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Naim Nur¹

¹Department of Public Health, Faculty of Medicine, Sivas Cumhuriyet University, Sivas, Türkiye. (Correspondence to N. Nur: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Suicide is one of the main causes of premature death and an important health concern globally because of its current rising prevalence.

Aims: To investigate suicidal thoughts and attempts among married women who have experienced intimate partner violence in Sivas, Türkiye.

Methods: This cross-sectional, population-based survey was conducted between January and December 2019 among 2243 currently married women aged 15–49 years, who had been residing in the centre of Sivas Province, Türkiye, for ≥ 6 months. Multistage clustered random sampling was used in the survey. The 12-item General Health Questionnaire was used for the measure of mental health, while the violence items were measured using the Conflict Tactic Scales-2. The data were analysed using SPSS version 16.0.

Results: Prevalence of suicidal thoughts and attempts was 9.5% and 4.8%, respectively. Multivariate logistic regression analysis showed that age < 25 years, mental health problems, being a victim of violence during childhood or marriage, and insufficient income were associated with suicidal thoughts. Age < 25 years, mental health problems, being a victim of violence during childhood or marriage were associated with suicidal attempts.

Conclusion: Intimate partner violence is a risk factor for poor health among women, including mental health, and it could result in suicidal thoughts and attempts. Intimate partner violence against women should be addressed by the relevant authorities to reduce suicidal thoughts and attempts, especially among younger women.

Keywords: partner violence, suicide, marriage, mental health, Türkiye

Citation: Nur N. Suicidal thoughts and attempts among married women who experience intimate partner violence in Türkiye. East Mediterr Health J. 2023;29(9):725–733. https://doi.org/10.26719/emhj.23.097 Received: 04/04/22; Accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo ).

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Introduction

Suicide is one of the main causes of premature death and an important global health concern because of its currently high prevalence (1). According to WHO, > 800 000 people globally commit suicide each year (2). Although suicide is the ninth leading cause of death in Türkiye (~1% of the total number of deaths), previous research has revealed that the rate of completed suicide is 9.9 per 100 000 people for men and 5.6 for women, which is lower than the global rate of 10.7 per 100 000 (3,4). However, as is the case globally, the number of suicides is likely to be underestimated because some are being classified as unintentional injuries for social, cultural, or political reasons (5).

Durkheim proposed that socioeconomic and psychological factors are critical in attempted suicide (6). He opined that breakdown in social integration and regulations is one of the driving forces behind attempted suicide. Hamermesh and Soss emphasized that income is an important socioeconomic factor in committing suicide. An increase in income leads to higher living standards and greater life satisfaction (7). Thus, higher income tends to be linked with a lower rate of suicide.

In recent years, suicide has become important among women who have experienced intimate partner violence. WHO estimates that women who endured such violence are almost 5 times more likely to attempt suicide (8). Similar statistics cannot be given for Türkiye because there are no complete data on suicidal thoughts and attempts among married women who have experienced intimate partner violence. However, in a study conducted in Sivas Province, the lifetime prevalence of suicidal thoughts and attempt in the general population was 2.23% and 3.58%, respectively (9).

Female suicidal thoughts and attempt in the context of violence, particularly intimate partner violence, have recently gained attention from researchers (10, 11). According to an international study on women’s health and domestic violence, nearly one half of ever-married women had faced intimate partner violence (11). In another study in the Islamic Republic of Iran, the prevalence of intimate partner violence among married women was 56.1% (12). In Türkiye, it is reported to vary between 33% and 40% (13,14). Experience of intimate partner violence is strongly linked with suicidal behaviour among women. An international study by WHO reported that intimate partner violence was a risk factor for poor health among women, including mental health, which could result in suicidal thoughts and attempt (15).

Child abuse is a risk factor for developing abusive behaviour or being a victim of violence in adulthood (16), and there is a link between exposure to child abuse and suicidal thoughts and attempt (17).

Although previous research has suggested that poor interpersonal relationships are associated with greater risk of suicidal behaviour, only a few studies have examined the association between intimate partner violence against women and suicidal behaviour (18).

Most studies of suicidal behaviour in Türkiye have been based on recorded data, or clinical rather than population-based samples and had small sample sizes (19,20). Given the complexity of suicidal behaviour, it is important to understand factors that contribute to suicidal thoughts and attempt among women. To our knowledge, this is the first study in Türkiye to estimate the prevalence of suicidal thought and attempt among married women who have experienced intimate partner violence, and to assess other associated factors.

Methods

Study setting and participants

This was a cross-sectional, population-based survey conducted between January and December 2019 of currently married women, aged 15–49 years, residing for ≥ 6 months in the centre of Sivas Province, Türkiye. All women had the ability to complete the questionnaire and to communicate with each other. Sivas City is located in the east of Middle Anatolia and has a heterogeneous population of ~630 000. As in the other parts of Türkiye, most inhabitants of Sivas are Muslim. Social life in Sivas has traditional norms and the social status of women is affected by male-dominant structures. The sample size was determined to be 2478, which was calculated using 99% confidence levels, 1% margin of error, 3.0 design effect, possible 10% nonresponse rate, and prevalence of 4% (based on reported suicidal behaviour in Türkiye) (19,20).

Multistage clustered random sampling was used in the survey. In the first stage, 9 residential quarters (as clusters) were selected randomly from the 63 quarters, with each having an approximately equal population size. After the first initially selected quarter, every subsequent seventh quarter was selected (i.e. 1st, 8th, and 15th). The list of the total number of households with their addresses was obtained from Sivas Governorate. The target population consisted of ~90 000 women aged 15–49 years from ~38 000 households. The starting point for each quarter was a randomly selected street and house numbers. After the first house in a cluster was randomly selected, starting with this household, interviewers approached every subsequent seventh house per cluster. Temporary residential (e.g. hotels) or nonresidential (e.g. commercial) properties and vacant households were excluded. A team was constituted to administer the questionnaires. A house-to-house survey was performed by these teams (all of whom were final-year female medical students) with a public health specialist (the author).

Because of the sensitive nature of the questions, the interviews were undertaken at the respondents’ places of residence between 10:00 and 15:00 hours, when their husbands were not expected to be at home. If more than 1 eligible woman was identified in the house, 1 of them was randomly selected for interview. To maximize the chance of obtaining an interview, a minimum of 2 return visits were made to each household at different times on different days. All women who participated in the survey were informed about the purpose of the study and told that their participation was voluntary and that all information obtained would be kept confidential and anonymous. Written informed consent was obtained from all eligible women prior to interview. Participants were informed about support services for victims of intimate partner violence at Sivas Cumhuriyet University Hospital. Ethical approval for the study was granted by the Human Research Ethics Committee of Sivas Cumhuriyet University.

Of the 2478 currently married women invited to participate, 141 did not meet the inclusion criteria or declined to provide consent, while 94 could not be contacted at their homes. A total of 2243 women agreed to participate which yielded a 90.5% participation rate.

Survey instrument and measures

Based on a literature review (18–21), a structured interview questionnaire was developed to obtain information on age, current marital status, educational and employment status, and annual household income. Based on self-reported data, annual household income was categorized into sufficient (≥ 85 000 Turkish lira; US$ 15 000) and insufficient (< 85 000 Turkish lira).

Measures of mental health

The 12-item General Health Questionnaire (22) focused on 2 major areas: inability to carry out normal functions, and the appearance of new and distressing psychological phenomena. This questionnaire has been validated for the Turkish population (23). In this questionnaire, response category scores were 0, 0, 1, and 1 respectively, which gave a range of 0–12. The total score was determined by adding the score obtained for each answer in the questionnaire. Scores ≥ 4 were considered as positive for emotional disorders. Mental health problems were coded as 1 (present) or 0 (absent).

Suicidal thoughts and attempts

Information related to suicidal thoughts and attempt during the past 12 months was collected through 2 questions: (1) Have you ever thought about ending your life? (2) Have you ever attempted suicide? A binary response of yes/no was provided.

Intimate partner violence

The definition of intimate partner violence was physical, emotional, or sexual violence experienced by women over the past 12 months, perpetrated by their current husband. The violence items in this survey were adapted from the Conflict Tactic Scales-2, which has been widely used in demographic health surveys across cultures and has been validated in the Turkish population (24). Emotional violence included verbal attacks (humiliation and insult), harassment, pursuit, and verbal threats. For physical violence, women were asked whether an intimate partner had ever: slapped them, or thrown something at them that could have caused injury; shoved or pushed them; burned or choked them on purpose; hit them with a fist or something else that could have caused injury; beaten, dragged, or kicked them; threatened them with, or actually used a knife, gun, or any other weapon. Sexual violence against women was defined as follows: being physically forced to have sexual intercourse against their will; having sexual intercourse because they were afraid of what their partner might do; or being forced to do something sexual that they found degrading or humiliating.

The violence during childhood variable was obtained with The Childhood Trauma Questionnaire – Short Form, which is a retrospective measurement tool for evaluating childhood abuse history. The reliability and validity of the questionnaire have been confirmed in the Turkish population (25).

Statistical analysis

The data were analysed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). Descriptive analyses, including mean, standard deviations, frequencies, and percentages were used to summarize sociodemographic, economic, and health-related characteristics of the participants. Analysis of data from the entire sample was performed using the χ2 test for categorical variables. Multivariate logistic regression analysis was performed to explore the association between suicidal thought/attempt and intimate partner violence, and taking into account the potential covariate effects, including participants’ mental health problems, age, level of education, household annual income, using adjusted odds ratio (OR) and 95% confidence interval (CI). Purposeful selection of candidate variables was done based on bivariate P < 0.200. Covariates that were associated with suicidal thought and attempt at P 10% were included in the logistic regression models, and were retained in the models if they were significant at P < 0.05. The fit of the multivariate logistic models was assessed with the Akaike information criterion (AIC). The model with the lowest AIC was accepted as the best-fitting model. An alpha level < 0.05 was considered to be statistically significant.

Results

The sample population consisted of 2243 currently married women with a mean age of 31.1 (9.0) years (Table 1). Suicidal ideation was reported by 9.5% of the married women, and 4.8% of them had attempted suicide. Nearly one-third (30.9%) of the women were aged 15–24 years, and 43.3% were in the first 5 years of marriage. Most women (73.6%) had an educational level lower than a university degree. More than a quarter of women (28.0%) were employed and earning an income, while 68.3% declared that their annual household income was insufficient for their needs. Only 5.5% of the women reported that they had some mental health problems. The rates of women who reported being a victim of parental/family violence during childhood and at some point in their married life in the year prior to the survey were 11.6% and 14.2%, respectively.

Compared with women who had no suicidal thought, a significantly higher proportion of women who had suicidal thought were younger (49.3% vs 29.0%, P < 0.001), in the first 5 years of marriage (52.6% vs 42.4%, P = 0.004), had some mental health problems (22.1% vs 3.7%, P < 0.001), had insufficient annual household income (77.9% vs 67.3%, P = 0.002), had experienced violence during childhood (42.3% vs 8.4%, P < 0.001), and had experienced intimate partner violence (48.8% vs 10.6%, P < 0.001) (Table 2).

Compared to women who had not attempted suicide, a greater proportion of women who had attempted suicide were younger (43.0% vs 30.3%, P < 0.001), had lower level of education (82.2% vs 71.6%, P = 0.016), had some mental health problems (28.0% vs 4.4%, P < 0.001), had experienced violence during childhood (33.6% vs 10.5%, P < 0.001), and had experienced intimate partner violence (43.0% vs 12.8%, P < 0.001) (Table 3).

Three logistic regression models were fitted for suicidal thought and the lowest AIC was 828.204. Three logistic regression models were created for attempted suicide and the lowest AIC was 831.055. Age < 25 years (AOR = 3.90, 95% CI 2.39–6.77, P < 0.001), mental health problems (AOR = 5.26, 95% CI 3.28–8.42, P < 0.001), experience of violence during childhood (AOR = 3.65, 95% CI 2.47–5.38, P < 0.001), experience of intimate partner violence (AOR = 4.96, 95% CI 3.38–7.28, P < 0.001), and insufficient annual household income (AOR = 1.65, 95% CI 1.15–2.94, P = 0.024) were significantly associated with suicidal thought (Table 4). Age < 25 years (AOR = 3.07, 95% CI 2.10–4.49, P < 0.001), mental health problems (AOR = 5.27, 95% CI 3.28–8.45, P < 0.001), experience of violence during childhood (AOR = 3.72, 95% CI 2.52–5.50, P < 0.001), and experience of intimate partner violence (AOR = 5.00, 95% CI 3.40–7.35, P < 0.001) were significantly associated with higher risk for attempted suicide (Table 5).

Discussion

This study revealed that suicidal thought and attempt were common among married women and more frequent among women who had been exposed to intimate partner violence.

Previous studies have shown that intimate partner violence has long been a risk factor associated with women’s poor health, including mental health and suicidal behaviour (15). It has also been reported that intimate partner violence is an important risk factor for attempted suicide among currently married women of reproductive age group. Consistent with the findings of Öner et al. (26) and Indu et al. (10), our results revealed that intimate partner violence was one of the factors for suicidal thoughts and attempt among married women, especially among younger women. It is possible that the experience of intimate partner violence contributed to women’s assessment that they could not endure more and that they felt the need to do something. It may be that the lack of support or help drove the women to consider suicide, as a last resort.

Devries et al. found that younger age was a major risk factor for attempted suicide among women, whereas

lower level of education was not (15). We found no significant independent relationship between educational level and attempted suicide among married women who had ever been victims of intimate partner violence; however, the rate of suicidal thought and attempt was higher among young women.

One of the aims of the current study was to understand the contribution of childhood violence to suicidal behaviour among married women. There is evidence that exposure to childhood violence can lead to parental attachment problems and early life difficulties (27). Such early exposure to violence can seriously affect the ability of women to cope with subsequent life stress, and establishing safe, strong, and healthy relationships with others (17). The stress response to intimate partner violence can increase feelings of helplessness and hopelessness that often precede suicidal thought and attempt among women (28). Previous studies have indicated important and consistent relationships between being a victim of parental/family violence during childhood and subsequent suicidal behaviour among men and women (17). Similarly, our study suggested a possible association between women who have been subjected to violence during childhood and suicidal thought and attempt.

Mental disorders (e.g. stress, anxiety, and depression) have been identified as an important consequence of violence in many cross-sectional studies, including the WHO multicentre study on domestic violence and women’s health (11,29). The WorldSafe study on the mental health consequences of intimate partner violence in Chile, Egypt, India, and the Philippines reported that violence increased the risk of attempted suicide in all populations studied (30). This may lead one to suppose that suicidal thought and attempt may be related to an emotional process that limits the perception of easily available solutions and drive some women towards despair and hopelessness, thus increasing the probability of suicidal behaviour (31). A study of Indian married women showed that mental health problems and suicidal behaviour were strongly related (32). The extent to which suicidal behaviour is attributable to intimate partner violence underlines the importance of safe and effective suicide and violence prevention programmes (18).

Although women in Türkiye have a legal right to work and there is no negative attitude towards female employment, most of the married women in our study were not economically active. This finding supports the view that close family ties, lack of autonomy, and being economically dependent can make life difficult for women in Türkiye (4). Low income levels, which dominate the lives of women in families with low socioeconomic status (33), increase the vulnerability of women to intimate partner violence and reduce their physical safety. Dufort et al. (34) found that unemployed and younger women with financial problems were more exposed to violence and reported more suicidal thoughts and attempts (34). Kim et al. indicated that low income level was associated with significantly higher rates of attempted suicide among young women (35). Consistent with previous results, our study demonstrated a strong relationship between insufficient income level and suicidal thought and attempt among married women.

The main strength of this study was that by directly surveying women who were already married, we were able to document exposure to highly sensitive, hidden issues that are impossible to detect by psychological autopsy. Other strengths were that the study involved a population-representative sample and had a high response rate. One limitation of the study was its cross-sectional design, which meant that definitive conclusions about causality could not be drawn.

Conclusion

Suicidal thoughts and attempts were prevalent among married women and more frequent in some groups, such as poorer and younger women who had experienced intimate partner violence, and who had mental health problems. Therefore, it is important to strengthen the capacity of health providers to assess mental health among poorer and younger women subjected to intimate partner violence, and to focus on mental health symptoms as a possible entry point for identifying such violence.

Funding: None

Competing interests: None declared.

Pensées suicidaires et tentatives de suicide chez les femmes mariées qui subissent des violences exercées par leur partenaire intime en Türkiye

Résumé

Contexte : Le suicide représente l'une des principales causes de décès prématuré et constitue une source de préoccupation majeure pour la santé dans le monde en raison de l'augmentation actuelle de sa prévalence.

Objectif : Examiner les pensées suicidaires et les tentatives de suicide parmi les femmes mariées ayant subi des violences de la part de leur partenaire intime à Sivas (Türkiye).

Méthodes : La présente enquête transversale en population a été menée entre janvier et décembre 2019 auprès de 2243 femmes de 15 à 49 ans, mariées au moment de l'étude, qui résidaient dans le centre de la province de Sivas depuis six mois ou plus. Un sondage aléatoire par grappes à plusieurs degrés a été utilisé dans l'enquête. Le questionnaire général sur la santé en 12 items a servi à mesurer la santé mentale, tandis que les items sur la violence ont été évalués à l'aide de l'échelle des stratégies de gestion des conflits CTS-2 (Conflict Tactic Scales). Les données ont été analysées au moyen du logiciel SPSS, version 16.0.

Résultats : La prévalence des pensées suicidaires et des tentatives de suicide était respectivement de 9,5 % et 4,8 %. L'analyse de régression logistique multivariée a montré que pour les femmes de moins de 25 ans, les problèmes de santé mentale, les violences subies pendant l'enfance ou pendant le mariage et un revenu insuffisant étaient associés à des pensées suicidaires. Le fait d'être âgée de moins de 25 ans, les problèmes de santé mentale, les violences subies pendant l'enfance ou pendant le mariage étaient associés à des tentatives de suicide.

Conclusion : Les violences exercées par un partenaire intime constituent un facteur de risque de mauvaise santé pour les femmes, y compris en matière de santé mentale, et elles pourraient entraîner des pensées suicidaires et des tentatives de suicide. Ce type de violence devrait être géré par les autorités compétentes afin de réduire les pensées suicidaires et les tentatives de suicide, en particulier chez les jeunes femmes.

الأفكار والمحاولات الانتحارية بين النساء المتزوجات اللاتي يتعرَّضن لعنف الشريك في تركيا

نعيم نور

الخلاصة

الخلفية: الانتحار أحد الأسباب الرئيسية للوفاة المبكرة، ومصدر قلق صحي رئيس على الصعيد العالمي بسبب ارتفاع معدل انتشار الانتحار حاليًّا.

الأهداف: استقصاء الأفكار والمحاولات الانتحارية بين النساء المتزوجات اللاتي يتعرَّضن لعنف الشريك في سيواس، بتركيا

طرق البحث: أُجري هذا المسح السكاني المستعرض في الفترة بين كانون الثاني/ يناير وكانون الأول/ ديسمبر 2019، وشمل 2243 امرأة متزوجة حاليًّا ممن تتراوح أعمارهن بين 15 و49 عامًا ويُقِمن في وسط محافظة سيواس بتركيا لمدة 6 أشهر أو أكثر. واستُخدم في المسح طريقة الاعتيان العشوائي المُجمَّع المتعدد المراحل. واستُخدم استبيان الصحة العامة المؤلف من 12 بندًا لقياس الصحة النفسية، في حين قيست بنود العنف باستخدام المقياس Conflict Tactic Scales-2. وحُللت البيانات باستخدام الإصدار 16.0 من برنامج SPSS.

النتائج: بلغ معدل انتشار الأفكار والمحاولات الانتحارية 9.5% و4.8% على التوالي. وأظهر تحليل الانحدار اللوجستي المتعدد المتغيرات أن ثمة ارتباطًا بين وجود الأفكار الانتحارية والانتماء للفئة العمرية دون 25 عامًا، ووجود مشكلات صحية نفسية، وكون الفرد ضحية للعنف في مرحلة الطفولة أو الزواج، وعدم كفاية الدخل. وتبين أن ثمة ارتباطًا بين محاولات الانتحار والانتماء للفئة العمرية دون 25 عامًا ووجود مشكلات صحية نفسية، أو الوقوع ضحية للعنف في أثناء الطفولة أو الزواج.

الاستنتاجات: عنف الشريك أحد عوامل الخطر التي تضر بصحة المرأة، بما فيها الصحة النفسية، وقد يؤدي إلى أفكار ومحاولات انتحارية. وينبغي أن تتصدى السلطات المختصة لعنف الشريك بحق المرأة بغرض الحد من الأفكار والمحاولات الانتحارية، ولا سيَّما بين الشابات.

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