Reviewing the effect of two methods of educational package and social inoculation on changing the attitudes towards domestic violence against women

Abstract

BACKGROUND:

Domestic violence (DV) is a serious problem all over the world which had been extended to boundaries of countries, economical, cultural and racial classes. 10-69 percent of women are exposed to physical, sexual and emotional violence which has numerous physical and emotional consequences. Therefore, males’ attitude towards women is one of the strongest predicting factors of violence against women, so one of the ways to remove the violence against women is to change the men's attitude. Changing the attitude, in the basic stages of the marriage for couples who are not yet involved with marital misunderstandings, will probably influence their future relationships, therefore, the present study reviewed two attitude changing methods of educational package (EP) and social inoculation (SI) which were used to change the attitude among male volunteers participating in the premarital counseling classes.

METHODS:

This was a semi-experimental study aimed to determine the influence of two methods of supplying EP and SI on the change of attitude toward DV against women. The study subjects included male volunteers participating in Isfahan Molla Hadi Sabzevari Premarital Counseling Center, where the attitudes of 183 subjects were investigated primarily using simple sampling method. Ninety-nine subjects who had positive attitude toward DV were selected and then, randomly distributed into three 33-subject groups. The first was SI group, the second was EP supply group and the third was the control group. Data collection tool was an evaluating questionnaire of the attitude toward DV against women which consisted of two parts, demographic data and 34 attitude evaluating questions. Scientific validity was determined by content validity method and scientific reliability was determined using Cronbach's alpha. Analyzing the data was done using descriptive (frequency and mean), analytical statistical methods (paired-t, independent t-tests, ANOVA, Duncan, Kruskal-Wallis and chi-square) and SPSS software.

RESULTS:

Among 183 participants, 99 of them (54%) had a positive attitude with an average score of 46.5 and 84 of them (45%) with an average score of 29 had a negative attitude toward violence against women. Before the intervention, the highest violence attitude was in emotional, physical and sexual areas, respectively. After the intervention in the inoculation group, the highest attitude changes were in physical, sexual and emotional areas, respectively and in the EP group, in total the attitude changes score after the intervention was significant compared to prior to it, although changes were observed only in physical and sexual areas. In SI group, more attitude changes were occurred than that in EP group. In control group, the attitude score after the intervention had no significant change compared to it before.

CONCLUSIONS:

Although attitude change has no guaranty for changing the behavior, in order to change the behavior, changing the attitude is required, in which for violence against women, it is better to be started at the beginning of the marital relationship. The SI method has been successfully applied in psychology Sciences and the health programs, but the EP method is not an effective method on its own to change the attitude, so it is better to be accompanied by other methods like group discussion, etc.

Domestic violence (DV) is a serious problem all over the world which is spread to the borders, social, economic, cultural, racial and ethnic classes.¹ In 2008, spouse abuse in Isfahan was reported at 17%.² Moreover, Jahanfar pointed out in one of the studies and announced that the percentage of Iranian women who were abused physically and psychologically by their husbands was 60.6%. He also believed that the prevalence of violence of Iranian men against women is much more than this phenomenon in other countries which is 15% physically, 61% psychologically and 24% sexually.³ Domestic violence is considered as the real violence or threat of violence in physical, sexual or psychological areas by the current or ex-sex partner.⁴ Violence would leave long-term adverse consequences for its survivors which will be continued even after the violent period. Adverse health conditions, poor quality of life and additional using of health care services are some of the effects of violent.⁵ But, what seems more destructive is the impact of this destructive violence on the future generation.¹ Violence among the parents would put children at the risk of behavioral, emotional and cognitive problems.⁶ In Iran, the attitude of men towards women in one hand, and women's attitudes towards their abilities and expectations on the other hand has led to incomplete observation of human rights in all its aspects to achieve gender equality. Inappropriate and insufficient legal safeguards and protection for the elimination of all forms of discrimination and violence against women has been one of the legal challenges in Iran. Besides, one of the future strategies is continuous efforts to change men and women's attitudes towards the women's role.⁷ it is known to all that premarital counseling has an important role in this regard and it is necessary to have channels to introduce appropriate, deliberate and proportionate training for the needs of young people in marriage and mental health.⁸ Premarital counseling means a reciprocal relationship between consultant and the couples in which the consultant in person tries to explain the acceptance of communication issues, social skills and define the hide emotions and feelings lies in the marriage.⁹ Most of the Iranian women have experienced their first husband's violence at the same period of engagement and marriage; one of the causes of this violence is the man’ power control over woman. It should be admitted that one of the strongest predictors of domestic violence against women is the attitude of men towards domestic violence against women.¹⁰ The attitude of men towards women should be changed and women should help men to revise their understandings toward them.¹¹ By knowing people's attitudes, their behaviors could be predicted and controlled. Although attitudes have considerable stability and persistence, there are some techniques introduced in psychology to change the attitudes.¹² Theory of “learning patterns” includes stimulus response theory, theory of incentives and aggressions, “cognitive patterns” theory includes theories of balance, consensus, harmony, cognitive and social judgments, and finally the “functional pattern” theory in which somewhat considerations of the interstitial aspect of learning patterns, learning and cognitive and response stimuli. Most of the time, attitude changing is temporary, and sometimes a strong resistance would be revealed against the change.¹³ Researchers, in the field of attitude change, are emphasizing on active transformation, expansion and arguments production rather than passive accepting. In fact, production and preparation of the arguments causes more changing attitudes rather than passively listening to the same arguments. Inoculation Theory of McGuire (1964) is focusing on resistance to persuasion and also emphasizing on the active thinking processes role. Presenting the outcome of a message, in a subject that opposed arguments are also available, will “vaccinate” the audience against future attacks which threaten the conclusion, so that an individual's cognitive system similar to body's immune system might be immunized against a full-blown counter attitude arguments by showing a weak version of the message from the counter attitude. Inoculation would be useful especially in the cases of beliefs which are kept in an ideological “germ-free” environment. This theory has been supported and confirmed in a large number of independent tests. Furthermore, theory-based measures and interventions successfully have been used in inoculation theory in the health education programs.¹⁴ In fact, ascending the knowledge that is underpinning the attitude can lead to increase the negative attitude to the positive attitude.¹⁵ This method has focused on the facilitating learning¹⁶ and emphasized the comprehensive active role in understanding and perception of the topics,¹⁷ and in comparison with social inoculation method requires no constant presence of the specialized force. According to the studies conducted in Iran, domestic violence is a common phenomenon and so far, there has not been any study done to evaluate the methods to change the attitudes in this area and considering that social inoculation method causes more stable changes due to active thinking and reasoning and unlike the educational package, it does not require the presence of professional and specialized force; therefore, this study aimed to evaluate the effect of two methods of attitude changing, i.e., educational package and social inoculation on changing the attitudes of the marriage male volunteers towards violence against women.

Methods

This was a triple group, three-step semi-experimental study which was conducted in Isfahan Molla Hadi Sabzevari Premarital Counseling Center in 2009. The study population included the entire male marriage volunteers who were referred to the center during the data collection period. The inclusion criteria included being at the first marriage and having at least primary literacy to complete the questionnaire. The exclusion criterion simply was lack of tendency to participate. Considering that the visitors who referred to this center were random and from all regions of Isfahan; therefore, the sampling was performed by the simple sampling method through the computer list of the volunteers’ names. Based on the sample size formula, 96 subjects were estimated to gather. Data collection tool was a researcher-made attitude survey questionnaire about the violence against women which had been developed using the books and articles related to the research topic. It consisted of two parts; the first part as demographic characteristics included age, education level, type of educational license, occupation, income, living with parents or others. The second part of the questionnaire included 34 “attitude survey” questions about domestic violence against women and three areas of physical, emotional and sexual harassment (control, neglect). The attitude questions were in compliance the Likert scale, i.e., the questions were five-degree questions and the range of the responses began with “strongly disagree” and afterwards ended with “strongly agree”. Scoring method for the attitude questions was as follows score1 for “strongly disagree” and consecutively to score5 for “strongly agree”. In cases which direction of the sentences was opposed to the subject of attitude, score 5 was given to the “strongly disagree” and in cases which direction of the sentences was agree with the attitude subject, score 5 was given to the “strongly agree”. Totally, the score range was between 34 to170; 34 represented the complete opposition with the domestic violence attitude and 170 represented the complete agreement attitude towards domestic violence. Meanwhile, those who had chosen “I have no idea” were people with neutral attitude. After completing the questionnaires and conducting the pre-test, 99 subjects (based on the predetermined sample size) who were agreed with domestic violence randomly divided into three equal groups. Cutting line of determining the people with agreed attitude with domestic violence was calculated through this relationship (2.5 > number of the questions/total of the scores). According to this relationship, those who obtained scores 85-170 had positive attitude towards domestic violence and those who had neutral attitudes or against the domestic violence (score > 85) were excluded from the study. After reviewing the results of the first test (pre-test), using the cutting line and the obtained score, the subjects with agreement attitude towards domestic violence were selected as the determined number of samples, i.e., 96 subjects. For loss probability, 5 other people were added at each group. Therefore, the total number of the samples reached to 111. Due to sample loss before the intervention (incompleteness of the questionnaire or withdrawal from the study), finally 99 subjects remained who randomly were divided into three 33-subject groups (random selecting based on the questionnaires code). Presenting the educational package was done in order to conduct the intervention in the first group, i.e., a pamphlet about domestic violence against women (definition, types, effects, examples, and methods to fight against it) was prepared using books, articles and comments of the university faculty members (the sources are attached in the appendix). Meanwhile, pamphlet (package) concepts were according to the understanding rate of the participants. They were given the pamphlets and also were told that two weeks later, through a phone call they should participate in a meeting to resolve problems and during this time, the phone number of the researchers was given to them in case of any problem. Post-test was performed after two weeks. Social inoculation method was performed in order to conduct the intervention in the second group during five 1-hour sessions every other day. In each session, some phrases were raised about agreement attitude of domestic violence against women by the researcher and the audiences were asked to comment about them. The phrases had very weak reasoning logically in a way that even the opponents of violence against women were opposed to the discussed phrases. For example; “women do not have a high ability to think and should not make decisions about the common goals of men's life” or “if the woman failed to cook well, the husband should have a serious and violent behavior with her so she does not repeat it again” or “women should obey and behave according to their husband's taste for choosing the color of their clothes”. In each session, the participant of the study began to object, however sometimes they corroborated the statements and brought arguments for their comments. For example, in response to “cooking” some of them stated that “if that was her first time, that is OK, but if she repeats it, we should mention it to her but not with violence”. In response to “color of the wife's clothes and husband's taste”, most of them announced that it should be according to the husband's taste, but another group said it should be according to the both side's taste. A very few of them also mentioned that female taste is more important. At the end of each session they gained a relative equilibrium. These opposed arguments caused activation of the participants thinking power about domestic violence against women and changed their attitudes, and besides, caused these attitudes to be consolidated and sustained. Because, somehow inoculation had happened for them and this caused their resistance if later on they expose to have positive attitude towards domestic violence. One month after finishing the fifth session, post-test was implemented for the participants. The third group also received the usual interventions (participate in the premarital counseling classes). This group also received a post-test after a month along with other study subjects. Then, the obtained results of the pretest and posttests were compared in each group and also between the groups. Scientific validity of the questionnaire obtained through content validity, i.e., it was given to a number of faculty members of School of Nursing and Midwifery, Educational Sciences and Psychology. Then their comments and amendments were applied. To obtain scientific reliability of the instrument, the researcher in a pilot study, gave the complied questionnaires to 20 eligible subjects who had inclusion criteria, then using SPSS software Cronbach's alpha of 80% was accepted. It should be noted that participants of the pilot study were excluded from the study subjects. Analyzing the data was conducted using descriptive statistics (frequency distribution table, mean and standard deviation) inferential statistics (paired t-test, independent t-test, ANOVA, Duncan, Kruskal-Wallis and chi-square). The maximum error of 5% was considered for all the tests.

Results

The results of this study indicated that out of 183 volunteers, who at the beginning filled in the questionnaire, 99 of them (54.1%) had a positive attitude and 84 of them (45.9%) had a negative attitude against violence. Demographic characteristics of the participants showed that the mean age of subjects in the three groups was 25.1 years old (4.06) and most of them were self-employed (62.6%) and in term of educational levels, they were high school graduates (42.4%) and moreover lived with both parents (77.8%). The mean violence score in the group with a positive attitude toward violence was 46.5 (6) and in the group with negative attitude toward violence was 29 (5.4). ANOVA showed that the mean violence score before the intervention was no significantly different in any of the aspects between the three groups (p = 0.8). The most violence score in the three groups was related to the emotional area (54, 54.8 and 54). ANOVA and Duncan showed that attitude score about physical and sexual violence in the social inoculation (SI) group was less than that in the educational package (EP) group and it was lower in the package group than that in the control group. Furthermore, the mean attitude score about emotional violence in the SI group was significantly lower than that in the two other groups (p = 0.001). But, the mean attitude score in emotional violence was similar in EP and the control group (p = 0.643) and the mean total score of domestic violence in the SI group was lower than that in the two other groups but was similar in the EP and control groups. Comparing the results of attitude scores before and after the intervention in each group was conducted using paired t-test; in the SI group, the mean violence score was reduced significantly after the intervention in all the aspects (sexually, emotionally and physically) (p = 0.001). Besides, in the EP group the mean domestic violence attitude score in the emotional area showed no significant difference after the intervention compared with that before it, but there was a significant difference after the intervention compared with that before it in physical and sexual aspects (p = 0.005). Besides, there was no significant difference in the attitude scores of the control group after the intervention compared with that before it (p = 0.421) (Table 1). ANOVA and Duncan showed the comparison of the attitude changes score between the groups; the most change in attitude score in DV was related to the SI group and the maximum and minimum score reduction were related to the sexual and emotional aspects, respectively. Besides, the maximum and minimum score reduction related to the EP group was in physical and sexual aspects. But, no changes were observed in the emotional area; totally, the educational package was not very effective (Table 2).

Table 1.

Comparison of mean attitude scores before and after the intervention in each group

Table 2.

Comparing mean attitude changes score in domestic violence after the intervention compared with that before

Discussion

The results of the present study showed that the social inoculation method was effective on attitude changing of the marriage male volunteers in three emotional, sexual and physical aspects. And educational package was somewhat effective only on physical and sexual aspects. The mean attitude scores before the intervention in three groups showed that the attitude violence score in the emotional area was more than that in physical and sexual areas. Malek Afzali et al (2004)¹¹ in his study titled as “studying forms of domestic violence against women in Isfahan” found that the most common violence against women was psychological and verbal violence and subsequently sexual, economical and physical violence, respectively.

Krantz (2005)¹⁸ in a qualitative study titled as “intimate partner violence forms” that had asked about men and women attitudes about definition, forms and consequences of violence against women found that emotional and psychological violence were the most dominant and most serious forms of violence in marital relationships and the sexual violence rate was far less than emotional and psychological violence rates and verbal abuse and violence was very common among the urban and educated people. According to the results of these studies, emotional violence was more common than physical and sexual violence and this might be due to extension of the cases involved with the emotional issues; besides, emotional issue are so subtle that perhaps they are not that tangible and the individual may not understand his/her own violent behavior and knows it as part of his/her rights.

The mean attitude scores after the intervenetion in the three groups of the study showed that physical and sexual attitudes were lower in the SI group than that in the EP group and in the EP group was lower than that in the control group. Moreover, the mean attitude score in the emotional violence was similar in the EP and control groups. Foshee et al ¹⁹ in a study to change attitudes and performance of the high school male and female students about violence in the relationship between the sexual partners, used conflict management skill trainings. The next month follow-up, studying the performance of the intervention group showed 25% reduction in the emotional abuse, 60% reduction in sexual abuse and 60% reduction in physical abuse in comparison with the control group. Macgowan²⁰ in a study aimed to change attitudes of middle school girls and boys about commit violence in dating and enhance dispute resolution skills which was done in five 1-hour sessions through discussions and dispute and conflict resolution exercises and training problem solving skills. Macgowan found that there were knowledge and attitude changes in the intervention group compared with the control group in the posttest about non-physical violence, while there was no change in the physical violence attitude. The reason of difference between the results of this study and the present study about the attitude change in emotional and physical areas was the differences between the study subjects; because people's attitude in a marriage threshold is different from those in puberty age. It should be noted that as mentioned earlier, every preventive act and intervention about violence against women must be started from the early stages of choosing sex partners which considering the religion and culture of our country, this would begin with marriage. In the study of Foshee et al and the present study there was a resistance in attitude change in emotional area. The reason is that people are not born with their attitudes but, they acquire them in the childhood through experiences and would learn conditioning, patterning and direct experience and etc in which the most important role is played by family and the community. It is known by all that childhood acquisitions are very deep, rooted and sustained. The most important difference between the attitudes and values and beliefs is that attitude has an evaluating element. This means that it lies in the belief of being good or bad. Therefore, attitude is interrelated with culture and values of every society. That is why changing people's attitude should be started at the early stages of childhood which is the mission and task of the governments to enhance the children and their parents’ knowledge level through the media ultimately and also change their attitudes gradually. Comparing the mean attitude scores before and after the intervention in violence against women in each group showed that all the aspects (emotional, physical and sexual) were reduced in the SI group after the intervention compared with that before it. Furthermore, in the EP group, the mean attitude score after the intervention had a minute reduction comparing to that before it which was only in physical and sexual areas. There was no difference in the control group among the areas (Table 1). Abedi et al in a study titled as “evaluation and comparison the efficacy of negative attitude change methods towards mathematics in high school girl students in Isfahan” used three negative to positive attitude change methods including social inoculation, documents reconstruction and cognitive inconsistency. The results indicated that every three methods were effective on changing negative attitudes towards mathematics.²¹ Bahadoran in another study aimed to compare negative attitude change methods toward menstruation of the girl students aged between 12-14 years old, used five attitude change methods including social inoculation, parental education, puberty ceremony, educational package and composing and writing articles in the praise of puberty. The results indicated that the mean attitude score towards puberty was not significantly different in the EP method in the posttest compared to the pretest, meanwhile the SI method was effective on changing the attitude.¹⁵ Inoculation theory-based interventions have been used successfully in education health programs.¹⁷ In addition, the social inoculation method is extremely effective on cultural issues and people's beliefs which have long been formed and show resistance against convincing. Besides, for the attitude change caused by social inoculation is produced by active thinking and reasoning about the attitude subject (violence against women); it will be so durable and stable, hence using social inoculation method seems so effective on the changing attitude towards violence against women. Akbarzadeh et al in a study aimed to compare the effect of educational package and peer-learning about breast self-testing on knowledge and attitude of students found that in the first posttest (immediately after the intervention) there was a significant difference in the knowledge level of the participants compared to the pretest in both methods but, in the second posttest (6 weeks later), there was no significant difference in the EP group in the attitude score compared to the pretest.²². Moreover, in the study of Bahadoran also no changes were obtained in the attitude using pamphlet. The results of these studies and the present study showed that if the educational package method used with other methods like pamphlet, group discussion and etc, it would produced more stable and stronger effects in changing the attitude. So, it can be concluded that providing educational package can only raise the knowledge but would have no long term and appropriate change on the attitude. As it is showed in the present study, the educational package was only effective on attitude changing in physical and sexual aspects; the reason might be that emotional violence is more rooted and is more influenced by the culture and consequently requires stronger interventions and longer time to be changed. Although one of the three attitude components is the cognitive component (emotionally - taking action) meaning the information that someone has with regards to the attitude subject and this part of attitude can be enhanced by increasing the knowledge however, enhanced through educational pamphlet or package. But, other studies and the present study also showed that the educational package alone cannot be such effective and would be beneficial along with other methods. Comparing the mean attitude change score after the intervention to that before it between the three groups showed that the most attitude change score was related to the SI group, i.e., the highest changes rate was in the physical area and the least was in the emotional area. Thereafter, the highest score change was related to the EP group only in physical and sexual areas. There was no change in any other areas before and after the intervention (Table 2). The study findings of Bahadoran (2006) showed that among the five changing attitude methods toward menstruation including social inoculation, parental education, puberty celebration, educational package and composing and writing articles in the praise of puberty; the social inoculation was the most effective method than all of the other methods to change the attitude.¹⁵

Considering the broad spectrum and prevalence of domestic violence¹ and also, the huge young population who want to get married in Iran and according to studied researches on the high probability of sexual partner violence in the early stages of the relationship between the couples and the fact that its prevention at the same early stages would prevent the violence,²³ and considering the necessity of participation of all the marriage candidates in the premarital counseling classes and considering that probably changing the attitude in this stage of marriage, for the couples who still are not involved in misunderstanding and marital conflicts, would be so effective on their future relationship; and considering that the inoculation method causes more stable and durable attitude changing due to active thinking, it is hoped that results of this study be applied to hold better premarital counseling classes.

The authors declare no conflict of interest in this study.