Menopause is the permanent cessation of menstruation which occurs averagely at the age of 51 years (1). Despite the sharp increase of "life expectancy" in women, the menopausal age has remained dramatically constant. Today, women in the United States spend about 30 years or more than one third of their life in the menopausal period (2). Menopausal age is apparently determined genetically and is not affected by race, socioeconomic status, menarche age, or previous ovulation (1).
The population of menopausal women in the world is predicted to reach more than 1.2 billion by 2030, with an increase of 47 million per year (3). By 2050, one per three people in most developed countries and one per five people in less developed countries will be ≥60 years of age (4). According to the General Population and Housing Census in Iran (2011 ), the number of women in the age group of 45-65 years are estimated to be 6,1008,688 (5), which is more than the estimation of five million people in 2021 (6). Complications of menopause include vasomotor disorders, urinary symptoms, atrophic vaginitis, and sexual disorders as well as long-term effects such as osteoporosis, cardiovascular disorders, and psychological complications (2).
Menopause can be a starting point of domestic violence against women due to decreased sexual intercourse, misconceptions about menopause, and the spouse's abnormal feelings about menopause (7). Prevalence of domestic violence against women in developing countries is reported to be 4-28% (8). The studies have shown that many risk factors play a role in the occurrence of unhealthy behaviors, among which violence plays an important role in the middle age of women's lives (9). Violence against women is a global phenomenon varying according to the political, social, and cultural characteristics of each place (10). Domestic violence includes physical, psychological, sexual, and economic violence perpetrated by a spouse and close relatives (11). Domestic violence as the most common type of violence against women creates fear and intimidation and commits abusive behaviors to exercise power and control over women and force deprivation of their individual and social freedom (12). The World Health Organization estimates that 45% of women suffer from domestic violence (13). According to an extensive study which was conducted in 28 provincial capitals, in 66% of families, women have experienced violence at least once in their life (14). The results of another study on married women referring Ahvaz's health centers showed that prevalence of violence against women varied between 27% and 83% (9). The other research showed that women who are victims of violence experience higher levels of stress (15). Violence can occur among all women in different age groups, although it is often neglected among older women. One study found that more than half of women over the age of 60 reported the onset of violence from 10 years earlier (16). According to international statistics, at least one per five women is subjected to domestic violence during the lifetime by her husband or close relatives (17).
The issue of menopausal violence is important for several reasons; older women are less likely to be employed and do not have regular contact outside the home to receive supportive services, second, abused older women often deny being abused, third, menopause can decrease sexual relations and cause abnormal feelings or addiction (7). Addiction also increases violence due to psychological and emotional problems. Men's personality and psychiatric problems are other sources of violence against women that stem from alcohol and substance abuse and addiction (18). Heidarinejad et al. (2017) reported that 63.3% of families with addicted fathers experience psychological and physical violence (19). As a result, the spouse's addiction reduces his supportive role in the family (18). So, the widespread effects of husband's violence and addiction on women's physical and mental health, specifically, during menopausal transition and its social and economic consequences can indicate the importance and necessity of research on violence against women. Therefore, due to the limited studies conducted in this field in Iran and the increase in life expectancy, the present study was conducted for the first time in Iran with aim to determine the relationship between husband's violence and addiction with menopausal experiences in Mashhad.
Materials and Methods
This descriptive cross-sectional study was performed on 250 women in Mashhad, Iran, during 2016-2017. Sampling was performed by multi-stage method. At first, the city of Mashhad was divided into five regions. Second, all urban health centers were listed and numbered, and several centers were selected by the simple random method. Then, the sample size inside each center was selected by quota method according to the population covered by each center. Finally, sampling was done by the available methods in the centers. The sample size was obtained based on the study of Simbaret al. (2013) and with the following formula:
The study's population included all the menopausal women referred to the centers. The inclusion criteria included written consent, age of 45 to 65 years, menopause, being Iranian, married, no known mental illness, not taking psychotropic drugs (imipramine, Diazepam, phenobarbital, fluoxetine, haloperidol, chlordiazepoxide), no drug or alcohol use, no serious event (death of first-degree relatives, accident, burglary, illness of the research's subjects or their close relatives) during last 6 months. The exclusion criteria were dissatisfaction, use of drugs affecting the psyche, use of alcohol, or not answering to 95% of the questions.
This study was conducted after approval by the ethics committee of Shahid Beheshti University of Medical Sciences and Health Services (license number 1980/1000) and after obtaining permission from the Vice Chancellor for Research Shahid Beheshti University of Medical Sciences. 20 women were excluded due to incomplete forms, and the final analysis was performed on 220 women. The intervention's variables were controlled by the exclusion criteria.
Data collection tools included demographic checklists, spouse's unhealthy behaviors (violence and addiction), and assessing women's experiences during menopause. The demographic checklist was consisted of two parts: demographic characteristics (age, education, occupation, housing status, and monthly income) and gynecology and obstetrics characteristics (number of pregnancies, number of deliveries, number of children, menstrual age, postmenopausal age, and duration of menopause).
Women's postmenopausal experience assessment questionnaire was designed and psychometized by Hakimi and Simbar in 2013 (20). This questionnaire includes six subscales: physical complications, psychological complications, anxiety, negative emotions, attitudes, and adjustment. Each subscale contains expressions with a Likert five-choice classification range (never, low, medium, high, very high). The scores ranged from 0 to 4 (from very high to at all). This questionnaire includes 44 items (12 items for anxiety dimension, 10 items for psychological effects, 11 items for physical effects, 5 items for negative emotions, 4 items for negative attitudes, and 2 items for adaptation).The overall score is from 0 to 176. A score of zero means low negative experiences and a score of 176 means high negative experiences. The questionnaire's content validity and reliability have been determined with equivalence reliability method by Hakimi and colleagues (2013) in Tabriz (20). The validity index of the tool was 0.98 and the validity ratio was 0.98. In the study of Simbar et al., the tool's stability was estimated to be 0.78 using retest and the tool's internal consistency was estimated to be 0.96 using Cronbach's alpha coefficient (19).
The researcher-made checklist of the spouse's unhealthy behavior was designed in two parts: the spouse's violence and addiction. The violence section includes physical dimensions with the questions (pushing - hitting - beating with a belt - beating leading to a broken limb - attack with a cold weapon - firearm - burning), sexual dimension (indifference - coercion in sexual intercourse - unconventional sexual coercion - coercion in illegal activities), psychological dimension (intimidation - threat of divorce - deprivation of children - deprivation of telephone contact), and economic dimension (tightening of household expenses- prohibition of employment - lack of funding- take over woman's income – suspicion) .Each dimension contains phrases marked with the answers (yes-no) and receives a score if yes, and a zero score if no. The answers to the questions of the violence section (20 questions) were added to the addiction section of the spouse (3 questions) and are expressed as a percentage in the form of unhealthy behavior. The total score is 0_23. A score of zero indicates lower unhealthy behavior and a score of 23 indicates higher unhealthy behavior. Content validity and reliability of the tool have been determined with the equivalence reliability method by Shariat Moghani and Simbar (2016) in Mashhad. The validity index of the tool was 0.97 and the validity ratio was 0.96.
Data were analyzed by SPSS software (version 16). Descriptive statistics including mean, standard deviation, absolute and relative frequency distributions, as well as analytical statistics including Pearson correlation coefficient (for quantitative normal variables) or Spearman (non-normal and rank variables) were used to determine the relationship between the variables. P< 0.05 was considered statistically significant.
A total of 220 menopausal women referring to health and hospital centers and public and cultural centers of Mashhad with mean age of 55.05± 5.72 years were included in the study. Mean (menstrual age was 13.17 ± 1.74 and menopause duration was 7.15 ± 5.91 and menopausal age was 48 ± 4.56 years).
Median was (number of pregnancies 4, number of deliveries 4, and number of children 4). The women's education in primary school was the highest at 37.7% and illiterate with the lowest at 5.5%. The wife's education was the highest in the university and the illiterate with the lowest. Table 1 showed the comparison of the mean score of total tools of postmenopausal women in percentage by the job, spouse occupation, housing status (Table 1).
Based on one-way analysis of variance test, there was no statistically significant difference in the mean total score of menopausal experiences in terms of woman's occupation, husband's occupation and housing status (p=0.467, p=0.785, p=0.544, respectively).
Also, the mean score to the percentage of different areas of women's experiences in menopause from highest to lowest, compatibility 62.4 ± 29.7, Mean score of negative emotions 34.6 ± 24.6, physical 34.5 ± 19.5, psychological 33.3 ± 21.3, anxiety 29.37 ± 21.9, and negative attitude was 27.6 ± 26.5.
Table 2 showed that the score of unhealthy behaviors of the spouse in the two dimensions of violence (73.3%) and addiction (26.7%).
Therefore 73.3% of women experienced domestic violence and 26.7% of husbands have addiction.
There was also a direct and significant relationship between the dimension of violence and the mental, physical, and emotional dimensions of postmenopausal experiences. Addiction had no significant relationship with any of the dimensions of menopausal experiences (Table 3).
The results showed that the score of physical dimension of violence had a direct and significant relationship with physical dimension of experiences and its sexual dimension had a direct and significant relationship with mental, physical, negative emotions, and attitudes of experiences. There was a direct and significant relationship between the mean score of the psychological dimension of violence with the dimension of experiences' negative emotional and between the mean score of the economic dimension of violence with the mental and physical dimensions of experiences (Table 4).
The present study was performed with aim to investigate the relationship between spouse's violence and addiction and women's experiences in menopause.
Accordingly, the results of the present study showed a statistically significant inverse relationship between spouse's education and the psychological dimension of menopausal experiences, and a significant relationship was observed with violence. Family income was significantly related to physical and psychological complications of menopausal women. The study by Vakili et al. (2010) in Kazerun found a significant relationship between domestic violence and family income, education level, and religious beliefs of spouses (21). In the study of Alizadeh et al. (2013) the level of education, occupation, and income of women in the group of domestic violence were lower than the two control groups (22). Studies have shown that men with higher levels of education use less violence against their wives. Given that the level of education of men is mainly related to their social and cultural status; violence against women is higher in families with lower social status (7). Despite the high education of the husband, the percentage of violence was high, emphasizing that the education of the spouse has no effect on reducing violence. Certainly, the traditional context and culture of the research community are of great importance.
Physical violence was significantly associated with the physical effects of menopausal women. It can be said that men are not familiar with all aspects of violence and often consider cases such as physical abuse as violence. As a result, its consequences are manifested in the form of physical complications. Also, women who receive less social support from their husbands are more exposed to physical and psychological problems following violence (23).
The present study showed a significant relationship between sexual violence in the mental, physical, emotional, and menopausal areas. Maria and Pico (2006) reported the relationship between sexual violence in women with severity of depression and anxiety, substance abuse and suicidal ideation (24). Akbari et al. (2014) found a direct relationship between sexual violence and depression in women (25). The results of various studies, especially those in Iran, show that sexual violence has a lower rank than other types of violence, which is inconsistent with the present study. The factors such as cultural barriers in reporting this type of violence have made the available statistics definitely lower than the actual amount, and as a result, this type of violence has a lower rank. Also, another reason for the low report of sexual violence is the different definition of sexual violence in Iran compared with European and Western countries (26, 27).
The present study also showed a significant relationship between psychological violence and the emotional dimension of women's menopausal experiences. Researchers reported that women who are victims of violence experience higher levels of stress (15). Recent studies have shown a relationship between stressful life events, anxiety, depression, stressful jobs, physical abuse, and low social support (28). Although all women are at risk of violence, other studies have used more verbal and psychological violence. Lack of physical symptoms in psychological and verbal violence has caused this type of violence to be done with more recklessness; since it is not easily provable even if the injured person is pursued, it has a higher rank among all types of violence (26,27). Sandra and colleagues (2012) showed that abused women are more likely to experience psychological problems and negative menopausal experiences (29). De Souza and colleagues (2013) showed the correlation between domestic violence and low quality of marital life and thus reported its impact on women's health (30).
The present study showed a statistically significant relationship between economic violence and the psychological and physical dimensions of postmenopausal status, indicating the importance of the husband's economic support of the woman. Delanoe (2012) stated that women's income was one of the factors affecting women's experiences of menopause (31). There is significant and inverse relationship between monthly income with the score of mental domain, physical domain, emotional domain, and total experiences of menopausal women (32). Bagherzadeh et al. (2008) and Shamsi and Bayati (2012) assessed the economic violence, and reported that it is 23%, with questions such as reluctant payment by the husband and failure to consult with the wife on household finances and obstruction of the woman's employment (34,33). Bagherzadeh et al. found the significant relationship between this factor and the emotional dimension (33). There was a significant relationship between female employment and physical dimension (34) and with psycho-verbal and sexual dimensions (35). McQuary (2009) showed that domestic violence affects women's empowerment and consequently their health and postmenopausal experiences (36). In general, more income can help people achieve better care and access to better health care. However, in the study by Simbar (2013), there was no such relationship (20). This difference may be due to the differences in the research environment or the diversity of research population or their income levels. In this study, the dimension of addiction didn't show any relationship with the dimensions of menopausal experiences. However, in some studies, husband's addiction has been reported as a factor in physical violence, which contradicts with our study. Ghorban Alipour and colleagues (2008) examined the reasons behind the violence from the perspective of women, including restrictions on women's action and no freedom of action in matters of life and social relations, pessimism and distrust of women, several physical punishments, and addiction, which contradicts with the present study (37). The concealment of facts and the lack of reporting of violence by women are the most likely reasons which should be considered as the study's limitation. Also, no complete ability to complete the questionnaire and less cooperation of postmenopausal women and fear of revealing their life's conditions were other limitations of the study. Talking and empathizing with postmenopausal women, ensuring that their information is kept confidential, improved their cooperation.
Given the critical role of menopausal period, and the important effect of stress and violence and addiction of the husband on women's menopausal experiences, it is recommended that more studies be conducted on the extent of violence against women and its relationship with understanding the symptoms and experiences of menopause.
Also, the aspects of violence were directly correlated with women's menopausal experiences. Therefore, counseling and empowerment of women and appropriate training are recommended to improve the level of health literacy, reduce spouses' violence, and thus decrease negative menopausal experiences.
This study is a part of a M.Sc. thesis on midwifery at Shaheed Beheshti University of MedicalSciences. The study isapproved by the ethics committee of Shaheed Beheshti University of Medical Sciences. The authors would like to thank Dean Deputy for Research and Technology of the university, Dean of the Nursing and Midwifery School, Head of Midwifery Department, and participants.
Conflicts of interest
Authors declared no conflicts of interest.