al Momenin Hospital, Social Security Organization, Ahvaz, Iran.
• 4 Department of Nursing, Faculty of Nursing and Midwifery, Semnan University of Medical Sciences, Semnan, Iran.
• 5 Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran.
• 6 Clinical Research Development Unit, Kowsar Educational, Research and Therapeutic Hospital, Semnan University of Medical Sciences, Semnan, Iran.
• 7 Student Research Committee, School of Allied Medical Sciences, Semnan University of Medical Sciences, Semnan, Iran.
• PMID: 37340321
• PMCID: PMC10283315
• DOI: 10.1186/s12905-023-02483-0

Background: Violence against women is one of the most widespread, persistent and detrimental violations of human rights in today's world, which has not been reported in most cases due to impunity, silence, stigma and shame, even in the age of social communication. Domestic violence against women harms individuals, families, and society. The objective of this study was to investigate the prevalence and experiences of domestic violence against women in Semnan.

Methods: This study was conducted as mixed research (cross-sectional descriptive and phenomenological qualitative methods) to investigate domestic violence against women, and some related factors (quantitative) and experiences of such violence (qualitative) simultaneously in Semnan. In quantitative study, cluster sampling was conducted based on the areas covered by health centers from married women living in Semnan since March 2021 to March 2022 using Domestic Violence Questionnaire. Then, the obtained data were analyzed by descriptive and inferential statistics. In qualitative study by phenomenological approach and purposive sampling until data saturation, 9 women were selected who had referred to the counseling units of Semnan health centers due to domestic violence, since March 2021 to March 2022 and in-depth and semi-structured interviews were conducted. The conducted interviews were analyzed using Colaizzi's 7-step method.

Results: In qualitative study, seven themes were found including "Facilitators", "Role failure", "Repressors", "Efforts to preserve the family", "Inappropriate solving of family conflicts", "Consequences", and "Inefficient supportive systems". In quantitative study, the variables of age, age difference and number of years of marriage had a positive and significant relationship, and the variable of the number of children had a negative and significant relationship with the total score and all fields of the questionnaire (p < 0.05). Also, increasing the level of female education and income both independently showed a significant relationship with increasing the score of violence.

Conclusions: Some of the variables of violence against women are known and the need for prevention and plans to take action before their occurrence is well felt. Also, supportive mechanisms with objective and taboo-breaking results should be implemented to minimize harm to women, and their children and families seriously.

Keywords: Cross-sectional studies; Domestic violence; Iran; Qualitative research.

© 2023. The Author(s).

• Cross-Sectional Studies
• Domestic Violence*
• Interviews as Topic
• Middle Aged
• Qualitative Research

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Wiley-Blackwell Online Open

Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research

Rebecca l. heron.

1 Department of Arts and Sciences, University of Houston‐Victoria, Victoria TX, USA

2 Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen The Netherlands

Maarten C. Eisma

Associated data.

The data that support the findings of this study are available in Table 1 and the Supporting Information of this article.

Domestic violence victims are in frequent contact with the healthcare service yet rarely disclose. Therefore, it is critical to understand victims' experiences and perceptions regarding disclosure in healthcare settings. The goal of this review is to provide an updated synthesis of qualitative research identifying barriers and facilitators, advice, and positive and negative outcomes of adult victims' disclosure of domestic violence to healthcare professionals (HCPs). A systematic search of PsychINFO, CINAHL and Web of Science was conducted in January 2018. Thirty‐four eligible studies were identified, including 783 domestic violence victims (781 females). Formal quality assessment indicated variable study quality. Barriers of disclosure included negative HCPs attitudes, victims' perceptions of safety and concerns about the consequences of disclosing. Facilitators of disclosing included a positive relationship with the HCP, HCPs directly asking victims about abuse, and HCPs ensuring that the environment is safe and disclosure is confidential. Victims advised increased awareness of HCPs reactions to disclosure and avoiding mirroring their perpetrators minimization. HCPs were encouraged to engage in direct questioning and maintain a supportive and secure environment. Positive and negative outcomes of abuse were identified, such as being able to leave the abuser or, on the other hand, the victims' situation not changing. Our results indicate that barriers for disclosure of domestic violence in healthcare settings persist despite the widespread implementation of policies and guidelines to counter them. Based on these findings, we provide recommendations for clinical practice and future research to help improve disclosure in healthcare settings.

What is known about this topic?

• Domestic violence victims are in frequent contact with healthcare professionals, yet rarely disclose.
• Disclosure can help victims become free from violence.
• International guidelines exist to facilitate disclosure in healthcare settings

What this paper adds?

• Our up‐to‐date synthesis of qualitative research identified a variety of barriers and facilitators of disclosure, victim advice on disclosure, and outcomes of disclosure in healthcare settings.
• Barriers and facilitators identified in previous studies persisted, yet we also identified new barriers and facilitators.
• Healthcare professionals are encouraged to engage in direct questioning and maintain a supportive and safe environment. Positive outcomes of disclosure included feeling validated and leaving the abuser. Negative outcomes included the stigmatization and continued abuse.

1. INTRODUCTION

Domestic violence, also referred to as intimate partner violence, is a large public health problem in the UK and worldwide (Campbell et al., 2002 ; Hegarty et al., 2004 ; World Health Organization, 2013a ). According to the Department of Health ( 2017 ) one in four women and one in six men in England and Wales suffer domestic violence in some form. Domestic violence refers to controlling, threatening, or coercive behaviour, violence or abuse between those aged 16 or older who are or have been intimate partners or family members. This includes psychological, physical, sexual, financial and emotional types of abuse (Home Office, 2013 ).

Victims of domestic violence commonly experience a variety of physical and mental health problems because of abuse (Diaz‐Olavarrieta et al., 2009 ; Hegarty, 2011 ; Hindin et al., 2008 ). Physical health problems include sexually transmitted infections, pelvic inflammatory diseases and menstrual irregularities (Plichta & Abraham, 1996 ; Schei & Bakketeig, 1989 ). Psychological health problems include post‐traumatic stress disorder, depression, anxiety, low self‐esteem, psychosomatic complaints, increased substance abuse, self‐harm and suicidal ideation (Bergman et al., 1987 ; Rounsaville and Weissman, 1977–1978 ). Consequently, abused women are much more likely to be in contact with the healthcare service than non‐abused women (Garcia‐Moreno et al., 2015 ) and are more likely to be in contact with the healthcare service than any other professional service (Feder et al., 2006 ). The healthcare service therefore appears uniquely positioned to prevent and intervene in domestic violence.

Accordingly, policies and regulations to improve healthcare services identification and responses to disclosures from victims of domestic violence have been introduced (Department of Health, 2000 ; World Health Organisation, 2013b ). Direct questioning is an effective strategy facilitating domestic violence victims' disclosures (Cann et al., 2001 ; Howard et al., 2010 ). Disclosure can help victims to become free from violence within 6 weeks in situations when they are given appropriate care following disclosure (Krasnoff & Moscati, 2002 ).

Yet, despite healthcare providers (HCPs) significant advantage in accessing this hard to reach population and the potential benefits of disclosure, HCPs have not always been effective in identifying victims of domestic violence (Campbell et al., 2002 ; Chapman & Monk, 2015 ; Feder et al., 2011 ). Only 10%–50% of the domestic violence cases are detected in healthcare services (Feder et al., 2006 ; Gremillion, & Kanof, 1996 ). A barrier to disclosure may be that HCPs do not feel capable or comfortable discussing domestic abuse (Taylor et al., 2013 ). Additionally, HCPs have reported that a lack of time, privacy, training, resources and knowledge on how to ask about domestic violence have prevented them from enquiring about abuse (Beynon et al., 2012 ; Sundborg et al., 2012 ). For example, doctors and nurses report receiving little or no training in responding to domestic violence (Rimmer, 2017 ; Taft et al., 2004 ). Perhaps unsurprisingly, victims have reported that HCPs have been inappropriate, inadequate and unhelpful in responses to disclosures of abuse (Pratt‐Erickson et al., 2014 ; Trevillion et al., 2011 , 2014 ).

To improve responses from HCPs, it is also important to understand how victims perceive and experience disclosure in healthcare settings. More than a decade ago, a systematic review of qualitative studies by Robinson and Spilsbury ( 2008 ) on disclosing domestic abuse to HCPs first summarized findings on this topic. They charted what barriers and facilitators of disclosure domestic violence victims reported. They found that victims wanted the topic of abuse to be routinely raised by HCPs to make it easier to disclose, yet also had concerns about disclosing. For example, victims felt that just one consultation with a professional was not enough to build the trust needed to disclose and that the brevity of appointments with their HCP limited opportunities for disclosure. Victims also reported that a lack of privacy at their healthcare setting prevented them from disclosing. Other major barriers were victims' fears that they would lose their children or that the abuse would escalate.

Robinson and Spilsbury's ( 2008 ) review focussed on the barriers and facilitators that victims experience and perceive when disclosing abuse to the health service, yet they did not look specifically at victims' advice provided to HCPs or their reported outcomes of disclosure. It appears important to also summarize such advice as victims themselves could be viewed as “experts” of their own experiences enabling them to bring unique insight and knowledge (Reid et al., 2005 ) which may improve future victims' experiences of disclosing abuse.

Additionally, it appears critical to investigate victims' reported outcomes of disclosure. For example, a positive outcome might be a victim experiencing direct change after disclosing such as them leaving their partner or filing a police report (Liebschutz et al., 2008 ), whereas a negative outcome of disclosure could be the victim feeling responsible for the abuse and becoming convinced that nothing will change (Damra et al., 2015 ). Charting such outcomes could provide further insight into the potential benefits or drawbacks of disclosing which in turn could help motivate HPCs to act in line with established guidelines and regulations to facilitate disclosure. The current review therefore sought to update and extend Robinson and Spilsbury's ( 2008 ) review, to provide a more comprehensive, up‐to‐date overview of qualitative research of victims' views and experiences related to disclosure.

1.1. Aim of the review

While Robinson and Spilsbury ( 2008 ) provided an important starting point to better understand barriers and facilitators of disclosure, their review was limited in size (including 10 papers), scope (focusing only on barriers and facilitators and including only studies from English‐speaking samples) and rigour (study quality was not systematically assessed). To overcome these limitations, we conducted an updated systematic review of qualitative studies that investigated experiences and perceptions of domestic violence victims on disclosure in healthcare settings. This review includes a decade of new research on barriers and facilitators, expands the scope of the review to include victims' advice and outcomes of disclosure, and weighs the evidence by providing a systematic assessment of study quality.

Specifically, the review aimed to address the following questions:

• What barriers and facilitators do victims of domestic violence experience or perceive when disclosing abuse to the healthcare service?
• What advice do victims give on ways that the healthcare service can increase victims' disclosures of domestic violence?
• What are the outcomes of disclosing domestic abuse to health professionals? (positive or negative, e.g., was the victim able to leave the abusive relationship?)

This review was conducted in agreement with the guidelines and criteria for systematic reviews reporting set out by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement (Moher et al., 2009 ). This review was not pre‐registered as the preparation for this review started before PRISMA was widely applied.

2.1. Search strategy

A comprehensive search of three electronic databases, PsychINFO, CINAHL and Web of Science, was conducted on the 30 January 2018 (see Appendix S1 ). The keywords used in the search strategy were drawn from the previous systematic review conducted by Robinson and Spilsbury ( 2008 ). Additional search terms were added by checking the keywords used in articles identified in preliminary searches. A Boolean approach was used, and the following search terms were chosen after scoping the literature: ["Domestic* violence*" OR "battered female*" OR "intimate partner violence” OR “partner abuse*” OR “domestic abuse*” OR “battered men*” OR “battered male**” OR “battered women*” OR “victim*” OR “spouse abuse*” OR “survivor*” OR “female survivor*” OR “male survivor*” OR “intimate partner violence survivor*”] AND [“Self‐Disclosure” OR "Disclosure*" OR "help seeking"] AND [“Health care service*”OR “Health care professional*” OR “Health Care Clinician*” OR “Health setting*” OR “Health Care Provider*” OR “nurse*” OR “doctor*” OR “primary care setting*” OR “antenatal service*” OR “mental health service*”].

2.2. Inclusion/Exclusion criteria

As the decision regarding which study designs to include in the review should be dictated by the review question (Nutbeam & Harris, 2004 ; Petticrew & Roberts, 2003 ), we included only qualitative studies as these would fully capture the victims' experiences and views of disclosing to the healthcare service. We also considered it important to synthesise qualitative evidence as this has been found to make a positive contribution to the knowledge available to international organisations, such as the World Health Organisation, when developing recommendations on public health topics (Metin Gülmezoglu et al., 2013 ).

Studies were further included if the study sample consisted of adult (16 years or older) domestic violence victims, who had experienced partner abuse. Thus, studies including victims of violence from other family members than the partner were excluded. Furthermore, the study should describe victims' experiences of disclosure/interactions within healthcare services (i.e., with professionals with health‐related qualifications, e.g., doctors, nurses, midwives). To safeguard study quality, readability and interpretability, we only included papers that were published in peer‐reviewed English language scientific journals. To capture most recent developments on barriers and facilitators of disclosure, we included papers published between 1996 and January 2018. Lastly, low quality studies (as determined by an adapted Critical Appraisal Skills Programme Checklist, CASP – see Section 3.4 ) were excluded.

2.3. Study selection

All references were exported to Endnote Web. Our searches identified 647 papers, which was reduced to 489 after removal of duplicates. Titles and abstracts, as well as full text articles, were screened independently against inclusion and exclusion criteria by two reviewers. Disagreements were resolved through discussion until consensus was reached. Forty‐two papers underwent full text review, of which 32 studies met inclusion criteria. Additionally, five articles were identified by screening the reference lists of included studies. Quality assessment led to the exclusion of three low quality papers, reducing the total number of studies to 34. For a PRISMA flowchart see Figure  1 .

PRISMA flow diagram: A schematic view of study identification. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses

2.4. Quality appraisal

The quality assessment was conducted with an adapted version of the CASP checklist for qualitative studies (Critical Appraisal Skills Programme, 2017 ). The quality of the studies was assessed on the domains research design, sampling and selection bias, attrition bias, performance bias, data collection, data analysis, and ethical issues (see Appendix S2 for the adapted checklist). Fourteen questions were answered to assess study quality in these domains and were answered positively with yes (+), negatively with no (−), or with not reported (N.R). A total score, number of unclear items, and a quality assessment score was given for each included article. The quality was rated on a rating scale from A – best (no risk of bias or only risk of bias in one of the assessed domains), B – good (risk of bias in two domains), C – sufficient (risk of bias in three domains), to D – insufficient (risk of bias in four or more domains). If the quality assessment score was D the study was excluded (see Appendix S3 for the methodological quality of included studies). To ensure reliability and uniformity of quality assessment, it was conducted independently by two evaluators. Any discrepancies in agreement were discussed and resolved and consensus was reached on the final quality assessment ratings by both reviewers.

2.5. Data extraction

Data were extracted on sample characteristics (e.g., age, gender), recruitment strategy and location, qualitative research methods and analysis, and findings of relevance to our research questions (barriers and facilitators, advice, and outcomes of disclosure), independently by two researchers. Differences in extracted information were discussed until consensus was reached.

3.1. Study characteristics

For a summary of findings from the included studies see Table  1 . Seven hundred and eighty female victims and two male victims of domestic abuse were included across all studies, with an age range from 18 to 90 years old. The participants were recruited through domestic violence and women's services (12), maternity/antenatal clinics (6), print media, i.e., advertisements, articles in papers, public campaigns, and public safety announcements (5), emergency departments/hospitals (3), general practitioner's offices (3), a combination of recruitment strategies (2) and through mental health services (1). The majority of samples were recruited through purposeful sampling (25). The remaining nine studies reported using convenience sampling. Thirty studies were conducted in western countries, i.e., the United States of America (16), Australia (6), the United Kingdom (5), the Netherlands (1), Canada (1) and Scotland (1). Two studies were conducted in Asia (Nepal and Malaysia), one study was conducted in the Middle East (Jordan), and another study was conducted in South‐America (Mexico). Data were collected through interviews (28) and focus groups (6). Methods for analysis encompassed a variety of techniques, yet predominantly thematic analysis (14), grounded theory analysis (5) or content analysis (5).

Study characteristics and main findings

Abbreviations: advice; DV, domestic violence; facilitators and barriers; GP, general practitioner; HCP, healthcare professional; IPV, intimate partner violence; outcomes; Q1, question 1; Q2, question 2; Q3, question 3.

3.2. Study quality

Three of the studies were of insufficient quality and thus excluded. Sixteen of the studies included in our review were rated as A – best (no risk of bias or only risk of bias in one of the assessed domains), 12 were rated as B – good (risk of bias in two domains) and six were rated as C – sufficient (risk of bias in three domains). The quality criteria that were most often judged as low was that of attrition bias (in all 34 included studies) and performance bias (in 16 included studies). Study quality was not explicitly considered when interpreting the findings, as the majority of studies were of good quality and variability in study quality was limited.

3.3. Main findings

Themes for each article were identified and grouped under three main headings: barriers and facilitators of disclosure, advice to improve disclosure and outcomes of disclosure.

3.3.1. Barriers and facilitators of disclosure

Of the 34 articles included in this review, 28 discussed barriers and/or facilitators for disclosure. Most of the articles (27) discussed barriers, and 11 (additionally) discussed facilitators.

Barriers to disclosure

One of the barriers that the victims often mentioned was a fear of the consequences that disclosing domestic abuse could have. The most feared consequence of disclosing was the fear that their children would be taken away (Bates et al., 2001 ; Gerbert et al., 1997 , 1999 ; Hathaway et al., 2002 ; Kelley, 2006 ; Lutz, 2005 ; McCauley et al., 1998 ; Peckover, 2003 ; Salmon et al., 2015 ; Spangaro, Herring, et al., 2016 ; Spangaro, Koziol‐McLain, et al., 2016 ).

Secondly, victims feared being judged/ negatively evaluated by either the HCP or their environment, i.e., their family, friends, neighbours, acquaintances (Damra et al., 2015 ; Hegarty & Taft, 2001 ; Lutz, 2005 ; McCauley et al., 1998 ; Narula et al., 2012 ; Othman et al., 2014 ; Rishal et al., 2016 ) and some victims feared that they would not be believed (Narula et al., 2012 ; Rose et al., 2011 ; Salmon et al., 2015 ).

Thirdly, victims communicated that fear of their abuser further prevented them from disclosing. For instance, they were fearful of what would happen if their abuser found out about their disclosure and they were worried about whether the healthcare service would be able to protect them, especially as in many cases their abuser made threats prior to them disclosing (Hathaway et al., 2002 ; Hegarty & Taft, 2001 ; Kelley, 2006 ; Lutenbacher et al., 2003 ; McCauley et al., 1998 ; Narula et al., 2012 ; Othman et al., 2014 ; Peckover, 2003 ; Rodriguez et al., 1996 ; Rose et al., 2011 ; Spangaro et al., 2011 ; Yam, 2000 ). Relatedly, three studies found that victims feared that confidentiality would be broken by the health service personnel (Gerbert et al., 1999 ; Peckover, 2003 ; Wallin et al., 2003 ) and they were also concerned about the lack of privacy at the healthcare service (Bacchus et al., 2003 ; Bates et al., 2001 ; Damra et al., 2015 ; McCauley et al., 1998 ; Reisenhofer & Siebold, 2013 ; Zink et al., 2004 ).

A lack of a positive relationship with the HCP was also viewed as a barrier to disclosure (Bacchus et al., 2003 ; Bates et al., 2001 ; Damra et al., 2015 ; Hathaway et al., 2002 ; Kelly, 2006 ; Narula et al., 2012 ; Nicolaidis et al., 2008 ; Rishal et al., 2016 ; Spangaro, Herring, et al., 2016 ; Spangaro, Koziol‐McLain, et al., 2016 ; Wallin et al., 2018 ; Yam, 2000 ). This included not trusting in the HCP, lack of continuity in the relationship or limited time with the HCP, and not expecting that the HCP would be empathetic.

Furthermore, the HCP having a negative attitude towards them or their disclosure, for example, by being unsympathetic, disinterested, not maintaining eye contact or not listening were also viewed as barriers to disclosure (Bacchus et al., 2003 ; Bates et al., 2001 ; Gerbert et al., 1997 ; Lutenbacher et al., 2003 ; McCauley et al., 1998 ; Reisenhofer & Seibold, 2013 ; Spangaro, Herring, et al., 2016 ; Spangaro, Koziol‐McLain, et al., 2016 ; Wallin et al., 2018 ; Yam, 2000 ). Victims perceptions of whether the HCP could handle their disclosure also acted as a barrier, specifically perceiving the HCP to have low capability to help them prevented victims from disclosing (Damra et al., 2015 ; Gerbert et al., 1999 ; Lutenbacher et al., 2003 ).

Additionally, personal barriers such as a low self‐esteem, feelings of shame, embarrassment, guilt and powerlessness also prevented victims from disclosing (Bacchus et al., 2003 ; Bates et al., 2001 ; Bradbury‐Jones et al., 2011 ; Gerbert et al., 1997 ; Hathaway et al., 2002 ; Hegarty & Taft, 2001 ; Lutz, 2005 ; McCauley et al., 1998 ; Narula et al., 2012 ; Reisenhofer & Seibold, 2013 ; Rodriguez et al., 1996 ; Rose et al., 2011 ; Salmon et al., 2015 ; Spangaro et al., 2011 ; Spangaro, Koziol‐McLain, et al., 2016 ; Wallin et al., 2018 ; Yam, 2000 ; Zink et al., 2004 ). Furthermore, victims chose not to disclose because they were at the time unaware that they were experiencing abuse (Narula et al., 2012 ; Zink et al., 2004 ). Some of the victims reported thinking that the abuse was normal and something that you just tolerate in a relationship (Hegarty & Taft, 2001 ; Othman et al., 2014 ; Reisenhofer & Seibold, 2013 ; Zink et al., 2004 ). Other reasons victims were reluctant to disclose was being in denial (Gerbert et al., 1999 ), not being ready to leave their abuser (McCauley et al., 1998 ; Othman et al., 2014 ), being financially dependent (Othman et al., 2014 ; Rodriguez et al., 1996 ), lacking social support (Rose et al., 2011 ; Yam, 2000 ) and trying to avoid reliving the trauma by not speaking about the abuse (Spangaro, Koziol‐McLain, et al., 2016 ).

A further barrier was the fact that many victims thought that healthcare services were not the appropriate place to discuss abuse, as they perceived that it was not a health issue that you discuss with a HCP (Gerbert et al., 1997 ; Narula et al., 2012 ; Othman et al., 2014 ; Peckover, 2003 ). Additionally, victims were also not always aware of their rights in terms of what choices or support they could gain by telling the HCP about abuse (Hathaway et al., 2002 ; Kelly, 2006 ; Othman et al., 2014 ).

Facilitators to disclosure

The 11 studies focused on facilitators for disclosure generally found that a positive and trusting relationship with the HCP was important for victims to enable disclosure (Bates et al., 2001 ; Battaglia et al., 2003 ; Bradbury‐Jones et al., 2011 ; Hathaway et al., 2002 ; Hegarty & Taft, 2001 ; Peckover, 2003 ; Rodriguez et al., 1996 ; Rose et al., 2011 ; Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ; Wong et al., 2008 ).

Other studies found that HCPs directly asking about abuse facilitated victims' disclosures (Hathaway et al., 2002 ; Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ; Wong et al., 2008 ). Additionally, victims stated that when they felt that the healthcare setting was safe and they were convinced that their disclosure would be kept confidential, they were more likely to disclose (Bates et al., 2001 ; Battaglia et al., 2003 ; Hathaway et al., 2002 ; Hegarty & Taft, 2001 ; Peckover, 2003 ; Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ).

Additional factors facilitating victims' disclosures were perceiving the HCP as knowledgeable and capable to handle the abuse (Battaglia et al., 2003 ; Hathaway et al., 2002 ), and the gender of the HCP; a woman facilitated disclosure among female victims (Bates et al., 2001 ). Victims further noted that feeling that they had a choice over what to disclose and how much, helped them to disclose (Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ). Finally, having leaflets and posters on domestic violence visible and available in waiting rooms further aided victims' disclosures (Bates et al., 2001 ).

3.3.2. Advice to improve disclosure

Of the 34 studies included in the review, 16 contained advice from victims on how the healthcare service may improve responding to victims' disclosures.

A commonly given advice was to make victims aware of the resources and options available to disclose in the healthcare service. This could either be by making posters and pamphlets visible and available in the waiting room or by talking about resources during the appointment (Bates et al., 2001 ; Chang, Cluss, et al., 2005 ; Chang, Decker, et al., 2005 ; Dienemann et al., 2005 ; Kelly, 2006 ; Rishal et al., 2016 ). Another oft‐mentioned advice was for HCPs to directly ask their patients about domestic abuse (Damra et al., 2015 ; Kelly, 2006 ; Rodriguez et al., 1996 ; Spangaro, Herring, et al., 2016 ).

It was further advised that HCPs put in an effort to make the environment safe, private and confidential for disclosure (Chang, Decker, et al., 2005 ; Rishal et al., 2016 ; Rodriguez et al., 1996 ; Yam, 2000 ). HCPs were also advised to be aware of how their attitude could influence the choice of a victim to disclose. Victims advised that a caring, non‐judgemental and supportive attitude is what would facilitate disclosure and they stressed the importance of respecting the victim and showing compassion (Keeling & Fisher, 2015 ; McCauley et al., 1998 ; Nicoladis et al., 2008 ; Rishal et al., 2016 ; Rodriguez et al., 1996 ; Yam, 2000 ; Zink et al., 2004 ).

Female victims also communicated finding it easier to talk about abuse to another woman (Damra et al., 2015 ) and so they advised that victims should be provided with an option to meet with a female HCP. Furthermore, it was advised that HCPs provide referrals and continued support (Narula et al., 2012 ; Rodriguez et al., 1996 ; Yam, 2000 ) and that they are specially trained to deal with domestic violence victims disclosures (Bates et al., 2001 ). It was also advised to make a mental health counsellor and a legal counsellor available (Chang, Cluss, et al., 2005 ; Yam, 2000 ). Lastly, victims recommended not to pressure patients into leaving their abuser (Hathaway et al., 2002 ; Zink et al., 2004 ).

3.3.3. Outcomes of disclosure

Nine of the 34 included articles discussed what victims experienced after their disclosure of domestic abuse to a HCP. The studies discussed both positive and negative outcomes of disclosure of domestic violence.

Positive outcomes of disclosure included victims feeling disclosure was a turning point (Gerbert et al., 1999 ), feeling validated (Gerbert et al., 1997 ; Hathaway et al., 2002 ; Zink et al., 2004 ), feeling optimistic about becoming free from violence (Wong et al., 2008 ), rethinking one's relationship, reductions in feelings of self‐blame, becoming aware of available support (Keeling & Fisher, 2015 ; Spangaro et al., 2011 ), and, ultimately, direct changes through filing of a police report and leaving one's abuser (Liebschutz et al., 2008 ). The latter steps appear particularly likely to be undertaken when initial responses to disclosure were a positive experience.

However, some of the studies from our review also reported negative outcomes of disclosure. For example, victims noted no change or improvement in their situations after disclosing (Damra et al., 2015 ; Wong et al., 2008 ) and instead feeling blamed, stigmatized or ignored by HCPs (Damra et al., 2015 ; Gerbert et al., 1997 ; Zink et al., 2004 ). After disclosing, some victims also reported feeling helpless and fearful (Wong et al., 2008 ) noting that they felt even more endangered after disclosing abuse (Liebschutz et al., 2008 ).

4. DISCUSSION

The aim of this systematic review was to synthesize qualitative research on the barriers and facilitators of disclosure that victims of domestic violence experience in healthcare settings. We also synthesized the advice that victims provide on the ways in which healthcare services can increase victims' disclosures of domestic abuse, and what outcomes they perceived after disclosing domestic abuse to a HCP.

Generally speaking, this review has demonstrated a continued scientific interest in domestic violence victims' experiences of disclosure in healthcare settings. Over the past 12 years, more than twice as many qualitative papers were written about this topic than in the 10 years preceding it. A majority of studies focus on barriers to disclosure, but facilitators of disclosure, victims' advice to HCPs, and outcomes of disclosure are increasingly investigated as well.

Barriers to disclosure within this review can be divided into two parts. Firstly, there are barriers related to opinions and feelings of the victims. These barriers consisted of victims' fear of their children being taken away by child protection services, their abuser, and being negatively judged by the HCP and/or their social environment. Victims also noted feelings of guilt, shame, embarrassment and not realizing that what they were experiencing was abuse, further acted as barriers to them disclosing, along with perceptions that the HCP was not competent or capable to handle their domestic abuse disclosure (Bacchus et al., 2003 ; Bates et al., 2001 ; Bradbury‐Jones et al., 2011 ; Gerbert et al., 1997 ; Gerbert et al., 1999 ; Hathaway et al., 2002 ; Hegarty & Taft, 2001 ; Kelly, 2006 ; Lutz, 2005 ; McCauley et al., 1998 ; Narula et al., 2012 ; Nicolaidis et al., 2008 ; Othman et al., 2014 ; Reisenhofer & Seibold, 2013 ; Rishal et al., 2016 ; Rodriguez et al., 1996 ; Rose et al., 2011 ; Salmon et al., 2015 ; Spangaro et al., 2011 ; Spangaro, Herring, et al., 2016 , Spangaro, Koziol‐McLain, et al., 2016 ; Wallin et al., 2018 ; Yam, 2000 ; Zink et al., 2004 ).

Secondly, victims also experienced institutional barriers which prevented them from disclosing. These included the inability to form a trusting relationship with the HCP, lack of continuity in care, and limited time with the HCP (Bacchus et al., 2003 ; Bates et al., 2001 ; Damra et al., 2015 ; Gerbert et al., 1997 ; Hathaway et al., 2002 ; Lutenbacher et al., 2003 ; Narula et al., 2012 ; Peckover, 2003 ; Rishal et al., 2016 ; Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ; Yam, 2000 ; Zink et al., 2004 ). Additionally, victims encountered a further institutional barrier of lack of privacy, which further prevented them from disclosing to HCPs (Bacchus et al., 2003 ; Bates et al., 2001 ; Damra et al., 2015 ; Reisenhof & Seibold, 2013 ; Zink et al., 2004 ).

Facilitators of disclosure included a trusting relationship with the HCP, directly being asked about domestic abuse, the availability of pamphlets and posters for domestic violence services in the waiting rooms, having privacy, and the option to see a female HCP for female victims (Bates et al., 2001 ; Battaglia et al., 2003 ; Bradbury‐Jones et al., 2011 ; Hathaway et al., 2002 ; Hegarty & Taft, 2001 ; Peckover, 2003 ; Rodriguez et al., 1996 ; Rose et al., 2011 ; Spangaro et al., 2011 ; Spangaro, Herring, et al., 2016 ; Wong et al., 2008 ).

When comparing present results against Robinson and Spilbury's ( 2008 ) review, two findings stand out. First, a substantial part of earlier findings on barriers and facilitators of disclosure have been replicated in more recent work. For example, a lack of a positive relationship with the HCP, the HCP having a negative attitude, the absence of privacy and fear of losing one's children have all been repeatedly identified as barriers preventing victims from disclosing domestic abuse. However, in recent years additional barriers were also identified. This included victims fearing not being believed by HCPs (Narula et al., 2012 ; Rose et al., 2011 ; Salmon et al., 2015 ), being concerned about re‐living the trauma when disclosing to a HCP (Spangaro, Koziol‐McLain, et al., 2016 ), having perception that the HCP is incapable to respond to disclosure (Damra et al., 2015 ), and a lack of eye contact with clients due to the use of computer screens (Spangaro, Koziol‐McLain, et al., 2016 ). Despite the development of national (e.g., National Institute for Health & Care Excellence [NICE], 2014 ) and international guidelines (Department of Health, 2000 ; World Health Organisation, 2013b ) and repeated recommendations by researchers on how HCPs can facilitate disclosure of abuse (Feder et al., 2011 ; Nyame et al., 2013 ), our review illustrates both the variety of barriers to disclosure and the continuity of such barriers over time and potentially across cultures.

Similarly, identified facilitators show some consistency across time. For example, both Robinson and Spilsbury's ( 2008 ) review and our review found that a positive and trusting relationship with the HCP, safety, the HCP being knowledgeable and ensuring that leaflets and posters were available within the healthcare setting facilitated disclosure. However, our review also identified new facilitators of disclosure such as victims having autonomy over what to disclose and how much (Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ) and them being questioned directly about abuse (Hathaway et al., 2002 ; Spangaro, Herring, et al., 2016 ; Spangaro et al., 2011 ; Wong et al., 2008 ). The findings from both our review therefore highlight that disclosure can be improved for victims. We recommended that HCPs be educated upon these ways with training, especially as training can help HCPs identify and respond better to victims of domestic abuse (Beynon et al., 2012 ).

Relatedly, when comparing results from our review with Robinson and Spilsbury's ( 2008 ) review, some consistency on advice provided by domestic violence victims to HCPs is apparent. While the prior review did not specifically set out to synthesize advice, it did show that when victims provide advice, this was in many respects similar as the advice identified in our review. For instance, many of the included studies in this review recommended that HCPs ensure that posters and pamphlets are made available (Bates et al., 2001 ; Chang, Cluss, et al., 2005 ; Chang, Decker, et al., 2005 ; Dienemann et al., 2005 ; Kelly, 2006 ; Rishal et al., 2016 ), that the environment is kept private and confidential to help victims to feel safe (Chang, Cluss, et al., 2005 ; Rishal et al., 2016 ; Yam, 2000 ; Zink et al., 2004 ), that victims disclosures should not be judged, that victims should not be pressured into leaving (Hathaway et al., 2002 ; Rishal et al., 2016 ; Zink et al., 2004 ), and that victims be provided with counselling and continued support after disclosing (Chang, Decker, et al., 2005 ; Narula et al., 2012 ; Rishal et al., 2016 ). However, our review also uniquely identified new advice such as that direct questioning should be carried out by HCPs (Damra et al., 2015 ; Kelly, 2006 ; Spangaro, Herring, et al., 2016 ). It should be noted though that screening has not always been supported in previous studies as it may negatively impact on women's mental health (Klevens et al., 2012 ). Other new advice included providing training to HCPs on how to react and deal with a domestic violence disclosure and avoiding minimizing victims' experiences of domestic violence when disclosing, as this could mirror perpetrators minimization of abuse (Keeling & Fisher, 2015 ).

With respect to the outcomes of disclosure, which was not covered by Robinson and Spilsbury ( 2008 ), a nuanced picture emerges. On the one hand, disclosure can help victims to feel validated and supported (Gerbert et al., 1997 ; Hathaway et al., 2002 ; Zink et al., 2004 ), which can be experienced as a turning point (Gerbert et al., 1999 ; Spangaro et al., 2011 ) resulting in victims deciding to leave their abuser (Liebschutz et al., 2008 ), or becoming aware of what support is available (Keeling & Fisher, 2015 ; Wong et al., 2008 ). Such findings are generally in line with quantitative research, which has for example demonstrated that approximately half of domestic violence victims can become free from violence within 6 weeks after disclosure if provided with appropriate care (Krasnoff & Moscati, 2002 ). However, on the other hand, potential negative consequences of disclosure should not be disregarded. For example, negative responses from HCPs can lead to victims feeling ignored, stigmatized (Gerbert et al., 1997 ; Zink et al., 2004 ), and blamed (Damra et al., 2015 ), resulting in them finding it more difficult to leave. Our review also highlighted how some victims could feel even more endangered (Liebschutz et al., 2008 ) and helpless to change their situations (Wong et al., 2008 ).

4.1. Implication for policy and practice

Based on the above, we conclude that training is important and should be provided to HCPs to help them to understand the complexities of the disclosure process and the variety of potential barriers and facilitators of disclosure that may be experienced. For example, research shows that HCPs would rather not ask about domestic violence because it makes them uncomfortable or afraid of offending their patients (Hamberger et al., 1998 ). However, several studies in our review showed that victims of domestic abuse would prefer being asked directly about abuse (e.g., Damra et al., 2015 ; Kelly, 2006 ). Thus, HCPs should be trained to help them understand what questions to ask under which circumstances. For example, HCPs could start off with indirect questions such as ‘Do you feel comfortable in your home’ or ‘do you feel in control of your life’ (Fulfer et al., 2007 ), and then gradually they could ask more direct questions such as, ‘Are you experiencing abuse emotional, physical or sexual?’ Training has been shown to be more effective if professionals are given the opportunity to observe and model good practice. For example, experiential and interactive training has been found to be effective in previous studies with HCPs (Haney et al., 2003 ; Zaher et al., 2014 ). Haney et al. ( 2003 ) demonstrated that HCPs confidence in asking about and responding to domestic violence markedly improved after completing an interactive training.

Additionally, healthcare services should take into account barriers unrelated to HCPs training and abilities. For instance, a lack of information about domestic violence, a lack of privacy or a lack of opportunity to disclose to a female HCP, all act as barriers to disclosure, yet could be targeted by implementing structural changes in healthcare facilities (Bacchus et al., 2003 ; Bates et al., 2001 ; McCauley et al., 1998 ; Reisenhofer & Seibold, 2013 ; Zink et al., 2004 ). For example, creating private areas for contact with female HCPs in Accident and Emergency hospitals or maternity clinics could directly reduce a barrier to disclosure. This might also help reduce the emotional barrier of feelings of shame and embarrassment. That is, if fewer people interact with a victim in a private environment, this could make her feel more comfortable to openly discuss her experiences.

Additionally, based on the findings from our review, we concluded that victims may find it difficult to disclose due to fears that their children will be removed. Victims' anxiety may be warranted as guidelines have highlighted that general practitioners do not always know what to do when presented with child safeguarding cases of domestic violence (General Medical Council, 2012 ). Thus, it is recommended that training is provided to HCP's and that they are reminded to be sensitive towards victims, making every effort not to blame them for difficulties they experience in protecting their children due to domestic violence (Lapierre, 2008 ; Radford & Hester, 2006 ). Instead HCP's should work closely with child protective services to ensure that victims are fully supported to be able to care and protect their children. Research by Mullender et al. ( 2002 ) also showed that children (aged 8–17) who were living in homes with domestic violence, wished to be treated as agentic and be involved in the decision‐making process on solutions to this problem, including whether they want to remain in their mother's care. These measures, combined with the provision of information on how child safeguarding is handled by healthcare professionals (e.g., in information brochures on domestic violence) could reduce victims fears about losing their children after disclosing.

Finally, after acknowledging victims' recommendations for what can improve disclosure, we also must not forget that disclosure does not always lead to positive consequences and may result in more harm if not responded to correctly (Liebschutz et al., 2008 ). Victims in one study advised that HCPs should be trained specifically on how to respond and deal with a disclosure (Keeling & Fisher, 2015 ). We need to ensure that we optimize the possibility of positive outcomes for victims when disclosing, especially since disclosure can lead to victims becoming free from violence if they are provided with appropriate care (Krasnoff & Moscati, 2002 ).

Appropriate care based on the qualitative findings from this review from the perspective of the victims would consist of the HCP responding in an empathic (e.g., ‘I am so sorry that this is happening to you’), validating (e.g., ‘you are correct what you are experiencing is abuse’), non‐judgemental (e.g., ‘You do not deserve this and none of this is your fault’) and non‐pressurizing way (e.g., ‘feel free to discuss with me when you feel ready’), within a safe and private environment (in a closed soundproof room without their partner present). Such a response from The HCP will allow the victim to (begin) establishing trust with the HCP and form a better relationship. To increase the odds of positive outcomes of disclosure, the HCP should have up to date information on where to refer the victim for appropriate support (e.g., women's shelters, legal advocacy), or care (e.g., counselling) so that the victim can be made aware of all their options. While not all victims will be at imminent risk of violence, the HCP should assess the victim's risk of violence, which would allow them to create a safety plan with the victim if needed, e.g., advising the victim to store money/documents etc so they can escape urgently if needed. HCPs should ideally also be trained to use tools, which could help them to assess the victim's risk, i.e., screening measures such as the woman abuse screening tool (Basile et al., 2007 ). Finally, after disclosure, the HCP should end their consultation by acknowledging the victim's courage to disclose abuse (‘I am very proud of you, it must not be easy to open up about your experiences’) and provide a follow‐up appointment if needed.

4.2. Limitations and future research

Multiple considerations should be taken into account when interpreting our findings. Some limitations relate to methodological choices. First, we only synthesised qualitative studies, as this would provide us with rich data, which would help us to understand victims' experiences and perspectives through their own voices. Due to the subjective nature of qualitative research various biases may have shaped results from our review. For example, social desirability may have influenced answers in both the interview or focus group studies, as participants may have adapted their answers due to wanting to be accepted or liked by the researchers or group members. A further limitation of this review was that it did not consider non‐English peer reviewed articles, or grey literature (dissertations, master theses), to safeguard interpretability of results. Future reviewers focusing on these topics could aim to be more comprehensive in their selection of manuscripts. A further limitation of our review was that we grouped findings on our main research questions together for all types of HCPs. While we are confident that the conclusions from our review are broadly applicable, some barriers and facilitators may be unique to specific settings or HCPs. For instance, unique barriers to victim disclosure exist within mental healthcare (Rose et al., 2011 ; Trevillion et al., 2016 ), such as concerns that mental illness is viewed as the main cause of abuse, rather than (other) personal or social factors (Du Mont & Forte, 2014 ).

Other limitations pertain to the acquired data. One of the limitations of this study is the lack of male participants in the included studies; only two male participants were included in our review. Relatedly, only 12% of victims included in our review were from non‐Western countries. Therefore, an important aim for future research is establishing if the present results generalize to male domestic violence victims, and victims from non‐western countries. The studies included in this review were deemed to be of sufficient to excellent quality, however, all of the studies had some level of attrition bias and selection/sampling biases were common. Future studies should aim to address these biases.

5. CONCLUSION

In summary, the present study strengthened the research base on disclosure of domestic violence in healthcare settings by providing a comprehensive, updated systematic review of qualitative research barriers and facilitators of disclosure, advice of victims on disclosure, and the potential outcomes of disclosure. Results were partly consistent with a prior review, but also demonstrated novel themes and issues relevant to disclosure in healthcare settings. The fact that barriers to disclosure persist despite the development of international guidelines and regulations for healthcare services suggests that improving HCP and healthcare service responsiveness to domestic violence remains an important goal for the future.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

Supporting information

Supplementary Material

Heron RL, Eisma MC. Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research . Health Soc Care Community . 2021; 29 :612–630. 10.1111/hsc.13282 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

• Bacchus, L. , Mezey, G. , & Bewley, S. (2003). Experiences of seeking help from health professionals in a sample of women who experienced domestic violence . Health and Social Care in the Community , 11 ( 1 ), 10–18. 10.1046/j.1365-2524.2003.00402.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Basile, K. C. , Hertz, M. F. , & Back, S. E. (2007). Intimate partner violence and sexual violence victimization assessment instruments for use in healthcare settings: Version 1 . Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf [ Google Scholar ]
• Bates, L. , Hancock, L. , & Peterkin, D. (2001). A little encouragement: Health services and domestic violence . International Journal of Health Care Quality Assurance , 14 ( 2 ), 49–56. 10.1108/09526860110386474 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Battaglia, T. A. , Finley, E. , & Liebschutz, J. M. (2003). Survivors of intimate partner violence speak out: Trust in the patient‐provider relationship . Journal of General Internal Medicine , 18 ( 8 ), 617–623. 10.1046/j.1525-1497.2003.21013.x [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bergman, B. , Larsson, G. , Brismar, B. , & Klang, M. (1987). Psychiatric morbidity and personality characteristics of battered women . Acta Psychiatrica Scandinavica , 76 , 678–683. 10.1111/j.1600-0447.1987.tb02939.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Beynon, C. E. , Gutmanis, I. A. , Tutty, L. M. , Wathen, C. N. , & MacMillan, H. L. (2012). Why physicians and nurses ask (or don't) about partner violence: A qualitative analysis . BMC Public Health , 12 ( 1 ). 10.1186/1471-2458-12-47 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bradbury‐Jones, C. , Duncan, F. , Kroll, T. , Moy, M. , & Taylor, J. (2011). Improving the health care of women living with domestic abuse . Nursing Standard , 25 ( 43 ), 35–40. 10.7748/ns.25.43.35.s47 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Campbell, J. , Jones, A. S. , Dienemann, J. , Kub, J. , Schollenberger, J. , O'Campo, P. , Gielen, A. C. , & Wynne, C. (2002). Intimate partner violence and physical health consequences . Archives of International Medicine , 162 ( 10 ), 1157–1163. 10.1001/archinte.162.10.1157 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cann, K. , Withnell, S. , Shakespeare, J. , Doll, H. , & Thomas, J. (2001). Intimate partner violence: A comparative survey of levels of detection, knowledge, and attitudes in healthcare workers . Public Health , 115 , 89–95. 10.1038/sj.ph.1900749 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chang, J. C. , Cluss, P. A. , Ranieri, L. , Hawker, L. , Buranosky, R. , Dado, D. , McNeil, M. , & Scholle, S. H. (2005). Health care interventions for intimate partner violence: What women want . Women's Health Issues , 15 ( 1 ), 21–30. 10.1016/j.whi.2004.08.007 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chang, J. C. , Decker, M. R. , Moracco, K. E. , Martin, S. L. , Petersen, R. , & Frasier, P. Y. (2005). Asking about intimate partner violence: Advice from female survivors to health care providers . Patient Education and Counselling , 59 ( 2 ), 141–147. 10.1016/j.pec.2004.10.008 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chapman, A. , & Monk, C. (2015). Domestic violence awareness . The American Journal of Psychiatry , 172 ( 10 ), 944–945. 10.1176/appi.ajp.2015.15070853 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Critical Appraisal Skills Programme . (2017). CASP qualitative checklist . Retrieved from http://www.casp‐uk.net/checklists [ Google Scholar ]
• Damra, J. , Abujilban, S. , Rock, M. , Tawalbeh, I. , Ghbari, T. , & Ghaith, S. (2015). Pregnant women's experiences of intimate partner violence and seeking help from health care professionals: A Jordanian qualitative study . Journal of Family Violence , 30 ( 6 ), 807–816. 10.1007/s10896-015-9720-z [ CrossRef ] [ Google Scholar ]
• Department of Health . (2000). Domestic violence – A resource manual for health professionals . Department of Health. [ Google Scholar ]
• Department of Health . (2017). Domestic abuse: A resource for health professionals . Department of Health. [ Google Scholar ]
• Diaz‐Olavarietta, C. , Wilson, K. , Garcia, S. , Revollo, R. , Richmond, K. , Paz, F. , & Chavez, L. (2009). The co‐occurrence in intimate partner violence and syphilis among pregnant women in Bolivia . Journal of Women's Health , 18 ( 12 ), 2077–2086. 10.1089/jwh.2008.1258 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dienemann, J. , Glass, N. , & Hyman, R. (2005). Survivor preferences for response to IPV disclosure . Clinical Nursing Research , 14 ( 3 ), 215–233. 10.1177/1054773805275287 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Du Mont, J. , & Forte, T. (2014). Intimate partner violence among women with mental health‐related activity limitations: A Canadian population based study . BMC Public Health , 14 , 51. 10.1186/1471-2458-14-51 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Feder, G. , Agnew‐Davies, R. , Baird, K. , Dunne, D. , Eldridge, S. , Griffiths, C. , & Sharp, C. (2011). Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: A cluster randomised controlled trial . The Lancet , 378 ( 9805 ), 1788–1795. 10.1016/S0140-6736(11)61179-3 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Feder, G. , Hutson, M. , Ramsay, J. , & Taket, A. (2006). Women exposed to intimate partner violence: Expectations and experiences when they encounter health care professionals . Archives of Internal Medicine , 166 , 22–37. 10.1001/archinte.166.1.22 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fulfer, J. L. , Tyler, J. J. , Choi, N. J. S. , Young, J. A. , Verhulst, S. J. , Kovach, R. , & Dorsey, J. K. (2007). Using indirect questions to detect intimate partner violence: The SAFE‐T questionnaire . Journal of Interpersonal Violence , 22 ( 2 ), 238–249. 10.1177/0886260506295814 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• García‐Moreno, C. , Hegarty, K. , d'Oliveira, A. , Koziol‐McLain, J. , Colombini, M. , & Feder, G. (2015). The health systems response to violence against women . The Lancet , 385 , 1567–1579. 10.1016/s0140-6736(14)61837-7 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• General Medical Council . (2012). Protecting children and young people: The responsibilities of all doctors . GMC. [ PubMed ] [ Google Scholar ]
• Gerbert, B. , Abercrombie, P. , Caspers, N. , Love, C. , & Bronstone, A. (1999). How health care providers help battered women: The survivor's perspective . Women & Health , 29 ( 3 ), 115–135. 10.1300/j013v29n03_08 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gerbert, B. , Johnston, K. , Caspers, N. , Bleecker, T. , Woods, A. , & Rosenbaum, A. (1997). Experiences of battered women in health care settings: A qualitative study . Women & Health , 24 ( 3 ), 1–2. 10.1300/j013v24n03_01 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gremillion, D. H. , & Kanof, E. P. (1996). Overcoming barriers to physician involvement in identifying and referring victims of domestic violence . Annals of Emergency Medicine , 27 ( 6 ), 769–773. 10.1016/s0196-0644(96)70200-7 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hamberger, L. K. , Ambuel, B. , Marbella, A. , & Donze, J. (1998). Physician interaction with battered women. The women's perspective . Archives of Family Medicine , 7 , 575–582. 10.1001/archfami.7.6.575 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Haney, K. , Kachur, E. , & Zabar, S. (2003). A brief but multi‐faceted approach improves clinicians' domestic violence confidence, competence and clinical performance . Medical Education , 37 ( 5 ), 488–489. 10.1046/j.1365-2923.2003.01502_19.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hathaway, J. E. , Willis, G. , & Zimmer, B. (2002). Listening to survivors' voices: Addressing partner abuse in the health care setting . Violence against Women , 8 ( 6 ), 687–719. 10.1177/107780120200800605 [ CrossRef ] [ Google Scholar ]
• Hegarty, K. (2011). Domestic violence: The hidden epidemic associated with mental illness . British Journal of Psychiatry , 198 , 169–170. 10.1192/bjp.bp.110.083758 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hegarty, K. , Gunn, J. , Chondros, P. , & Small, R. (2004). Association between depression and abuse by partners of women attending general practice: A descriptive cross sectional survey . British Medical Journal , 328 , 621–624. 10.1136/bmj.328.7440.621 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hegarty, K. , & Taft, A. (2001). Overcoming the barriers to disclosure and inquiry of partner abuse for women attending general practice . Australian and New Zealand Journal of Public Health , 25 ( 5 ), 433–437. 10.1111/j.1467-842x.2001.tb00288.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hindin, M. J. , Kishor, S. , & Ansara, D. L. (2008). Intimate partner violence among couples in 10 DHS countries: Predictors and health outcomes . DHS analytical studies no. 18. Macro International Inc. Retrieved from http://www.measuredhs.com/pubs/pdf/AS18/AS18.pdf [ Google Scholar ]
• Home Office . (2013). Definition of domestic violence and abuse: Guide for local areas . Home Office. [ Google Scholar ]
• Howard, L. , Trevillion, K. , Khalifeh, H. , Woodall, A. , Agnew‐Davies, R. , & Feder, G. (2010). Domestic violence and severe psychiatric disorders: Prevalence and interventions . Psychological Medicine , 40 , 881–893. 10.1017/s0033291709991589 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Keeling, J. , & Fisher, C. (2015). Health professionals' responses to women's disclosure of domestic violence . Journal of Interpersonal Violence , 30 ( 13 ), 2363–2378. 10.1177/0886260514552449 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kelly, U. (2006). 'What will happen if I tell you?' battered Latina women's experiences of health care . Canadian Journal of Nursing Research , 38 ( 4 ), 78–95. [ PubMed ] [ Google Scholar ]
• Klevens, J. , Kee, R. , Trick, W. , Garcia, D. , Angulo, F. R. , Jones, R. , & Sadowski, L. S. (2012). Effect of screening for partner violence on women's quality of life: A randomized controlled trial . The Journal of the American Medical Association , 308 , 681–689. 10.1001/jama.2012.6434 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Krasnoff, M. , & Moscati, R. (2002). Domestic violence screening and referral can be effective . Annals of Emergency Medicine , 40 , 485–492. 10.1067/mem.2002.128872 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lapierre, S. (2008). Mothering in the context of domestic violence: The pervasiveness of a deficit model of mothering . Child and Family Social Work , 13 ( 4 ), 454–463. 10.1111/j.1365-2206.2008.00563.x [ CrossRef ] [ Google Scholar ]
• Liebschutz, J. , Battaglia, T. , Finley, E. , & Averbuch, T. (2008). Disclosing intimate partner violence to health care clinicians – What a difference the setting makes: A qualitative study . BMC Public Health , 8 , 229–236. 10.1186/1471-2458-8-229 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lutenbacher, M. , Cohen, A. , & Mitzel, J. (2003). Do we really help? Perspectives of abused women . Public Health Nursing , 20 ( 1 ), 56–64. 10.1046/j.1525-1446.2003.20108.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lutz, K. F. (2005). Abused pregnant women's interactions with health care providers during the childbearing year . Journal of Obstetric, Gynecologic & Neonatal Nursing , 34 ( 2 ), 151–162. 10.1177/0884217505274580 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• McCauley, J. , Yurk, R. , Jenckes, M. , & Ford, D. (1998). Inside "pandora's box": Abused women's experiences with clinicians and health services . Journal of General Internal Medicine , 13 ( 8 ), 549–555. 10.1046/j.1525-1497.1998.00166.x [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Metin Gülmezoglu, A. , Chandler, J. , Shepperd, S. , & Pantoja, T. (2013). Reviews of qualitative evidence: A new milestone for Cochrane . Cochrane Database of Systematic Reviews , 11 . 10.1002/14651858.ed000073 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Moher, D. , Liberati, A. , Tetzlaff, J. , & Altman, D. G. ; The PRISMA Group . (2009). Preferred reporting items for systematic reviews and meta‐analyses: The PRISMA statement . PLoS Medicine , 6 ( 7 ), 1–6. 10.1371/journal.pmed.1000097 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mullender, A. , Hague, G. , Imam, U. , Kelly, L. , Malos, E. , & Regan, L. (2002). Children's perspectives on domestic violence . Sage. [ Google Scholar ]
• Narula, A. , Agarwal, G. , & McCarthy, L. (2012). Intimate partner violence: Patients' experiences and perceptions in family practice . Family Practice , 29 ( 5 ), 593–600. 10.1093/fampra/cms008 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• National Institute for Health and Care Excellence (NICE) . (2014). Domestic violence and abuse – How health service, social care and organizations they work with can respond effectively . NICE. [ Google Scholar ]
• Nicolaidis, C. , Gregg, J. , Galian, H. , McFarland, B. , Curry, M. , & Gerrity, M. (2008). 'You always end up feeling like you're some hypochondriac': Intimate partner violence survivors' experiences addressing depression and pain . Journal of General Internal Medicine , 23 ( 8 ), 1157–1163. 10.1007/s11606-008-0606-0 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nutbeam, D. , & Harris, E. (2004). Theory in a nutshell: A practical guide to health promotion theory . McGraw‐Hill. [ Google Scholar ]
• Nyame, S. , Howard, L. M. , Feder, G. , & Trevillion, K. (2013). A survey of mental health professionals' knowledge, attitudes and preparedness to respond to domestic violence . Journal of Mental Health , 26 , 536–543. 10.3109/09638237.2013.841871 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Othman, S. , Goddard, C. , & Piterman, L. (2014). Victims' barriers to discussing domestic violence in clinical consultations: A qualitative enquiry . Journal of Interpersonal Violence , 29 ( 8 ), 1497–1513. 10.1177/0886260513507136 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Peckover, S. (2003). 'I could have just done with a little more help': An analysis of women's help‐seeking from health visitors in the context of domestic violence . Health and Social Care in the Community , 11 ( 3 ), 275–282. 10.1046/j.1365-2524.2003.00423.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Petticrew, M. , & Roberts, H. (2003). Evidence, hierarchies, and typologies: Horses for courses . Journal of Epidemiology & Community Health , 57 , 527–529. 10.1136/jech.57.7.527 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Plichta, S. B. , & Abraham, C. (1996). Violence and gynecologic health in women <50 years old . American Journal of Obstetrics and Gynecology , 174 , 903–907. 10.1016/s0002-9378(96)70323-x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pratt‐Eriksson, D. , Bergbom, I. , & Lyckhage, E. D. (2014). Don't ask don't tell: Battered women living in Sweden encounter with healthcare personnel and their experience of the care given . International Journal of Qualitative Studies on Health and Well‐Being , 9 , 23166. 10.3402/qhw.v9.23166 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Radford, L. , & Hester, M. (2006). Mothering through domestic violence . Jessica Kingsley Publishers. [ Google Scholar ]
• Reid, K. , Flowers, P. , & Larkin, M. (2005). Exploring lived experience . The Psychologist , 18 ( 1 ), 20–23. [ Google Scholar ]
• Reisenhofer, S. , & Seibold, C. (2013). Emergency healthcare experiences of women living with intimate partner violence . Journal of Clinical Nursing , 22 ( 15/16 ), 2253–2263. 10.1111/j.1365-2702.2012.04311.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rimmer, A. (2017). Domestic violence is poorly covered in medical training, study finds . British Medical Journal , 359 , j4646. 10.1136/bmj.j4646 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rishal, P. , Joshi, S. K. , Lukasse, M. , Schei, B. , & Swahnberg, K. ; ADVANCE Study Group . (2016). 'They just walk away' – Women's perception of being silenced by antenatal health workers: A qualitative study on women survivors of domestic violence in Nepal . Global Health Action , 9 , 31838. 10.3402/gha.v9.31838 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Robinson, L. , & Spilsbury, K. (2008). Systematic review of the perceptions and experiences of accessing health services by adult victims of domestic violence . Health and Social Care in the Community , 16 ( 1 ), 16–30. 10.1111/j.1365-2524.2007.00721.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rodriguez, M. A. , Quiroga, S. S. , & Bauer, H. M. (1996). Breaking the silence: Battered women's perspectives on medical care . Archives of Family Medicine , 5 , 153–158. 10.1001/archfami.5.3.153 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rose, D. , Trevillion, K. , Woodall, A. , Morgan, C. , Feder, G. , & Howard, L. (2011). Barriers and facilitators of disclosures of domestic violence by mental health service users: Qualitative study . The British Journal of Psychiatry , 198 ( 3 ), 189–194. 10.1192/bjp.bp.109.072389 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rounsaville, B. , & Weissman, M. (1977–1978). Battered women: A medical problem requiring detection . International Journal of Psychiatry and Medicine , 8 , 191–201. 10.2190/cdhj-dplg-183q-t0b8 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Salmon, D. , Baird, K. M. , & White, P. (2015). Women's views and experiences of antenatal enquiry for domestic abuse during pregnancy . Health Expectations , 18 ( 5 ), 867–878. 10.1111/hex.12060 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Schei, B. , & Bakketeig, L. S. (1989). Gynaecological impact of sexual and physical abuse by spouse. A study of a random sample of Norwegian women (see comments) . British Journal of Obstetrics & Gynecology , 96 ( 12 ), 1379–1383. 10.1111/j.1471-0528.1989.tb06298.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Spangaro, J. , Herring, S. , Koziol‐Mclain, J. , Rutherford, A. , Frail, M. , & Zwi, A. B. (2016). 'They aren't really black fellas but they are easy to talk to': Factors which influence Australian aboriginal women's decision to disclose intimate partner violence during pregnancy . Midwifery , 41 , 79–88. 10.1016/j.midw.2016.08.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Spangaro, J. , Koziol‐McLain, J. , Zwi, A. , Rutherford, A. , Frail, M. , & Ruane, J. (2016). Deciding to tell: Qualitative configurational analysis of decisions to disclose experience of intimate partner violence in antenatal care . Social Science & Medicine , 154 , 45–53. 10.1016/j.socscimed.2016.02.032 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Spangaro, J. M. , & Zwi, A. B. , & Poulos, R. G. (2011). “Persist, persist”: A qualitative study of women's decisions to disclose and their perceptions of the impact of routine screening for intimate partner violence . Psychology of Violence , 1 ( 2 ), 150–162. 10.1037/a0023136 [ CrossRef ] [ Google Scholar ]
• Sundborg, E. M. , Saleh‐Stattin, N. , Wandell, P. , & Tornkvist, L. (2012). Nurses' preparedness to care for women exposed to intimate partner violence: A quantitative study in primary health care . BioMed Central Nursing , 11 , 1. 10.1186/1472-6955-11-1 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Taft, A. , Broom, D. H. , & Legge, D. (2004). General practitioner management of intimate partner abuse and the whole family: A qualitative study . British Medical Journal , 328 , 618–621. 10.1136/bmj.38014.627535.0b [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Taylor, J. , Bradbury‐Jones, C. , Kroll, T. , & Duncan, F. (2013). Health professionals' beliefs about domestic abuse and the issue of disclosure: A critical incident technique study . Health & Social Care in the Community , 21 ( 5 ), 489–499. 10.1111/hsc.12037 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Trevillion, K. , Agnew‐Davies, R. , & Howard, L. M. (2011). Domestic violence: Responding to the needs of patients . Nursing Standard , 25 ( 26 ), 48–56. 10.7748/ns2011.03.25.26.48.c8371 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Trevillion, K. , Corker, E. , Capron, L. E. , & Oram, S. (2016). Improving mental health service responses to domestic violence and abuse . International Review of Psychiatry , 28 , 423–432. 10.1080/09540261.2016.1201053 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Trevillion, K. , Hughes, B. , Feder, G. , Borschmann, R. , Oram, S. , & Howard, L. M. (2014). Disclosure of domestic violence in mental health settings: A qualitative meta‐synthesis . International Review of Psychiatry , 26 ( 4 ), 430–444. 10.3109/09540261.2014.924095 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wallin Lundell, I. , Eulau, L. , Bjarneby, F. , & Westerbotn, M. (2018). Women's experiences with healthcare professionals after suffering from gender‐based violence: An interview study . Journal of Clinical Nursing , 27 ( 5/6 ), 949–957. 10.1111/jocn.14046 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wong, S. L. F. , Wester, F. , Mol, S. , Römkens, R. , Hezemans, D. , & Lagro‐Janssen, T. (2008). Talking matters: Abused women's views on disclosure of partner abuse to the family doctor and its role in handling the abuse situation . Patient Education and Counseling , 70 ( 3 ), 386–394. 10.1016/j.pec.2007.11.013 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization . (2013a). Global and regional estimates of violence against women. Prevalence and health effects of intimate partner violence and non‐partner sexual violence . Retrieved from http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf [ Google Scholar ]
• World Health Organization . (2013b). Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines . Retrieved from http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf [ PubMed ] [ Google Scholar ]
• Yam, M. (2000). Seen but not heard: Battered women's perceptions of the ED experience . Journal of Emergency Nursing , 26 ( 5 ), 464–470. 10.1067/men.2000.110432 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zaher, E. , Keogh, K. , & Ratnapalan, S. (2014). Effect of domestic violence training: Systematic review of randomized controlled trials . Canadian Family Physician , 60 ( 7 ), 618–624. 10.1037/e529382014-198 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zink, T. , Jacobson, C. J. , Regan, S. , & Pabst, S. (2004). Hidden victims: The healthcare needs and experiences of older women in abusive relationships . Journal of Women's Health , 13 ( 8 ), 898–908. 10.1089/jwh.2004.13.898 [ PubMed ] [ CrossRef ] [ Google Scholar ]