Strategies against domestic violence and its consequences amongst Iranian women: A review study

Background and aims: Domestic violence against women is a problem that might cause irreparable damage to women’s health. This study aims to review the studies on the strategies regarding domestic violence against women in Iran. Methods: This study is a narrative review of published articles on strategies to prevent domestic violence against women in Iran from 2009 to 2019. Two scholars on valid databases searched. Articles were selected based on the time and setting of studies, purpose, and research structure framework. The full text of the articles and the publication language were included in the study. The quality of the articles was assessed using the “ checklist of original research articles ,” which comprises five sections; the structure of the abstract, the title and introduction, the review method, the results, the conclusion, and the keywords. The general opinion of the reviewer was also taken into consideration. Results: 13 eligible articles were reviewed, including 11 in Persian and 2 in English. The finding of the reviews indicated the interventions implemented to reduce and prevent domestic violence against women in Iran. These interventions focused on life skills in three categories (a) Communication and Interpersonal Skills (such as resilience based on spirituality, mindfulness techniques, motivational interview, and emotionally focused couple therapy), (b) decision-making and critical thinking skills, including problem-solving, decision-making, narrative exposure therapy, and conflict resolution related to domestic violence against women), and (c) coping and self-management skills (such as anger management, marital adjustment, and self-defense). Conclusion: The effective implementation of life skills can serve as practical methods to prevent domestic violence against women.


Introduction
Violence against women appears in different situations, forms, and manifestations.Domestic violence or intimate partner violence is the most common form against women (1).Domestic violence against women is considered a violation of human rights (2) and has been reported as one of the most severe social problems that transcend cultural, social, and regional boundaries (3).Laws to prohibit violence against women have been approved in most countries, but the significant statistics of this social problem have been globally demonstrated, including in Iran (4).Domestic violence is any incident or behavior associated with physical (5), sexual, financial, or emotional threat, violence, and abuse (6).The World Health Organization (WHO) classifies domestic violence as interpersonal violence.It states that domestic violence encompasses any behavior carried out against a woman in any marital status, whether legal or illegal, with the intent to gain or exercise power (4).Domestic violence is the most frequent and prevalent type, yet it is the least reported to the police, leading to the highest social, emotional, and economic consequences.According to WHO reports, the prevalence of domestic violence ranges from 15% in Japan to 71% in rural areas of Ethiopia.Additionally, partners are responsible for 40% to 70% of women who are murdered (7).In the United States, two million women are physically raped by their husbands, resulting in 73 000 hospitalizations and 1500 deaths (8).Obtaining accurate statistics about the prevalence of domestic violence against women in Iran is difficult due to the cultural belief that violence is a private matter, discouraging women victims from speaking out and raising awareness in society (1).Furthermore, official sources in society are reluctant to collect and disclose official statistics in this field.However, survey research in Iran revealed that 66% of Iranian women had experienced domestic violence at least once (1).
Among the underlying causes of violence against Fighting domestic violence against women Iranian women in the last 11 years are psychological and economic problems, alcohol abuse, COVID-19, education level, family conflicts, women's age, husband's occupation or women's employment, type of marriage (forced or voluntary), the experience of parental violence in childhood, quality of married life, differences in cultural education, family patriarchy, religious beliefs, and the criminal history of the spouse can be mentioned (9).Factors influencing domestic violence against women also include sexual dissatisfaction (10), low family and social support, economic dependence, social attitudes toward violence and women, lack of awareness of available resources (11), and power inequality within the family (12).The types of domestic violence include mentalemotional, physical, and sexual violence.Mentalemotional violence refers to humiliation and control over the victim's behaviors, inhibiting awareness of daily issues, isolating the person from society, and interfering with relationships with family and relatives.Physical violence involves using force to harm, injure, or kill the victim.In contrast, sexual violence includes using physical force to engage in sexual behaviors against the victim's will or attempting to have intercourse with disabled individuals (8).The results of one study conducted in 28 cities in Iran showed that 66% of women had experienced domestic violence at least once in their marriage (8).It was also reported that emotional violence is the most prevalent type at 81.8%, followed by sexual and physical violence (10).
Violence against women affects their physical and mental health.It has also been recognized as a public health problem (7,11).The physical consequences of violence against women include murder, recurrent injuries, and neurological symptoms such as migraines, headaches, pain syndromes, abdominal pain, arthritis, coronary heart disease, stomach ulcers, and other gastrointestinal disorders (11,12).Additionally, domestic violence can lead to other unpleasant effects and gynecological problems such as pelvic inflammatory disease, painful sexual intercourse, AIDS, sexual harassment, vaginal bleeding, pelvic pain, and urinary tract infection (7,(11)(12)(13).
Victims primarily experience the negative consequences of violence as psychological symptoms, including anxiety, depression, suicidal ideation, fear, obsession, low selfesteem, post-traumatic stress disorder (PTSD), feelings of worthlessness, and engaging in high-risk behaviors such as smoking and addiction.They may also face difficulties raising children and cannot fulfill their critical roles within the family and community.These individuals might exhibit behaviors such as running away from home, child abuse, corruption, suicide, or attempting to murder their spouse (8,11).
In Iran, women are expected to preserve their family's honor by keeping their problems within the family, and they are often advised to tolerate any difficulties in their marriage and resolve problems by themselves (14).
Violence and divorce have a two-way relationship, with effects that include a reduction in women's self-confidence, the prevalence of constant fear and worry when dealing with and facing problems, an increase in deviant behavior in the city, statistics related to children of divorce, damages caused by the lack of proper educational supervision by parents due to behavioral crises towards their children, involvement with judicial and family courts, and delays in processing filed cases.In judicial courts, one of the negative consequences of divorce caused by men's violence against women is the serious harm it causes to others.(15) Divorce can have financial, social, and emotional consequences, especially for women.Therefore, women might prefer to stay in an abusive relationship for different reasons, such as fear of defamation, losing custody of their children, lack of social and legal support, and pressure from social norms that stigmatize divorce (16).
Several strategies have been implemented to cope with violence against women, including educational, legal, and supportive approaches.These strategies involve providing psychoanalytic training for men and women, empowering families to enhance their skills in addressing spousal violence, raising awareness and educating the community, improving premarital education, and modifying existing laws (10,17).
According to Ansari et al, promoting communication skills among women can help reduce violence against them (18).Khalili et al also found that implementing instructional interventions significantly reduced psychological anxiety among pregnant women who experienced violence (19).Cognitive-behavioral interventions have been effective in reducing anxiety and depression and increasing self-esteem among women who have experienced violence (20).Additionally, Tiwari et al demonstrated that supportive training sessions could improve mental health among Chinese women (21).
The health and welfare of women are recognized as fundamental human rights, and they are believed to impact the health and well-being of families and society.Domestic violence is currently one of the most significant and distinct forms of human rights violations, and unfortunately, women are not immune to this type of violence.Women who are victims of domestic violence cannot fulfill their crucial roles in the family and society, and they may engage in negative behaviors such as running away from home, child abuse, sexual misconduct, suicide, or even harming their spouse.This comprehensive review aims to investigate strategies against domestic violence and its consequences for Iranian women.The study seeks to provide a foundation for selecting and implementing appropriate and effective interventions, offering researchers better solutions to prevent harm to families and society.

Materials and Methods
This narrative review study was conducted from October to December 2019.To access studies on strategies regarding domestic violence against Iranian women, the researchers conducted an electronic search using keywords such as violence, domestic violence, spouse abuse, intimate partner abuse, women, and Iran in the Scopus, PubMed, Web of Science, Embase, Magiran, and SID databases from 2009 to 2019.Boolean connectors and truncation symbols "OR" and "AND" were used to merge the terms and focus and expand the search.Articles were identified by evaluating the title and abstract for relevance to the review objective and then retrieving the full text for further assessment.The inclusion criteria included the time of research (2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018)(2019), setting of research (Iran), relevance to the purpose of the research, having a structured framework, access to the full text, intervention studies (random and non-random clinical trials, and clinical trials without a control group), and publications in Persian and English.The quality of included studies was independently evaluated by two reviewers using criteria adapted from validated tools.The checklist for original research articles (RCTs and Quasi-experiment) was used to evaluate the quality of these articles.This checklist contains 31 questions in 5 sections: a) the structure of the abstract, title and introduction (10 points), the review method (27 points), the results (13 points), the conclusion (12 points), the keywords (3 points) and the general opinion of the reviewer (20 points), the total score of the checklist is 85 (22).Reviewers compared scores and resolved disagreements before allocating a final appraisal score.Moreover, in terms of quality, the articles were divided into three categories of good (with more than 75% of the total score), moderate (with 50% to 75% of the total score), and poor (less than 50% of the total score).In the current study, only good articles with more than 75% of the total score were included (23).The quality assessment results are presented in Table 1.

Results
A total of 483 articles were assessed; eventually, 13 articles (11 articles in Persian and two in English) were selected for the review process.The characteristics of these articles are presented in Table 2.
The findings of the reviews showed that the interventions to reduce and prevent domestic violence against women in Iran significantly rely on life skills.Among all the articles studied, only one investigated the effectiveness of general life skills training (32), while 12 highlighted the impact of specific life skills-related interventions on domestic violence against women.In the reviewed articles, the interventions were designed based on life skills.Therefore, the WHO classification was used to classify the results and assigned them into three categories: (a) communication and interpersonal skills, (b) decision-making and critical thinking skills, and (c) coping and self-management skills (29) as follows:

a. Communication and interpersonal skills
Amongst the articles under review, only one article (7.69%) investigated the impact of educational intervention on general life skills, including communication and interpersonal skills such as the relationship with spouse and self-confidence on domestic violence.Eight articles (61.53%) focused on interventions based on individual skills (resilience based on spirituality, mindfulness techniques, motivational interview, self-efficacy, and selfesteem) as well as interpersonal skills (emotionally focused couple therapy).These interventions, conducted through education, counseling, group discussion, interviews, empirical demonstrations, and movies, significantly reduce domestic violence and its consequences, such as anxiety, stress, and general health.In other words, self-awareness, learning techniques to control emotions, resolving doubts and ambivalence, learning coping strategies, increasing self-esteem, and establishing an empathetic relationship with one's spouse can effectively reduce intimate partner violence.

Discussion
In recent decades, the primary prevention of domestic violence against women, identification of abused women, and management of these cases have been women's health priorities in many countries.Various interventions, including educational, supportive, and legal solutions, have been designed and implemented to address this significant problem of women's health properly.One of the main strengths of this study is the summation of various studies and the simultaneous presentation of proposed solutions regarding this social and health problem.However, one limitation of this study is that it only summarizes published findings.The findings of the reviews demonstrate that the interventions to reduce violence and improve the consequences of violence against women in Iran are largely based on life skills.These strategies were divided into three areas, (a) Communication and interpersonal skills, (b) decisionmaking and critical thinking skills, and (a) coping and self-management skills (37).They will be examined as follows:

a. Communication and interpersonal skills
These skills belong to a group of skills that the individuals acquire, contribute to social acceptance, and lay the foundations of healthy behavior and social relationships (37,38).The studies show that spouses with good communication skills can effectively control their partner's undesirable behavior and improve their behavior.Additionally, communication skills can help increase the level of agreement between the spouses and foster intimacy within the family (39).Therefore, women must learn communication skills, particularly how to communicate with their spouses, to eliminate domestic violence.Ansari et al showed that strengthening women's communication skills can help reduce violence, especially physical violence (18).The acquisition of general life skills is considered one of the components of communication and interpersonal skills.These abilities enable individuals to act positively, adapt to relationships with others, their community, culture, and environment, and maintain their mental health.Learning life skills increases selfesteem, promotes rational expression of thoughts and feelings, reduces anxiety, improves social communication skills, fosters consideration for the rights of others, and helps individuals assert their rights, ultimately leading to increased life satisfaction and happiness (30).Previous research indicates the effectiveness of life skills on satisfaction among young couples (40) and rural married women (41).
Resilience is one of the essential interpersonal skills for coping with higher stress levels.Resilience helps individuals assess and manage stressful situations by adopting rational solutions, leading to feelings of satisfaction and self-confidence.Sincere and optimist individuals committed to religious principles are usually more resilient (25).Hamid et al conducted a study that showed that religion-based cognitive-behavioral therapy helped reduce depression among divorced women (42).

Mindfulness-based technique
Mindfulness allows individuals to respond to events and incidents thoughtfully rather than spontaneously (43).Mindfulness-based therapy significantly impacts the treatment and prevention of the recurrence of anxiety and depression; mindfulness exercises can also change mental patterns and improve mental health (26).The results of another study by Basharpoor and Jani reported that mindfulness and emotional suppression are considered influential factors in depression and anxiety among women who have experienced violence (43).Moreover, related research indicates the effectiveness of mindfulness in reducing social anxiety, increasing resilience and regulating emotions in women who are victims of domestic violence (26), and increasing marital satisfaction (44).

Motivational interview
Motivational interviewing is considered one of the most effective treatments for reducing violence.Moser and Murphy stated that conducting motivational interviews lead to behavioral changes, such as improving responsibility and controlling the physical behavior in individuals with violent behavior (28).Zalmanowitz et al demonstrated the effectiveness of motivational interviewing on men involved in domestic violence.Their results showed that motivational interviewing effectively changed the violent behavior of the men studied (45).

Marital adjustment test
The findings showed that teaching life skills significantly affects the enhancement of marital adjustment (P < 0.001).Besides, the results of the present study indicated that teaching life skills and anger management has led to a significant decrease in domestic violence amongst the study population (P < 0.001).
Porzoor et al Shiraz 2018 (25) Examining the effectiveness of a Spiritual Intervention on the personal and social resiliency of women victims of domestic violence.The findings showed a significant difference between the pre-test scores in the intervention and control groups regarding marital satisfaction and tendency toward marital infidelity (P < 0.05).Given the current study's findings, it could be asserted that emotionally focused couple therapy might improve marital satisfaction and reduce the tendency toward marital infidelity amongst women who experienced intimate partner violence.

Semi
Aslani et al Ahvaz 2016 (28) Determining the effectiveness of Motivational Interviews (MI) in reducing violence against women referred to courts, dispute resolution councils, and counseling centers in Ahwaz.

Empirical design with post-test in intervention and control groups
Available sampling N = 20

Violence against women questionnaire
The findings showed that motivational interviewing reduces physical violence (F = 6.33,P = 0.02) and psychological violence (F = 40, P = 0.00) against women.However, there was no significant difference between sexual violence (F = 3.02, P = 0.10) and economic violence (F = 0.83, P = 0.54).There was a significant decrease in domestic violence after the intervention (-11.25 vs. -1.62,P < 0.001).Besides, family functioning also improved after the intervention compared to the control group (6.25 vs. -1.69,P = 0.001).The study's findings indicated that educational interventions significantly reduced the mean score of public health amongst the study population (P < 0.05).Also, there was a statistically significant decrease in the frequency of general violence and its aspects, including verbal violence, physical and sexual violence (P > 0.05).

Basharpoor et al
Fighting domestic violence against women

b. Decision-making and critical thinking skills
Individuals learn how to analyze the impact of their own and others' values on their decision-making process and the solutions they choose (38).

Problem-solving training
Problem-solving skills aim to find practical solutions for maintaining a healthy interpersonal relationship.Successful problem-solving reduces incompatibility and increases positive adaptation.According to evidence, couples may encounter problems in their marital relationships.Therefore, it is necessary to acquire problem-solving and coping skills to avoid conflicts and intimate partner violence.Positive problem-solving and communication skills are considered essential components of a healthy family.They can reduce conflicts, promote positive family relationships, and help families cope with internal and external stressors (55).Alamshahi et al examined the effect of problem-solving-based group counseling on the experience of violence against pregnant women.They reported that such counseling sessions significantly reduced the rate of domestic violence against pregnant women (56).
Furthermore, motivational interviewing helped reduce depression symptoms among women who experienced domestic violence (46).

The emotionally focused couple therapy
Emotionally focused couple therapy is one of the practical approaches to resolving marital problems.According to this treatment model, emotions have an inherently adaptive capacity that, when activated, can help couples change their undesirable emotional expressions.Various studies investigated and confirmed the effectiveness of emotionally focused couple therapy in improving depression and increasing the quality of marital relationships (47), enhancing marital satisfaction and managing family behavior (48), increasing sexual satisfaction in couples (49), improving couples' communication patterns (50), reducing marital exhaustion (51), Improving marital adjustment and quality of life amongst infertile couples (52), and alleviating symptoms of depression and PTSD caused by extramarital relationships (53).Additionally, the results of a metaanalysis conducted in 2019 showed that emotion-oriented couple therapy interventions significantly reduced marital problems (54).

Decision-making training
Decision-making skills help individuals choose and implement the best solution from various options, considering sufficient information, awareness, and realistic goals and accepting the consequences (38).

Conflict resolution training
Learning how to manage conflicts effectively is crucial for building strong relationships.Accordingly, in a win-win relationship, each spouse takes responsibility and seeks common ground, increasing intimacy and trust (57).
Previous studies have indicated that teaching effective conflict solution strategies can help reduce emotional reactions, including depression and aggression among women (57).
Narrative exposure therapy Narrative exposure therapy (NET) is an evidencebased, short-term treatment designed to address the repercussions of exposure to accumulative and multiple types of traumas, mainly among victims of war, torture, and organized violence.Several studies showed the efficacy and feasibility of NET in reducing PTSD symptoms and depression and improving daily function and physical health (36).

c. Coping and self-management skills
These skills help to enhance the basis of internal control, allowing individuals to learn that they can influence others and make a difference.Using coping skills to deal with violence could reduce its psychological outcomes (38).The coping and self-management skills reviewed in the current study include anger management, marital adjustment, and self-defense.

Anger management
Anger management could reduce the incidence of violent behavior among family members.It prevents adverse consequences in all aspects of life and has been identified as a health priority requiring skill acquisition (32).McFarlane et al showed that providing instructions and educating the women referred to the American Urban Domestic Violence Legal Unit (AUDVLU) could significantly affect the reduction of threats and physical violence (58).

Self-defense training
Self-defense training prevents violence between couples and ultimately improves appropriate interpersonal interactions.These instructions involve learning the physical actions of simple and practical actions in small groups that could be used in an attack or a conflict when other defensive options are unavailable.Self-defense training provides women with a new set of decisive responses leading to fighting against intimidation, threats, and various forms of domestic violence (59).Sinclair et al examined the effectiveness of a self-defense program in reducing the incidence of sexual harassment among Korean girls.They reported that respective training could reduce the occurrence of sexual harassment (60).Moreover, the results of another study by Hollander indicated that empowerment based on self-defense education helps change the underlying conditions that increase violence against women (59).

Marital adjustment
Marital adjustment is considered one of the most critical factors influencing family functioning.It also affects the quality of parental functioning, life expectancy, health, life satisfaction, loneliness, growth, upbringing of children, social relationships, and the tendency toward social deviations.Couples that communicate effectively use constructive methods to resolve problems and conflicts.
Learning life skills increases rational expression of thoughts and feelings, reduces anxiety, improves social communication skills and consideration for the rights of others, and at the same time, helps pursue their rights, eventually increasing marital compatibility and happiness (30).Previous research indicates the effectiveness of life skills on satisfaction among young couples (40) and rural married women (41).Nurses, as an essential part of the healthcare team, could identify the causes of domestic violence against women through careful analysis of the families.They could also modify or eliminate such factors independently or with the family's cooperation, especially the spouse and other healthcare team members, to benefit from the appropriate solutions such as training, consultation, or referral to the related resources.However, the limitations of this review study are the low quality of some of the articles and the need for more access to some scientific evidence that is under publication.
Intimate partner violence was reported as a social problem and a significant concern in Iran, and it is still viewed as a private issue.Inadequate domestic violence legislation and limited access to emergency accommodation for temporary leave force intimate partner violence exposed to suffer in silence (36).To understand the seriousness of this problem, it must be considered that the female population constitutes 49.7% of the total population in Iran.Hence, the consequences of this violence affect the whole society (61).
The current study's results could be applicable in training healthcare providers dealing with the women victims of intimate partner violence.These findings could also help caregivers, advocators, and policymakers design efficient care packages for abused women.

Conclusion
This review study showed that using and training life skills in various dimensions can effectively reduce domestic violence against women and improve its consequences.Utilizing communication and interpersonal skills such as resilience based on spirituality, mindfulness techniques, Fighting domestic violence against women motivational interview, and emotionally based couple therapy, decision-making skills, and critical thinking, including problem-solving, decision-making, narrative exposure therapy, and conflict resolution regarding domestic violence against women, can be considered effective strategies to prevent domestic violence.As additionally, coping and self-management skills such as anger management, marital adjustment, and self-defense, are also effective in addressing domestic violence against women.
of life skill education program on the decline of domestic violence and general health score.

Table 1 .
Quality assessment of reviewed studies based on a checklist of original research articles

Table 2 .
Characteristics of the reviewed articles