Dimensions of Women’s Empowerment in Prevention of Domestic Violence: A Qualitative Study in Iran


 Background: Empowerment is a key goal in anti-violence programs against women that can empower women against violence in a variety of situations and minimize its negative consequences. Therefore, the present study was conducted to identify the dimensions of women's empowerment in prevention of domestic violence (PDV) in Iranian women.Methods: In this qualitative study, an exploratory sequential mixed-methods design was used and conventional content analysis was carried out. Thirty-one participants (fifteen professionals and sixteen married women) were selected by purposeful sampling. Data were gathered through 21 individual semi-constructed interviews and two five-person focus group discussions in 2019. Guba and Lincoln’s criteria for establishing trustworthiness were explored.Results: After the data analysis, multiple revisions and merging of 892 primary codes based on similarity were led to the extraction of 18 sub-categories. Then, five main-categories were identified as dimensions of women's empowerment in PDV, which were: marital social skills, knowledge, perceptions & self-evaluations, agency in family finance and economic independence, spiritual health, and access to resources.Conclusion: The results of this study provide a comprehensive view of the dimensions of women's empowerment in PDV in Iran. Participants cited the marital skills, knowledge, perceptions and self-evaluation as most important dimensions in facilitating women's empowerment to deal effectively with domestic violence. These findings can be used as a basis for planning interventions to reduce violence against women.


Introduction
Violence against women is a global public health issue [1]. Until recently, most governments considered domestic violence against women as a relatively minor social problem, while this type of violence is common form of violence against women [2], and is include sexual, physical, and emotional abuse, and controlling behaviors by spouse [3], which make substantial consequences on women's physical and mental health [4]. The WHO declared almost 1 in 3 women of ever-married/partnered women of reproductive age (15-49 years) have experienced physical and/or sexual violence at least once in their lifetime [1]. Researchers reported that the highest level of the prevalence of domestic violence by spouses, on average, can be observed in the southeast of Asia (37.07%), East Mediterranean (37%) and Africa (36.6%) respectively [5], with the lowest in Japan (15%) and the highest in Ethiopia (71%) [4].
Violence against women also is a social problem in Iran, similar to many other countries [6], although there are not many reliable statistics for this issue in Iran but there are enough evidences for this [7], so that a national survey in 28 provinces of Iran showed that 66% of Iranian women were victims of domestic violence at least once [8]. In Tehran province in 2006, domestic violence against women was estimated that physical and emotional-psychological violence were 30% and 29% respectively [9]. Also, a study conducted in Urmia City in 2014, found that 89.3% of women were subjected to physical violence in various forms [10]. To understand the seriousness of this problem, it must be considered that the female population includes 49.7% of the total population of Iran [11], therefore, the consequences of this violence would de nitely affect the whole society [12].
In the recent decades, the quantity of interventions to address violence against women worldwide has been increased [13], and advocates within the domestic violence movement, have named "empowerment" as a main aim of services [14], because if the level of women's empowerment increases, the experience of domestic violence decreases [15].
Therefore, since the consensus on the de ning features of the empowerment structure is unclear, a clear de nition of empowerment and its dimensions would promote the development of common metrics for research and assessment. [16] To addresses this gap in knowledge, we conducted a qualitative-research to explore the research participants' perspectives on the women's empowerment in PDV, in order to obtain a clear concept of empowerment and its dimensions.
Expected, the results of this study, can be used as a guideline for developing and facilitating the framework of a speci c educational interventions in PDV, and as well as designing a tool for evaluating the level of women's empowerment in Iran.

Study Design
We applied a qualitative approach and a conventional content analysis method, because it was a useful way to study less known, and culture-sensitive issues. Figure1 below shows the summary steps of this study.

Participants and Sampling
Participants were selected using purposive sampling, and theoretical sampling was utilized to calculate the number of participants with extensive experience or with knowledge of the event. Also, to create the greatest diversity in the data, women with different demographic characteristics (Table1) from social emergency centers and health centers in Tehran and Urmia and specialists in various scienti c and occupational elds (Table2) in Tehran and Urmia Universities of Medical Sciences were selected. Inclusion criteria for women included: being married, age over 18, agreeing to participate in the study and sharing their experiences. Inclusion criteria for specialists were: having a background in scienti c research or professional experience and knowledge related to women's health and violence against women.

Data analysis
The analysis process simultaneously was performed with data collection. All interviews were coded with open thematic coding and analyzed through inductive thematic analysis. MAXQDA (2018) was applied to manage coding the interviews. Graneheim and Lundman's ve-step qualitative content analysis approach [17] was employed for data analyzing, as following: Initially, each interview transcript was read several times to gain a general understanding about its overt and covert content. Then, meaning units were extracted and coded. In the next step, the codes were classi ed according to their similarities and differences into sub-categories and main-categories.

Trustworthiness
The criteria proposed by Guba and Lincoln were used to ensure the validity and reliability of the ndings.
To increase credibility, immersion, members checking, and peer review were considered. Research process was monitored by two independent colleagues to achieve dependability. To ensure con rmability, all the research stages were documented and revised, and purposeful sampling was performed with maximum variety, accurate description of participants and research environment for increasing transmissibility.

Results
The data from interviews and FGDs were analyzed. 892 primary codes were extracted. Five effective parameters on marital social skills were emphasized by participants as following: Assertive behavior Most of interviewees emphasized that assertive behaviors could be an important step in empowering women in PDV, which was manifested through saying no to husband's unreasonable wishes, defending themselves, freely expressing wishes, expectations and opinions.
"It is very important for women to be able to express their sexual desires and needs, but women are ashamed and this leads to sexual violence against them." (Social Worker Expert)

Conversation and intimate communication
Effective and respectful conversation with full attention and considering the appropriate time for conversation, along with understanding, supporting, prioritizing the spouse and maintaining his respect and value in front of others could strengthen intimacy and love in marital relationships and protect the woman from spouse violence.
"I spend time with my husband every day, sitting and talking to him and listening to him, when my husband sees how I treat him, he treats me well." (31 years old woman) exibility Woman's exibility will allow her to accept more issues, which can lead to less con ict between her and her husband. Adapting to the situation by changing thoughts and behavior, accepting the individual differences and different tastes, and adapting to di cult situations in life were emphasized as components of women exibility in marital life.
"You always want your husband to be the way you want him to be, you want to change him exactly what you like. This is one of the things that causes violence, because you cannot accept differences and this is problematic". (Health specialist)

Emotion management
Woman's ability to control anger, regulate emotions, controlling the expression of anger and provoking the husband's anger, also not worry to express opinions and feelings, overcoming negative emotions, internal fears, and daily stresses, were important in women's ability to control husband's violent behaviors.
"When a woman has poor anger management skill, provokes her husband's violence and he hits her. A man who hits should not be provoke". (Social worker expert)

Decision-making
Independence in decision-making, decisively and consciously decision-making without immediate feelings, participation in family decisions and accepting their responsibility, were considered as components of women's active decision-making which increased women's self-con dence and her ability to solve problems.
"Many women like their husbands to decide for them, but if my husband decides without me, I protest, he always consults with me and it makes me feel important and I can help solve problems". (38 years old woman) Category 2: Knowledge, Perceptions and Self-evaluation Five crucial factors in knowledge, perceptions, and self-evaluation (self-e cacy and self-esteem) were emphasized by most of interviewees.

Self-Knowledge
We react to the issues around us, based on our knowledge of our weaknesses and strengths, so woman's knowledge of her inner strengths and weaknesses, expectations, roles, responsibilities and her rights in life, can make her capability or incapability of facing violence.
"A woman that sees herself more capable, will more strongly stand against her husband's violence, until she sees herself as weak." (40 years old woman)

Knowing husband
The interviewees believed that increasing knowledge of the mood and characteristics of the husband helped women to better coordinate their behavior with the mood of the husband in any situation and had better control over the situation.
"She has a way with her husband's, means she knows how her husband is, whether she can talk to him or not, what behavior she does now is better. These help her a lot, and certainly have a good result." (Psychonursing-specialist)

Perception of traditional norms and gender differences
The respondents believed that rejection of gender superiority, the rejection of women's conviction to silence and continuation of marital life under any condition, rejecting the taboo of divorce for women, not recognizing violence against women as normal in married life, could empower women in PDV.
"I thought divorce is a taboo. I thought I should go on with this life because I thought a woman who divorces would be miserable." (Abused-48-year-old-woman)

Self-e cacy
Women's belief in their ability to prevent husband violence, improve living conditions and rely on themselves in decision-making, removes fear from them and increases their self-con dence in trying to save from husband violence.
"Women must rst put fear aside. They must be con dent. They must believe that no one but themselves can help them." (38-years-old-woman)

Self-esteem
Women who don't consider themselves worthy of any abusive behavior, unconditionally accept themselves, and believe in their worth as a woman, can motivate themselves to strive and get rid of husband violence, and be empowered.
"I think some women are satis ed with the minimum, they do not know they deserve more, so they do not try to change the situation, and tolerate any behavior." (32 years old woman)

Category 3: Agency in Family Finance and Economic Independence
Women's agency in nance and economic independence at the family through management and participation in economic decision-making, authority and independence in nance, was another women's empowerment dimension in PDV.

Family economic management and decision-making
The participants believed that women who could have a plan to spend family revenue, adjust living expenses, and be involved in cost decision-making and management, could prevent the husband's violent behavior.
"If woman makes the right decision to spend money, won't have economic violence. But mostly men don't give their wives any choice because they think women spend extravagantly." (Health-Educator)

Authority and independence in nance
According to the interviewees, having nancial independence, nancial self-reliance and personal income management enables women to make decisive decisions to get rid of their husbands' violence.
"If I had a job and an income when my husband was harassing me, I could have made a better decision. It helped me a lot since I became independent."(Abused 41 years old woman)

Category 4: Spiritual Health
Spiritual empowerment was considered as another of women's empowerment dimension including following parameters:

Hope and trust in God's help
Interviewees believed that trusting in God's help, and hoping that their prayers for deliverance from violence would be answered, could give women hope to get rid of violence.
"Ever since I went to Quran class, I have learned not to lose hope, one day God answer my prayer and I will be saved." (Abused 40 years old woman)

Feeling of satisfaction
Women's satisfaction with themselves, marital life and their efforts to satisfy their husband's desires, was cited as a crucial factor in reducing marital con icts.
"Many women are dissatis ed with life with their husbands and seek happiness elsewhere, which leads to more intimacy and con ict." (40 years old woman)

Patience and forgiveness
Patience and resilience were mentioned as the personality traits that helped women control their anger, which were considered as the most important signs of spiritual health.
"Patience is very important in marital life. A woman should be patient so that when her husband says something, she takes time to reply it in a calmer situation." (Social worker expert)

Positive-thinking
Focusing on positive thoughts, not blaming themselves for all problems, and not being pessimistic the problems in marital life, were mentioned as spiritual-wellbeing factors in PDV.
"I always thought our ght would not end and there would never be happiness in our house, I said maybe it's my fault that we ght." (Abused 38 years old woman)

Category 5: Access to resources
According to the interviewees, women access to social and family support, and also education and learning opportunities could increase their ability to controlling and prevention of husband's violence. In the following, we will investigate these subcategories.

Access to advocacy resources
Existence and access of support centers in society for women, and bene t from the advocacy of family members, especially parents, could help to increase women's knowledge and receive the training and guide needed to properly deal with the husband's violence. Also, could increase the feeling of power and security in women, and could reduce the psychological stress caused by feeling lonely in life.
"A woman who lives in a remote area or a village certainly does not have easy access to the centers that help her, so she may accept the conditions. When there is no help, she has to compromise, without enjoying her own life". (A health specialist) "Family, it is very important. If you do not have a father who supports you, your husband will do whatever he wants to you". (Abused 39 years old woman)

Access to educational and learning opportunities
The interviewees mentioned access to education, information, and learning opportunities such as the presence of a successful woman or an independent and capable mother in women's life, growing up and being educated with an emphasis on independence and responsibility, having the opportunity to progress, freedom of choice and decision-making, as important resources for education, learning and understanding the right path of life for women and girls.
"The inner weakness of a woman goes back to her childhood, who was always dominated, punished, not given the right to choose. This will cause a girl, when entering life, not having self-con dence, and is afraid of everything to do alone, of making mistakes, always dependent and seek approval". (A Psycho-Nursing) "Our people do not receive training on marital life skills at all, especially mutual understanding and respect, and all of which is forced to be gained through experience after a few years of marital life which should be gained before marriage". (A Family Psychologist)

Discussion
The present study is the rst qualitative study in Iran led to identify 4 dimensions in women's empowerment in PDV. The most important dimension that repeatedly emphasized was the marital social skills, which included a set of psychosocial competencies, interpersonal skills, and adaptive behaviors that made women capable to face the demands and challenges of everyday life effectively. The most emphasized skill was courageous behavior that could empower women to respectfully express needs, ideas, feelings, and boundaries which could reduce threats or abuse [18]. This nding supports studies show that the lack of courageous behaviors lead challenges in relationships with spouse resulting in experiencing a variety of sexual, physical, and multiple abuses [19].
In the present study, communication and conversation skills were considered as key factors that could prevent and control the marital violence. Consistent with this nding, other studies illustrated a positive relationship between high quality relations of couples and stability of marriage [20] . On the other hand, women's ability to empathize through understanding, supporting, accompanying, and having realistic expectations of their husbands, helped them to avoid violence. This result is in line with other studies. [21][22][23] Women's exibility or ability to accept and adapt with differences, was also an important factor, which previous studies suggested as a key psychological variable to stop partner violence [24]. Furthermore, anger management and emotion regulation were considered as important parameters. It was illustrated that women with higher skill in anger management could overcome many of problems [25]. According to the participants, decision-making skill would empower women in PDV. Similar to this nding, it was indicated that this skill improved abused women's health and quality of life [26], and women who made more decisions jointly with their partner were less likely to experience violence [27,28].
In this study, knowledge, perceptions and self-evaluation through two components of self-e cacy and self-esteem, were considered as another dimension of women's empowerment in PDV. Consistent with this nding, studies indicated that high emotional self-e cacy led women to better cope with negative emotions such as anger [29], and low self-esteem caused abused women to remain in violent relationships and not to pursue more constructive solutions [30,31].
The experts also believed that more knowledge of women, especially about themselves and the psychological characteristics of the husband, provides the necessary conditions for their successful entering marital life [32]. Regarding to women's perceptions of traditional norms governing society, studies in Iran illustrated that maintaining many traditional principles and patriarchal attitudes in the Iranian society had the greatest effect on violence against women [33]. Therefore, according to Samahgan et al., Changing gender norms and attitudes could be a key factor in preventing these women from becoming victims [34].
Women's agency in family nance and economic independence were another dimension which considered as an effective factor in PDV and as promoted self-con dence to leave a violent life. In line with this nding, several studies suggested that employment and revenue of women were a protective parameter against the husband's violence [35,36], and showed that women's lack of power to decide on their revenue could make them more vulnerable to the risk of violence of the intimate partner [37].
Evidence showed that spiritual health and religious participation facilitated women's empowerment against violence [38]. In the present study, this parameter strengthened self-con dence, and sense of control over life. Other studies also indicated that couples with higher religious beliefs were more likely to have marital satisfaction with less violence to each other [39], and women's active involvement in spiritual practices such as mosque and church attendance increased their ability to cope with stressful situation [40].
According to the interviewees, access to advocacy resources and learning opportunities including social and family advocacy, education, information and higher education, positive learning models, and a secure job could be a strong construct in the empowerment structure for the prevention and control of the husband's violence. This nding was consistent with studies that showing women who had economic, occupational and educational power and access to social and family advocacy resources were less likely to be abused by their husbands [41][42][43]. Having a job and higher education were other protective factors that were considered as empowerment resources, which was consistent with the studies by Sen & Bolsoy The most important limitation of this study was women's fear of participating in the study, which was addressed by ensuring that their personal information was kept con dential. Despite this limitation, our ndings offer important recommendation for public health interventions in PDV through women's empowerment programs such as marital life skills training, as well as informing women of their rights and values.

Conclusion
Domestic violence against women in Iran, like other countries, is a serious problem and many studies have emphasized the empowerment of women as one of the most important strategies to deal with it.
According to the results of this study, the concept of women's empowerment in the eld of violence included ve main dimensions. Participants cited marital social skills, knowledge, perceptions and selfevaluation as most important factors in facilitating women's empowerment to deal effectively with domestic violence. Also, further analysis showed that spiritual health, agency in family nance and economic independence, and access to resources, were other key dimensions in shaping the concept of women's empowerment in PDV. Therefore, in order to stop or reduce domestic violence against women, it is suggested to pay attention to interventions planning for improving marital social skills, especially assertive behaviors, promoting knowledge and perceptions, spiritual health, economic independence, agency in family nance, and providing the necessary conditions and facilities for access to advocacy resources and learning opportunities. It is hope that by emphasizing the dimensions identi ed in this study in planning interventions to reduce violence against women, we will observe the promotion of more women's health in the family and the society. Written and verbally informed consent was received from the participants prior to the interviews after presenting the information sheet of the study and consent form of the study, and we anonymized all transcribed interviews.

Consent for publication
Not applicable Availability of data and materials The text and audio les of the interviews are in the possession of the primary researcher of the project Maryam Mataji Amirroud. As participants can be identi ed from the data, they will not be shared publicly.
Interested persons can inquire through the contact information of the relevant author. Summary of the steps of this study