Introduction

Chronic pain affects approximately 35% of older adults and is a leading cause of disability, but rates of pain double to 60–75% for older adults in underserved communities.^1–8 Quantitative studies have demonstrated that chronic pain interferes with work, social relationships, and activities of daily living.^1,9 Chronic pain also markedly impacts psychological functioning, with high rates of depression and anxiety, which can in turn cyclically exacerbate pain intensity and interference.¹⁰ Healthcare staff often have difficulty fully addressing the needs of patients with chronic pain, especially in under-resourced community clinics, where many underserved and historically marginalized patients receive their care.¹¹ Considering the perspectives of medical staff and older adult patients with chronic pain is crucial for developing treatments that fully meet the needs of patients in the context of the limited resources of community clinics.

There has been a recent push to understand how contextual factors intersect to impact health conditions, such as chronic pain, especially for individuals from underserved communities whose health is often affected by communal and structural factors outside of their immediate control.¹² In particular, the socioecological model (SEM) provides a framework through which to comprehensively view the interplay of factors that impact and are impacted by pain at four levels of analysis: individual, interpersonal, community, and societal.^13–15 Individual factors include the cognitive, affective, and behavioral experience of chronic pain, including interference of pain in work, social, and emotional functioning. Interpersonal factors represent those between two individuals or within a single family (eg, relationship satisfaction, relationships with healthcare providers), while community factors include the social (eg, culture, religion) and physical (eg, city transportation) context that the individual lives in. The structural level describes broader societal factors (eg, discrimination, healthcare policy), which dictate an individual’s place in society and the resources they have access to. The SEM is thus a helpful tool for organizing our understanding of a population that moves beyond focusing solely on the individual. While our interventions are mostly centered on addressing individual factors, previous research suggests all four levels may be relevant for the experience of chronic pain. For example, at the individual level, some older adults display an acceptance of their pain experience and understanding that pain is sometimes a normal part of aging,^16–18 while others experience increased depression and anxiety.¹⁰ These individual factors can be viewed in the context of interpersonal factors, including the dynamics of a family unit and the availability of social support.¹⁹ These in turn interact with broader cultural/community factors, such as language and ethnic cultural background, while societal factors (eg, discrimination) often exert stress on individuals that can exacerbate chronic pain.²⁰

While quantitative findings have enabled a general evaluation of the contributors to and effects of pain, qualitative methods are particularly useful for elucidating the contextual factors highlighted in the socioecological model. Qualitative methods can help to expound not just individuals’ quantitative ratings of pain interference but also the detailed ways in which pain interferes in their lives, as well as the contribution of interpersonal relationships to their pain, including relationships with medical staff. In explaining the specific ways in which pain interferes in their lives, older adults express particular frustration with their loss of ability to perform activities of daily living and subsequent feelings of uselessness due to pain and age.^16,21 This disrupted sense of self is paired with a sense of disconnect from others, and older adults report large impacts of pain on their relationships,²² including those with medical staff.^17,23,24 Meanwhile, medical staff report understanding the difficulty of living with chronic pain²⁵ while experiencing frustration with patients’ lack of willingness to acknowledge psychosocial contributors to pain.²⁶ All told, patients often experience chronic pain as a disabling condition that takes away their sense of who they once were, while medical staff feel the burden of educating and connecting with patients whose needs they cannot always meet. However, much of this existing research was conducted with higher-SES populations, and there is an absence of qualitative information regarding the communal and societal contributors to pain from the patient and staff perspective.

These existing qualitative analyses of chronic pain in older adults provide a foundation of information about the individual perspectives of medical staff and patients with chronic pain. An unmet need remains using qualitative methods to synthesize these perspectives in the context of the larger communal, cultural, and societal influences on chronic pain.^27,28 Further, given that most behavioral pain treatments were developed with higher SES populations in ethnically homogeneous trials,²⁹ it is especially important to consider these broader levels of analysis when seeking to understand the factors that interact with chronic pain for older adult patients in underserved settings. In these populations, aging is accelerated by a range of life factors, including increased financial stress,³⁰ and pain outcomes can be worse due to stressors, including class and ethnicity-based discrimination.^31,32 While the socioecological model has been used to examine the experience of a range of health conditions and behaviors,^33–35 it has yet to be used as a framework for the qualitative assessment of chronic pain for older adults in underserved communities. Such an analysis is essential for understanding the factors that impact and are impacted by chronic pain, including points of intervention across all socioecological levels of analysis. By understanding the comprehensive factors affecting the pain experience, we can better implement evidence-based pain management interventions in the community.

The present study aimed to elucidate individual, interpersonal, community, and societal factors associated with chronic pain from the perception of older adult patients and medical staff from a community health clinic, using qualitative analyses grounded in the socioecological model. Our primary research question centered on understanding the multi-layered factors influencing the pain experience in this clinic to inform future treatment development and implementation. We used thematic analysis to create a descriptive narrative of the experience of this patient population. This analysis will help to bridge the gap between patients and medical staff by identifying the commonalities and discrepancies between patient and staff perceptions of the factors that impact and are impacted by chronic pain for older adults in a community primary care setting. We also aim to broaden our understanding of the contextual circumstances that are often ignored in biomedically focused treatment planning.

Materials and Methods

Study Overview

We conducted 4 focus groups and 2 individual interviews with medical staff (n=25) and 3 focus groups and 7 individual interviews (n=18) with older adult patients (age 55+) with chronic pain at a primary care clinic in an economically and ethnically diverse community. Approximately half of patients in the clinic identify as Latino, Asian, Black, multiracial, and/or were born outside the United States. The purpose of these qualitative interviews was to understand the unique needs of diverse older adults with chronic pain in this clinic to inform the adaptation of a mind-body activity intervention, which was initially developed in a predominantly White, affluent sample. We followed the Criteria for Reporting Qualitative Research (COREQ)³⁶ in acquiring, analyzing, and reporting on qualitative data for this study.

Participants

Clinic Staff

For the staff groups and interviews, we purposively sampled and conducted groups based on clinic role (eg, primary care physicians, nurse practitioners, administrative staff) to gather a range of staff perspectives. The medical director, administrative staff, and clinic “champions” assisted with recruitment following a similar sampling procedure in a prior treatment development study in rural and low-income settings.³⁷ Participants did not have a prior relationship with the interviewers; however, they were made aware of the research purpose prior to participation.

Patients

We recruited older adults (55+) with chronic pain from a community health clinic using purposive sampling. Clinic champions and other clinic staff referred patients to the study. Staff who participated in the focus groups were encouraged to refer. Staff were encouraged to refer any patients with chronic pain who were 55 or older. Other participants self-referred through flyers posted in the clinic or through a clinic-wide platform for advertising research studies. The majority of patient participants were referred from providers (n=15) as opposed to flyer referrals (n=3). There were no prior relationships between the patients and the interviewers; patients were aware of the purposes of the research prior to participating. For both staff and patients, only those participating in the study were present in the qualitative assessments. Participant demographic characteristics are presented in Table 1. Patient participants were generally characteristic of those seen at the clinic, although we were unable to recruit patients from some immigrant communities due to language barriers (eg, Khmer and Arabic-speaking patients).

Table 1 Demographics for the Staff and Patient Qualitative Assessments, Mean (SD) and N (%)

Ethics Statement

The study was approved by the Massachusetts General Hospital Institutional Review Board (IRB), who determined that this qualitative study was exempt from written informed consent (protocol number: 2022P001691). The study complies with the Declaration of Helsinki guidelines for conducting research with human subjects. In accordance with IRB policies, participants reviewed a fact sheet, which included a statement that the deidentified results of the focus groups (for example, participant quotes) will be shared and published in relevant scholarly journals, and provided verbal consent to participate prior to data collection.

Procedure

We developed two semi-structured interview guides, one for staff and one for patients, using the socioecological model^13–15 and prior chronic pain literature.^38,39 The scripts began with general questions (eg, for patients: aspects of their personal background impact their pain), followed by questions probing at the environmental (eg, socioeconomic, employment, finances, caregiver roles), sociocultural (eg, culture, social support), behavioral (eg, behavioral changes due to pain), and medical factors (eg, managing pain and comorbidities) that impact and are impacted by pain. For the full interview guide, please see the supplemental material.

Two PhD-level clinical psychologists (female: KM, male: JG) and one master’s level research assistant trained by the clinical psychologists (one female: ME) conducted the focus groups and individual interviews either in person, using HIPAA-approved Zoom video calls, or through telephone audio calls. The PhD-level facilitators had backgrounds in chronic pain. All facilitators were cognizant of potential bias resulting from the discrepancy between their main work in an academic medical center to this community setting; probes were built into the interview guide to encourage facilitator openness to differences between the settings. One master’s level or bachelor’s level female trained research assistant (RA; ME, NL) took field notes during the interview that were then used in rapid data analysis (RDA).⁴⁰ We used RDA to evaluate thematic saturation (ie, was consistent information obtained throughout assessments) in a timely manner to inform the additional qualitative assessments. RDA involved deductively mapping field notes and observations from the qualitative assessment onto a template summarizing the interview guide. RDA was conducted with the RA and the interviewer in the 24 hours after the qualitative assessment. RDA notes were consolidated into a matrix, which was consulted during the larger coding process, following established procedures.⁴⁰ The matrix was created using a hybrid inductive-deductive manner by using the domains from the RDA template alongside pertinent information from the assessments. One row summarized the information reported in the present manuscript regarding the clinic population, while the other rows consisted of information related to pain treatment experiences and feedback on a proposed mind-body intervention.

The focus groups and interviews lasted between 30 and 60 minutes. Individual interviews were conducted with staff when there was a sole individual in a particular role (eg, clinic director, pain psychologist). Initially, we planned to conduct only focus groups for patient qualitative assessments but found this to be impractical due to scheduling conflicts (eg, numerous medical appointments) and other responsibilities (eg, caregiving) that made scheduling groups difficult for this patient population. We audio recorded, de-identified, and transcribed verbatim all interviews and focus groups. De-identified data was stored on a secure qualitative platform (Dedoose version 9.0.90), where it was coded. Neither data (ie, transcripts) nor results were returned to participants. There were no repeat interviews.

Data Analysis

We conducted a hybrid inductive-deductive thematic analysis of our transcripts, following the Framework Method.⁴¹ Step 1 was completed with the verbatim transcription of the interviews. Step 2 (familiarization with the qualitative data) was completed by the lead author (KM) and research assistant (NL), who conducted, reviewed transcripts, or were present for most interviews. In steps 3 (coding) and 4 (developing a working analytical framework), we (KM and JG) first developed two separate codebooks using a hybrid deductive-inductive approach. We pre-specified potential domains such as “individual factors” deductively based on the socioecological model. We used a deductive-inductive approach to specify potential parent and child codes such as “psychological factors (depression, anxiety, emotional distress)”, “resiliency factors”, or “health literacy” based on prior research in chronic pain and the socioecological model as well as information gathered from conducting the interviews and rapid data analysis.⁴⁰ We allowed for themes to overlap. JG and KM met to review and integrate preliminary codes into a single codebook. Next, the larger team (AP – PhD-level male clinical psychologist, CR – PhD-level female clinical psychologist, JG, KM, and NL) each reviewed a transcript and the RDA matrix summarizing the RDA findings to inform edits to the codebook. Using this iteration of the codebook, ME and NL independently coded 20% of the transcripts. During this “first pass” of coding they continued to inductively revise parent and child codes as novel information emerged from the data (eg, merging the codes for immigration status and citizenship, addition of physical function into a code for other individual factors).

After the two RAs coded 20% of the transcripts, they then met with CR and AP to discuss novel codes that emerged during the initial coding process and to examine the concordance between the coders’ coded transcripts. To ensure strong consistency in the application of codes, the team resolved coding discrepancies via discussion informed by the codebook. The team then updated the codebook to include the new, inductively derived codes. In step 5 (applying the analytical framework), the RAs used the refined, hybrid deductive-inductive codebook to recode the 20% of transcripts they initially coded and to code the remaining 80%. CR met with the RAs regularly during the coding process to provide guidance and problem solve as needed.

In step 6 (charting data into the framework matrix), we first extracted the coded excerpts from Dedoose and compiled into an Excel document. In step 7 (interpreting the data), AP and KM then independently and systematically reviewed the excerpts by creating summary codes, which were compiled into suggested themes and subthemes. AP and KM then met to discuss the emergent patterns from the excerpts, and to finalize themes and subthemes.

Results

A summary of the findings and illustrative quotes is presented in Table 2.

Table 2 Socioecological Model Domains, Themes, and Illustrative Quotes

Individual Domain

At the individual level, we identified three themes: 1) Older adults with complex care needs. (Subthemes: 1a) Multimorbidity, 1b) Multiple life stressors, and 1c) Low health literacy); 2) Impact of pain (Subthemes: 2a) Physical functioning, 2b) Emotional functioning, 2c) Work participation and financial insecurity, 2d) Identity); and 3) Coping with pain (Subthemes 3a) Adaptive coping and 3b) Maladaptive coping).

Older Adults with Complex Care Needs

Multimorbidity

Medical staff described their older adult patients with chronic pain as often presenting with complex medical and mental health comorbidities. Older adults with chronic pain presented with a wide range of pain conditions, including arthritis, back pain, neck pain, irritable bowel syndrome, herniated discs, and neuropathy. Comorbidities included diabetes, sickle cell anemia, obesity, depression, anxiety, and bipolar disorder. Many patients reported previous falls and fear of falling again. There were also interactions between comorbidities, including an interplay between physical and mental health conditions.

Multiple Life Stressors

Staff and patients highlighted multiple stressors patients face that exacerbate pain, including financial concerns, grief, and trauma. Patients described multiple stressors co-existing and compounding each other to the extent that it was difficult to engage in stress management.

Low Health Literacy

Staff highlighted that many patients within the clinic have difficulty understanding medical concepts and had little knowledge of the medical system. They noted that some patients do not know the difference between the roles of different medical staff, and others do not have a primary care physician to help them navigate the healthcare system. Staff expressed that patients often lacked understanding of pain education and that providers struggle to have the resources in both time and training needed to address these deficits.

Impact of Pain

Patients and staff reported negative effects of pain on multiple types of functioning with interactions between physical functioning, emotional functioning, work participation and financial insecurity, and identity. Pain was noted to worsen patients’ mobility, which often led to difficulty with work, increased depression and anxiety, and feeling like they could not be the selves they once were.

Physical Functioning

Staff and patients described the patient population as one with many mobility difficulties resulting both from pain itself and fear of pain. They noted bidirectional relationships between the physical and emotional experience of pain. Some patients expressed the fear that physical movement would lead to an increase in pain, which led to greater sedentariness. Other patients described stopping activities that they used to enjoy because of the perception that the cost of completing them was too much.

Emotional Functioning

Both staff and patients discussed the negative impact of pain on emotional functioning. Patients particularly described fear of pain and increased emotional reactivity to pain, including irritability, anxiety, depression, and helplessness. For example, one patient noted the interaction between pain’s impacts on physical and emotional functioning by stating, “When you have pain, you are in such misery, you do not want to do anything.”

Work Participation and Financial Insecurity

Many patients reported that they had lost the ability to participate in work at their prior ability level due to pain; others reported being unable to work altogether and needing to rely on disability. This in turn led to feelings of financial insecurity, which interacted with impacts of pain on physical and emotional functioning.

Identity

Some patients expressed strong beliefs about the immense impact of pain on their lives across multiple domains, leading them to feel unlike the person they were before pain. Many expressed that they could not do the activities that used to be core to their sense of self and felt that they will always be limited in these ways because of their pain.

Coping with Pain

Adaptive Coping

Some patients described maintaining a resilient outlook characterized by acceptance of pain and willingness to engage in physical activity despite pain. Others reported finding creative ways to cope with pain and embracing identity changes in positive ways through the learning of new coping skills.

Maladaptive Coping

Some patients exhibited stoicism and expressed that they had been taught to push through pain, while others exhibited avoidance of activity due to fear of exacerbating pain. Additionally, staff expressed that some older adults in the clinic exhibited a maladaptive acceptance of pain, such that they did not seek treatment that could improve functioning.

Interpersonal Domain

At the interpersonal level, we identified the following themes: 1) Complex relationships with social supports and 2) Complex relationships with medical staff.

Complex Relationship with Social Supports

Both patients and staff shared that quality of social support was critical for coping with pain. Many patients perceived that social support and connection enable them to stay active despite pain, to cope emotionally with the effects of pain, and to reduce the intensity of pain. Still, others discussed their willingness to prioritize social connection despite pain. Both patients and staff also highlighted the important role that instrumental social support plays in coping with pain.

On the other hand, many discussed complexities and barriers to connecting with social supports. Many patients expressed that the pain experience is isolating, and often leads to losing social experiences and entire relationships due to mobility concerns. In addition to physical limitations, some patients described the negative impact of emotional reactivity, including irritability, shame, and guilt, on social relationships. Others noted that the experience of pain can strain their relationships, such as feeling invalidated. Both patients and staff discussed patients’ concerns about becoming a burden on their family, leading to withdrawal, so as to not ask too much of social supports.

Patients and staff also discussed that interpersonal responsibilities could lead to barriers to instrumental support, including assistance with transportation to medical appointments. Some patients, especially those from lower-income backgrounds, relied on their working children for transportation and had caregiving responsibilities that sometimes necessitated prioritizing others’ well-being over their own.

Patients and staff discussed how family dynamics can help patients cope with pain but also contribute to sedentariness over time. For example, social supports can remove the burden of physical activity away from older adult patients, but this can also decrease function long term.

Complex Relationships with Medical Staff

Patients and staff described the patient–staff relationship as being important but sometimes contentious. They described a disconnect between expectations of pain treatment from staff and patients, with patients being more solution-focused with greater expectations for pain management. Patients expressed concerns about invalidation and at times feeling misunderstood or abandoned by medical staff. Staff reported that the strongest relationships exist between patients and medical interpreters and that due to these trusting relationships, patients share more with interpreters than they do other staff.

Community Domain

At the community level, we identified two themes: 1) need for community resources and 2) need for culturally informed care.

Need for Community Resources

Nearly all patients and staff discussed a considerable need for community resources to facilitate or encourage older adults with chronic pain to walk. In particular, participants discussed the need for safe outdoor amenities and affordable indoor facilities to adapt to the local colder climate. They noted that while there were safe places to walk in the warmer months, the community lacked resources for encouraging physical activity in the colder months, especially with surfaces that were suitable for older adults with chronic pain.

Need for Culturally Informed Care

Staff discussed the need for tailored care at the clinic, including a need for chronic pain programming to be delivered in groups of older adults with similar culture and language to aid in establishing cohesion. Many shared how the large ethnolinguistic diversity of the clinic population can create challenges to providing equitable and culturally adapted pain treatment, especially given that there is no single majority ethnic population that the clinic serves.

Staff described difficulty bridging the cultural, linguistic, and generational divide between staff and patients, especially those who speak languages other than English. Staff and patients also discussed the importance of religious institutions and cultural values to some patients. They noted ways in which cultural factors impact pain treatment, including that there may be practices of families providing support at the expense of patient mobility and independence. They also discussed that a subset of the community clinic population encountered many traumas prior to emigrating to the United States, which thus requires trauma-informed care.

Societal Domain

At the societal level, we identified one theme: Socioeconomic and immigration status impacts the availability of resources for managing chronic pain.

Patients and staff reported a discrepancy between individuals with access to resources and those who depended on insufficient or unavailable government services, including foreign-born patients who lacked access to programming. Staff also noted that some patients were limited in the types of jobs they could work and were more likely to have labor jobs that increased their pain and necessitated greater demand for time-limited pain treatments. Socioeconomic status interacted with issues at other socioecological levels, including increasing stress and frustration and worsening multimorbidity, including through lack of access to healthy food.

Discussion

We conducted a qualitative analysis informed by the socioecological model of the individual, interpersonal, community, and societal factors associated with the experience of living with chronic pain as perceived by older adult patients and medical staff from an underserved community clinic. We aimed to understand the contextual factors influencing the pain experience in this population in order to inform treatment implementation. Patients and staff noted a high burden of pain on older adult patients combined with complexity in their relationships with their personal social support systems and their relationships with medical staff. Further, community resources were noted to be limited in comparison to the need for resource-intensive, culturally informed care. Societal factors, especially socioeconomic status, interacted with these factors to increase the negative impact of pain. Variability was noted as well, with some patients experiencing more resilience, support, and resources than others. There were interactions between the domains at all four levels of the socioecological model, suggesting that the standard approach for pain management to intervene only at the individual level is likely to be inadequate for patients in the community.

Regarding individual factors, staff and patients highlighted that older adults at the clinic had complex care needs, with many comorbidities and stressors. Some themes were similar to what has been reported in existing qualitative analyses of older adults with chronic pain, including the large impact of pain on functioning and sense of identity^16,21 and the bidirectional relationships between physical and emotional functioning,^10,28 which can create a spiral of increased disability and sedentariness over time. At the same time, staff noted greater complexity in this patient population compared to more affluent populations and a tendency for individual factors to compound each other in ways they may not for patients with greater access to resources and support. For example, staff noted that although older adult patients with chronic pain often present to the clinic with more psychiatric and medical comorbidities, they also often exhibit low health literacy that made it difficult for them to navigate the medical system to gain access to care for these conditions. Patients were also more likely to have financial stressors, including those resulting from the impact of pain on occupational functioning, which can then contribute to elevated emotional distress and worse pain.

In addition to interactions within factors at the individual level of the socioecological model, there were also interactions between individual, interpersonal, community, and societal factors. Patients and staff emphasized the importance of social support and connection to facilitate physical activity and emotional coping. Many patients noted that their support systems were crucial to living well despite pain. In contrast, many patients also endorsed feelings of isolation in association with their pain condition, including fewer social interactions and lost relationships. An individual’s emotional reactivity to pain could have strong effects on interpersonal functioning, including increased irritability, shame, and guilt, which could then worsen relationships in a bidirectional cycle. At the societal level, patients of lower SES endorsed more complex family dynamics and greater caregiving responsibilities that necessitated prioritizing others’ well-being over their own.

Across domains, an absence of resources commensurate with the needs of the population was noted. In keeping with prior qualitative research,^17,23,24 staff noted being unable to meet the needs of patients’ treatment expectations with the resources at their disposal, and patients endorsed feeling at times invalidated and disconnected from their medical staff. At the community level, patients and staff noted a need for more community resources both physically and culturally, including resources to facilitate older adults’ engagement in safe physical activity. Of specific concern was a lack of indoor community spaces for exercise during the winter when the weather is unfavorable and hazardous for older adults. Further, given the ethnolinguistic diversity of the community, staff also identified a need for more programming to be delivered in patients’ languages and with staff from the same culture than was available based on existing clinic resources. At the societal level, the intersectionality between societal factors (eg, SES, immigration status) and individual factors was noted because lower SES patients can endorse greater pain severity (eg, from working labor-intensive jobs without access to options for alternative employment), more stressors and worse overall health (eg, more comorbidities, less access to healthy diet) and reduced access to resources for managing chronic pain. Foreign-born and older adult immigrant patients were found to be disadvantaged in their access to resources (eg, adult daycares) that could increase health and socialization, a key factor at the interpersonal level.

Existing pain management therapies typically intervene only at the individual level.²⁹ Our findings suggest that the individual experience does not exist in a vacuum but rather is greatly intertwined with interpersonal, community, and societal factors. Thus, to implement evidence-based pain interventions for older adults in the community, we need to tailor them to consider all levels of the socioecological model. For example, to address the considerable multimorbidity that can result from a lifetime of higher stress and lower health literacy/access to care, it is important to include a medical check-in within the context of a pain intervention. Medical check-ins can be incorporated into shared medical visits,⁴² which also facilitate group cohesion to address the isolation at the interpersonal level and can reduce the need for as many trained staff that the community does not have in resource-strapped clinics.¹¹

The present study has several limitations worth noting. In this initial qualitative analysis, we only interviewed English-speaking patients. Qualitative research targeting the needs and treatment experiences of linguistic minorities with chronic pain is needed. Additionally, while we were very successful with recruitment for the staff focus groups and interviews, recruiting patients was more difficult because of competing demands on patients’ resource-strapped time. Thus, it is likely we missed patient perspectives of those for whom life’s demands interfered, including many of the patients the staff discussed as having the most difficulty coping with chronic pain.

Conclusion

The present study provides important perspectives on the intersection between individual, interpersonal, community, and societal factors on the chronic pain experience for older adults in an underserved community clinic. Older adult patients and staff described considerable complexity among this patient population, with various stressors, comorbidities, interpersonal difficulties, and communal and societal factors impacting pain. Patients with more financial strain, less social support, more responsibilities, and cultural complexity tended to need more resources than they had available at the clinic. Older adults in underserved community clinics may be more likely to have broader community and societal factors that impact their already complex individual and interpersonal experience of their health, yet many interventions are developed to address factors at the individual level only. Our findings highlight the crucial need to develop pain management interventions to address the intersecting individual, interpersonal, community, and societal needs of older adults with chronic pain in the community.

Data Sharing Statement

Our qualitative study was not pre-registered. The analysis plan of this manuscript was not formally pre-registered. De-identified data from this study are available in the Vivli data repository. There is no analytic code associated with this qualitative study. The interview is available in the supplementary material for this manuscript.

Acknowledgments

Christine S Ritchie and Ana-Maria Vranceanu are co-senior authors for this study. This study was funded by the HEAL Initiative (https://heal.nih.gov/): Advancing Health Equity in Pain Management. We also thank those who provided meaningful contributions by way of thoughtful study participation.

Funding

This work was supported by the National Institute on Aging/National Institute of Neurological Disorders and Stroke [1R61AG08103402 to AMV and CR], the National Institute on Aging [3R61AG081034-01S1 to KM], and the National Center for Complementary and Integrative Health [K24AT011760 to AMV, K23AT012789-01 to KM, K23AT01065301A1 to JG, K23AT012363 to TP].

Disclosure

The authors report no conflicts of interest in this work.

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21. Simonsen Lentz P, Havelund Rasmussen A, Yurtsever A, Melgaard D. Missing diagnosis, pain, and loss of function in older adults with rheumatoid arthritis and insufficiency fractures: a qualitative study of the patient’s perspective. Geriatrics. 2020;5(4):94. doi:10.3390/geriatrics5040094

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Introduction

A serious global public health concern, violence against women affects not only the health of the victims but also that of their families and society as a whole. Physical violence is defined as using force against another person by shoving, biting, slapping, stabbing, shooting, or pinching. Verbal abuse is the use of words to cause harm to the person being addressed. Although brutal, it is still the least acknowledged violation of fundamental human rights.¹ Any behavior that threatens, intimidates, or diminishes the victim’s sense of self-worth or self-esteem is considered emotional, intimate partner violence (also known as psychological or mental abuse).^2,3 Sexual violence occurs when a wife is physically coerced into having sex against her will, coerced into having sex out of fear, or coerced into doing something sexual that she finds demeaning or humiliating.^2,4 Economic abuse happens when an intimate partner has control over the victim’s finances.^2,5

According to estimates, 35% of women worldwide have experienced intimate partner violence (IPV) at some point in their lives.2 Nevertheless, because abuse against women is frequently unreported, this figure is probably underestimated. Thirty percent of women report experiencing physical or sexual abuse at the hands of their relationships. A WHO poll conducted in ten countries revealed that between 15% (Japan City) and 71% (Ethiopia Province) of women who had ever been in a relationship reported having suffered physical or sexual abuse (or both) at some point in their lives from an intimate partner.⁶ It is alarming to learn that men, usually men in their close social circles, are responsible for almost 4 out of 10 (38%) female homicides.

The field of IPV research is lacking in the Middle East.⁷ A systematic review of IPV prevalence in Arab countries found that the reported prevalence (ever) ranged from 6% to more than half (59%) for physical abuse, from 3 to 40% for sexual abuse, and from 5 to 91% for emotional/ psychological abuse.⁸ A study on women accessing medical facilities in Alexandria, Egypt in 2012 found that 77% of the women had experienced domestic abuse.⁹ A previous study found that the lifetime prevalence rates of emotional, physical, and sexual abuse were 39%, 30%, and 6% respectively.¹⁰

The lifetime prevalence rate of intimate partner violence (IPV) varies from 35% to 45% in different parts of the Kingdom.^11–16 According to earlier research, between 20% and 30.3% of female patients in primary care clinics in Riyadh,¹⁷ central Saudi Arabia, and Al-Jawf province, northern Saudi Arabia,¹⁸ had experienced IPV in the previous year. According to previous surveys, 39.3% of married women in Al Ahsa,¹¹ the eastern province of Saudi Arabia, and 34% of married women in Jeddah,¹² western Saudi Arabia,¹² reported having experienced violence at some point in their lives. The disparity most likely results from differences in each local sub-community’s sociodemographic makeup.

Women’s acceptance of their beliefs about domestic abuse reveals their status in a particular social and cultural context and provides insights into the social, cultural, and behavioral transformation stage of the countries’ evolution towards a gender-democratic society.^19–24 Women’s perceptions of men’s power over women’s behavior and the cultural acceptance of that power are the best indicators of domestic violence, according to studies.²¹ A systematic evaluation of 15 Ethiopian studies²⁵ found that over 50% of women support domestic abuse. These perceptions have a negative impact on women’s lives in several ways, including re-victimization, seeking help when needed, and the effectiveness of government and non-governmental organizations’ efforts to reduce domestic abuse.^19,26,27 Reasons for using violence included burning food, fighting with the spouse, leaving the house without telling anybody, neglecting the child, refusing sex, being unfaithful, defying, and having suspicions of adultery. Sayem et al²⁸ found that approximately 49.5% of Bangladeshi women who experienced physical violence believed that a man should be able to beat his wife. The proportion of women who think their husbands should be allowed to beat their wives was higher among rural women.²⁹

When discussing varying levels of women’s independence, “autonomy” and “women’s empowerment” are frequently used interchangeably. Most studies focus on women’s decision-making and physical autonomy (movement freedom).¹¹ Numerous studies have examined other facets of autonomy, including speaking one’s mind, keeping one’s health, and participating in the labor force.³⁰

Social conventions in Saudi society restrict the choices available to women, even with education.¹¹ However, this empowerment may not protect them from domestic abuse. A recent evidence assessment evaluating preventative interventions for violence against women and girls concluded that there was “insufficient evidence to recommend social empowerment interventions”.³¹ A study of 744 married Indian women living in urban areas found that career training and social clubs—participatory treatments meant to enhance women’s social empowerment—increased the risk of domestic violence.³² Due to the dearth of data and the adverse health effects Saudi Arabian research has shown, a current study that links the prevalence rate to protective and risk factors is necessary. A prior study conducted in Bangladesh found that longer-married, more powerful women were less likely to experience physical abuse. This might be the case because, in Bangladeshi society, a stronger woman obtains some protection against physical abuse during a longer marriage. This is expected since women are shielded by having more children as their marriages last longer. The discovery that more powerful women who had only sons were less likely to experience physical abuse lends credence to this.³³

Studies contend that women’s empowerment can give women the autonomy and power to mitigate IPV through education, enabling them to know their place in society.³⁴ Empowerment is associated with lower levels of intimate partner violence (IPV) revictimization, though the direction of this association is still unknown. This claim, though, appears pointless because some strong-willed women nonetheless encounter IPV.^35,36 Empowerment was linked to better outcomes for six months among women who experienced IPV in a prospective national study of women veterans from all eras of military service living in US households.³⁷ The study’s conclusion suggested that empowerment may play a significant role in protecting IPV victims from unfavorable outcomes in the future. These findings support the idea that empowerment plays a crucial role in helping victims of violence recover.^38,39 An investigation into whether women’s empowerment guarantees a decrease in intimate partner violence (IPV) in Bangladesh found that older cohorts of more empowered women were more vulnerable to physical violence than younger, less empowered women.³³ Less empowered women who were childless had a higher chance of experiencing physical violence than more empowered women who had only male children. Compared to more empowered, primary-educated women, women with less education and power were more likely to be victims of physical abuse. Compared to more powerful women who had been married for over 19 years, less powerful women who had been married for less time were more likely to experience physical abuse.

The most important challenges in achieving the Sustainable Development Goals (SDGs) are closing the gender gap and empowering women. Women who are empowered will have greater freedom of movement, financial and social independence, and family decision-making authority. In addition, this would eventually lead to the adoption of contemporary contraception, prenatal care, institutional delivery, trained birth attendance, and—above all—a superior standard of health for children. Further comprehensive research is necessary to ascertain the impact of women’s empowerment on intimate partner violence (IPV).^40,41 The Saudi Arabian government implemented the Law for Protection against Abuse in September 2013, which aims to protect against all forms of abuse and to provide social, psychological, and medical treatment. According to the Saudi Vision 2030, women would have more freedom to travel, new career options, and more autonomy and decision-making authority (a driver’s license was first provided in 2016). The recent spike in women’s empowerment in the workforce and society will influence future research conducted in Saudi Arabia on the prevalence of intimate partner violence.

In our previous study, we asked 400 married women attending the Ministry of National Guard-Health Affairs primary healthcare centers in Riyadh, Saudi Arabia, to rate the prevalence of various forms of domestic abuse and the factors that contribute to it.⁴² We found a 44.8% lifetime overall prevalence of IPV. The present study used the same data to investigate three main areas: (1) the level of views Saudi women have towards IPV, (2) their relationship to IPV prevalence, and (3) the relationship between women’s empowerment and IPV prevalence in Saudi Arabia. This study was conceived based on the growing concern about violence against women, particularly by intimate partners, but also the lack of knowledge regarding the underlying risk factors that are related explicitly to husbands and women’s empowerment traits. In Saudi Arabia, no prior research has looked into the potential connection between IPV and women’s empowerment. This could serve as a springboard for future nationwide studies.

Materials and Methods

Study Area/Setting

Saudi citizens, National Guard members, and their relatives can receive state-of-the-art medical care from National Guard Health Affairs, a sizable healthcare institution. Four of Riyadh’s top main and secondary care facilities serve the population that visits National Guard Health Services. The following primary healthcare facilities’ out-patient clinics were used to recruit participants: 1) King Abdulaziz Iskan City Clinic (which serves 60,000 people); 2) Khashm Al-Aan Clinic (which serves 150000 people); 3) Umm Al-Hammam Clinic (which serves 90,000 people); and 4) Dirab clinic (which serves 10,000 people).

Study Subjects

Married women between the ages of 15 and 65 who participated in outpatient clinics at Ministry of National Guards-Health Affairs (MNG-HA) primary care centers in Riyadh during the survey were included in our study. Women who came with their spouses were not allowed.

Study Design

This study is an analytical cross-sectional research.

Sampling Method and Sample Size

An estimated 350 women were needed, based on a 25% global lifetime prevalence rate of women impacted by IPV² (the degree of precision is considered to be 0.05 and 95% CI). To compensate for the incompleteness of the data collection, 400 married women were sampled.

The target population for the study consisted of all married female patients between the ages of 15 and 65 who were willing to participate in the outpatient clinics at the primary healthcare centers (PHCCs) of the NGHA in Riyadh. With the premise that the distribution of females matches the precise distribution of the catchment area of the four PHC centers, a straightforward random selection procedure was used to choose samples proportionate to the size of the entire catchment area of each center (as previously noted). As a result, 190 individuals from Khashm Al Aan, 115 from Umm Al Hamam, and 15 from Dirab PHCCs were selected as participants for Iskan.

Data Collection

1. Attitude toward IPV:

The WHO multi-country (WHOMC) VAW instrument, validated in Arabic, was used in this study.^6,43 The questionnaire contained a part on attitudes towards women’s roles in society and when a husband has the right to abuse his wife. Based on this section, 10 items regarding attitudes towards IPV were answered on a 3-point Likert scale: agree (0 points), disapprove (2 points), and not sure (1 point). The total and percent mean scores (PMS) were calculated for each woman. Each woman’s attitude was divided into three categories: “positive” (>80%), “neutral” (60–80%), and “negative” (<60%).

B. Assessment of women’s empowerment:

Based on data from the 2000 National Health Survey of Oman, Al Riyami and Afifi³⁰ developed a questionnaire for this assessment. The women’s empowerment module includes two indices measuring women’s participation in decision-making and freedom of mobility.

1. The decision-making process: We asked married women, “Who gets the last word on”. The eight things that involve making decisions are cooking, family planning, spending money on the house, buying clothes for the kids, medicine, health care, problem-solving, and seeing family. A woman is empowered for everything when she accepts responsibility for her choice. The decision-making index had eight points; a woman with an index value of zero is considered least empowered, and a woman with an index of eight is considered most empowered. The reliability of the decision-making index was evaluated using the Cronbach-alpha coefficient, which had a value of 0.56.³⁰ The continuous variable was then converted to a bivariate by applying a cut to the score higher than the 25th percentile.
2. Freedom of movement. Married women were asked, ”Does your husband allow you to go alone? For six locations: shopping, visiting a hospital or health facility, dropping by a child’s school, seeing friends and family, and going for a walk. In such field, a woman is considered powerful if she can go alone the majority of the time, if not always. The index’s point value ranges from 0 to 6. Regarding freedom of movement, women who score zero are the least empowered, while those who score six are the most empowered. This index’s Cronbach-α coefficient is 0.82.³⁰ A cut score greater than the upper 25th percentile was then utilized to turn the continuous variable into a bivariate. Women in the other group were perceived as having great authority, whereas those who scored between 0 and 5 had little freedom of movement.

C. IPV screening as an outcome measure:

This study used the WHO multi-country (WHOMC) VAW instrument, which has been validated in Arabic.^6,43 The questionnaire consists of 12 components. The questionnaire included sections on demographics, IPV, and injuries to the respondent and her partner that were deemed culturally appropriate to enquire; other sections on general health were left out. The four forms of IPV that are covered by the modified questionnaire are (1) physical violence, (2) emotional abuse, (3) sexual abuse, and (4) economic abuse.

Data on the following was gathered for every form of IPV:

1. The degree and frequency of violent experiences in the past and present, whether they were frequent, infrequent, rare, or never. When a person answered “always” to any of the IPV items, violence was taken into consideration, and the prevalence of various forms of violence was calculated in accordance. Based on the woman’s reporting of one or more forms of violence, the overall prevalence of IPV was assessed.
2. Reasons for IPV: The Family Violence Prevention Fund’s suggested screening questions were used to determine these causes.⁴³
3. The history of child abuse and maltreatment by the woman and her husband, including beatings, sexual harassment, witnessing the father hit the mother, etc.
4. Demographic information about the lady and her spouse, such as age, education, occupation, and income, as well as their relationship, such as consanguinity, length of marriage, subsequent marriages, cohabitation in the same home, and additional children from previous marriages. A thorough explanation of the questionnaire’s components was provided in our earlier study.⁴²

The National Family Safety Program (NFSP) data collectors at MNG-HA in Riyadh were invited. The NFSP is a unique national program in Saudi Arabia that combats IPV by raising public awareness, creating preventative efforts, and providing support to victims of abuse. The staff members of this program are specialized social workers and researchers who have conducted research, dealt with women on delicate matters, addressed confidentiality issues, and provided participants with safety strategies in case they report IPV. We made sure that none of these staff members worked in primary health care (PHC) clinics to reduce any potential adverse effect on recruitment should it turn out that any of them knew the ladies or had previously visited them. They approached the woman about participating in the study while waiting to see the doctor. They were trained in data collection techniques, privacy assurance, and effective communication strategies. The best ways to approach participants were as follows: (1) establish trust; (2) comprehend the dynamics of intimate partner violence; (3) comprehend the safety and autonomy of abused women; (4) learn how to ask questions about abuse; and (5) be straightforward and nonjudgmental.⁴⁴ Women were informed they could withdraw from the study or not participate.

A pilot study was carried out to determine if the study would be feasible in terms of participant willingness, the number of women recruited in each clinic, the most efficient way to approach participants, the time needed to complete the questionnaire, and possible dropout reasons. It also helped us decide if the validity and reliability of the tool were adequate. Twenty pilot study participants were selected, randomly evaluated, and subsequently excluded from the main trial. The results of the pilot research were taken into consideration while making any necessary modifications.

Data Management

Data input and statistical analysis were performed using IBM Corporation’s SPSS^® version 20.0 (Armonk, NY, USA). Descriptive statistics, such as percentages, frequencies, means, and standard deviations, were used to measure the attitude statement responses and demographic characteristics. Before determining which statistical test to employ, the Shapiro–Wilk test was used to examine the data for normality of the following variables: women’s empowerment score, women’s attitude score, and women’s age. The association between women’s views (positive, neutral, and negative) and degrees of empowerment (empowered and non-empowered) with all forms of IPV and total violence was investigated using analytical statistics. These included the Mn-Whitney test, the Person Chi-square test, and the Chi-square test for linear trend. The following independent variables were used in the logistic regression analysis to see if women’s empowerment could independently predict IPV: woman’s age (in years), women’s attitude (score), husband’s and wife’s experience of child abuse (yes versus no), women’s empowerment (score), and polygamy (yes versus no). A p-value of 0.05 was used in all analyses to indicate statistical significance.

Results

The Demographic Traits of Wives and Their Spouses

The demographic characteristics of women and their spouses are shown in Table 1. About 96% of women lived with their spouses, and for 97% of women, this was their first marriage. According to 14.8% of women, their husbands were living with other spouses, and 29.4% of those husbands were married to other individuals. Of the women surveyed, 64.1% said they were married to a relative (44.4% to 19.7%, respectively). According to Table 1, 59% of husbands and 40.5% of women said they had experienced abuse as children.

Table 1 Sociodemographic Characteristics of the Study Sample

Women’s Beliefs and Attitudes on the Abuse of Women

Among the overall number of women, 54.9% held a positive opinion on women being assaulted, 15.5% had a negative attitude, and 29.6% held a neutral attitude. While 29.7% of all women believed that a wife should sleep with her husband regardless of her desires, around one-third (34.8%) felt that a woman should obey her husband regardless of her opinions. Table 2 shows that women thought that a husband should be allowed to beat his wife if she is suspected of treason (27.8%), leaves the house without informing him (21.4%), or neglects to raise the children (18.4%).

Table 2 Women’s Response to Beliefs and Attitude Statements to Women’s Violence

Empowerment of Women

Over two-thirds of women (67%) and one-third (33%) were classified as less empowered based on the decision-making measure (Table 3). Table 4 shows that 40% of women were classified as less empowered and 60% as highly empowered based on the Freedom to Move index.

Table 3 Response of Women to Decision-Making Process Index

Table 4 Response of Women to Freedom to Move Index

Association Between Attitude and the Occurrence of IPV

Between women who reported a positive attitude towards IPV (ie, being against abuse) and those who reported neutral or negative attitudes (ie, agreeing to be abused by husbands), the prevalence of IPV increased significantly (χ2_LT=4.35, p=0.037) to 45% and 56.8%, respectively. A strong correlation was found between the attitude level and the overall prevalence of IPV. (Table 5 and Figure 1)

Table 5 Prevalence of IPV according to Women Empowerment and Women’s Attitude to Violence

Figure 1 Association of women’s empowerment and women’s attitude to IPV with IPV prevalence.

Association Between Empowerment and IPV Prevalence

There was a significant correlation (p<0.001) between the women empowerment decision-making process index and all forms of domestic abuse. Empowered women reported a significantly lower prevalence of total IPV (30.1% versus 77%, χ2=74.91, p<0.001) than non-empowered women. Only physical types of IPV showed a significant correlation with the measure of women’s empowerment known as freedom of movement. The rate of domestic violence reports by empowered women was significantly lower (16.2% versus 27.7%, χ2=5.77, p=0.016). (Table 5 and Figure 1).

Figure 2 shows the correlation between the mean score of women’s empowerment and the reporting of violence against intimate partners. A significant relationship was observed between the reporting of abuse and lower mean perceptions of women’s empowerment in all types of abuse.

Figure 2 Association between women empowerment (mean score) and reporting of intimate partner violence.

In the logistic regression study of IPV, women’s empowerment was included as an independent variable after controlling for the age of the wife, women’s attitudes towards IPV, the wife and husband’s experiences with child abuse, and polygamy. Women’s empowerment was a protective factor (OR=0.734, 95% CI: 0.63–0.85) against IPV, whereas the wife’s history of child abuse was a risk factor (OR=3.98, 95% CI: 1.88–8.42). (Table 6).

Table 6 Predictors of Intimate Partner Violence Among Women

Discussion

Forty-five percent of the 400 Saudi women surveyed said they have been victims of IPV. Compared to non-empowered women, empowered women had a significantly reduced prevalence of IPV when it comes to decision-making and mobility. When possible confounders were considered, women’s empowerment was a significant IPV protective. There was some, but not much, correlation between a favorable attitude towards IPV and a lower risk of domestic abuse.

Women’s acceptance of their views regarding domestic abuse reveals a lot about their status in a given social and cultural context and provides insights into the social, cultural, and behavioral transformation stage of the countries’ evolution towards a gender-democratic society.^19,26,27 A systematic review of fifteen studies found that more than 50% of women support domestic abuse. Among the reasons given were food burning,^19,27,45 arguments with the spouse,^{19,26,27,44,45} leaving the house without telling the husband,^{19,26,27,43,45} child neglect,^19,26,27,45 refusing sex,^{19,25–27,43,45–48} being unfaithful,^{19,25,43,46,47} disobeying her husband,^19,25,48 and suspicion of infidelity.^19,25,47,48 In our study,15.5% of the women said they had a negative attitude, which meant they put up with their husbands’ mistreatment. A third of the ladies agreed that a wife should obey her husband’s orders even if she is not convinced to do so and should sleep with him even if it makes her uncomfortable About 25% of women agreed that a husband had the right to beat his wife if she was accused of betraying him, leaving the house without warning him, or not giving the kids enough attention. These findings were consistent with a prior study that examined the extent and correlates of conditional acceptance of wife-beating among men and women in Benin, Ethiopia, Malawi, Mali, Rwanda, Uganda, and Zimbabwe using data from the demographic and health surveys (DHS).⁴⁹ The study demonstrated that wife-beating was widely accepted by both men and women in all the countries examined under specific conditions. It was nearly universally accepted in Uganda, Mali, and Ethiopia. A prior survey indicated that some women consider beating to be a regular and loving behavior.⁵⁰

Rules or standards of behaviour in society that people choose to follow even when they break them are known as cultural and social norms that encourage violence.^22–24,51 The Saudi Law for Protection against Abuse⁵² addresses behavior in society that is considered unpleasant and may foster an environment that is favorable to abuse. Additionally, it broadens the public’s comprehension of what constitutes abuse and its repercussions while creating valuable and scientific instruments to combat it. It also provides legal processes for the prosecution and holding perpetrators accountable It was discovered that there was a substantial correlation between the attitude and the overall prevalence of IPV. In particular, the prevalence of IPV was much lower among women who expressed positive views regarding IPV—that is, those who do not accept being mistreated by their husbands—than among those who reported neutral or negative attitudes. However, after controlling for confounding variables, women’s attitudes toward IPV were not a significant predictor of IPV prevalence. To put it another way, attitude might not be sufficient to end IPV.

There may be differences in the pattern of IPV in less industrialized environments compared to more industrialized ones.⁵³ The context influences the intensity of the violence; traditional rural settings typically have higher rates of violence than urban settings.⁶ Women who lack social and economic authority are more vulnerable to domestic abuse.^54,55 In our research, women who felt empowered reported significantly lower rates of domestic abuse. Even after taking into consideration the wife’s age, women’s views towards IPV, and the wife and husband’s histories of child abuse and polygamy, women’s empowerment remained a protective factor. As a result of women’s empowerment, the prevalence of IPV may decrease by more than thirty percent. All forms of IPV were found to have a strong correlation with the women empowerment decision-making process index in our research. The results of our investigation corroborated those of a prior study,⁴¹ which discovered that women with more remarkable decision-making ability had a much lower incidence of IPV. Although not significantly, women who scored higher on autonomy were less likely to be victims of intimate partner violence. Previous research has also reported this correlation.^33,56,57 It is possible that this association stems from the fact that higher decision-making facilitates open communication, compromise, and problem-solving, lowering the risk of disagreements turning violent in intimate partner relationships. Another possibility is that women who actively participate in decision-making subvert stereotypes and conventional gender norms, which uphold unequal power dynamics.⁵⁸ This subverts the underlying beliefs that may encourage abusive behavior.

In India, it was discovered that women’s economic independence was a risk factor for intimate partner violence (IPV).⁵⁹ Women’s empowerment, in conjunction with gender equity, can lower the incidence of violence against women. This might result from their increased family participation and the ensuing disagreement over decisions about how to spend their money and what to do about their kids’ medical needs. When paired with gender parity, women’s empowerment can lower the rate of violence against women. The women empowerment decision-making process index showed a strong correlation with all forms of IPV, including economic violence. Empowered women reported a significantly lower occurrence of both financial and general violence than did non-empowered women.

Previous research has linked child abuse to victimization later on.^60–65 The adverse effects of maltreatment or neglect in childhood, as well as the development of insufficient coping mechanisms, may shed light on the relationship between IPV victimization and childhood maltreatment.⁶⁶ In our study, the wife’s history of maltreatment of children was found to be a significant predictor of IPV. Women who experienced maltreatment as children were four times more likely to experience intimate partner violence (IPV) in the future than non-victimized women. These findings suggest that when it comes to IPV (victimization and perpetration), individuals with past histories of child abuse or neglect ought to be given more consideration. Polygamy and an increased risk of intimate partner violence (IPV) have been linked by numerous studies, including ones carried out in Saudi Arabia.^6,16 Alquaiz et al¹⁶ discovered in their Riyadh study that polygamy, perceived poor self-health, lack of family support, and women’s young age were risk factors for IPV in Saudi women. However, this study did not find that polygamy or the age of the women were independent predictors of IPV.

Limitations

This research is subject to many limitations. Since our study is cross-sectional, conclusions on causality cannot be made. To assess IPV more correctly, longitudinal cohort studies should be carried out to ascertain baseline IPV exposure from the previous year and receipt of IPV-relevant prophylactic interventions. An interview questionnaire served as the basis for this investigation. Because of this, there may be remembrance bias and cultural prejudice in the disclosure of some issues. Due to social conventions, feelings of shame or embarrassment, and the stigma associated with talking about marital issues—particularly sex—the majority of women tend to underreport concerns linked to empowerment and violence.⁶⁷ We did not include wives and spouses in our study. If this exclusion reflects a secure marriage where the husband is more supportive of his wife, then it may have increased the occurrence of IPV. Moreover, employing a convenient sample resulted in practical difficulties in addressing women formally and methodically, which might have led to selection bias. In addition, the study’s recruitment included women who went to PHCCs for minor ailments. As a result, it’s possible that this group does not fairly reflect all women in the intended audience. Furthermore, it is challenging to quantify research on gender-based violence due to the long history of highly subjective meanings of terms like abuse and violence, which differ among cultures. Strict interviewer training, painstaking questionnaire pre-testing, and standardized instruments comprised the study’s methodology. We think that these actions contributed to a decrease in bias.

Conclusion

Over the past 20 years, Saudi Arabia has made enormous progress in preventing domestic abuse and empowering women. The National Family Safety Program was started by a royal decree in 2005, and it is now required to protect family members from abuse and violence. The first national law to protect women from domestic abuse and violence was the “Protection from Abuse Law”, which was passed shortly after in 2013. Despite these significant advancements in human rights, women’s empowerment was not officially on the governmental agenda until the 2016 publication of Saudi Vision 2030. Saudi Vision 2030 includes a dedicated national initiative on women’s empowerment. It targets women’s rights in all circumstances, including decision-making and movement, and collaborates with all governmental and non-governmental organizations. This national initiative, coupled with strict legislative measures against domestic abuse, would not only protect women after the fact but also prevent violence against them. Consequently, over time, the prevalence of IPV will progressively decline.

According to our research, women’s empowerment is a strong predictor of IPV in women. Women’s empowerment could serve as a deterrent to violence against intimate partners. Women’s attitudes towards violence were not a good approach to measure it. The support of women who lack social and economic power should be the aim of government action. Social standards in Saudi Arabia restrict the choices available to women, even with an education. This could change our perspective and allow for developing a brand-new metric for women’s empowerment.

Using focused empowerment techniques to address IPV is crucial to creating a culture in which women can prosper without facing violence or oppression. Future studies should keep looking for creative ways to combine comprehensive violence prevention programs with empowerment initiatives so that all women have access to the tools and assistance they need to live safe lives. It is advised to implement advocacy programs and economic livelihood empowerment projects to change women’s perspectives on domestic abuse and to increase their ability for social independence, autonomy, and decision-making. The main goals of these interventions ought to be to alter public perceptions of violence and provide women the authority to engage in decision-making.

Abbreviations

IPV, Intimate partner violence; VAW, Violence Against Women; PMS, percentage mean score; NFSP, National Family Safety Program; PHC, primary health care; IRB, Institutional Review Board; MNG-HA, Ministry of National Guard-Health Affairs; KAIMRC, King Abdullah International Medical Research Center.

Ethics Approval and Consent to Participate

Approval from the Institutional Review Board (IRB) at NGHA was obtained [Ref.# RC14/059 R]. Selected women were given a cover letter that describes the study objectives, their right to refuse participation or answer any question, the participants’ anonymity (absence of personal identities), and confidentiality of their responses (availability of data to the research team only). Then, verbal consent was obtained from all participants, and the IRB approved this verbal consent. The voluntary nature of participating in the survey was made explicit and unambiguous in the cover letter. Interviews occurred privately; no spouses, relatives, or friends were present. This study was conducted following the Declaration of Helsinki.

Data Sharing Statement

Most of the data supporting our findings is contained within the manuscript, and all others, excluding identifying/confidential patient data, will be shared upon request by contacting the corresponding author [Mostafa Abolfotouh [email protected]].

Acknowledgments

The King Abdullah International Medical Research Center (KAIMRC) initiated and funded this study. The research coordinators from the Population Health Research Section at KAIMRC—Ms. Oraynab Abou Abbas, Ms. Shahla Al Dhukair, Ms. Donna Elsayed, and Dr. Maliha Nasim—would like to express their gratitude for their efforts in searching and reviewing the literature. Special thanks go to Ms. Sereen Al-Madani, the research coordinator from the National Safety Program at King Abdulaziz Medical City, Riyadh, Saudi Arabia, for her continuous supervision and monitoring of the clinic data collectors. All individuals included in this section have consented to the acknowledgment.

Funding

There is no funding to report.

Disclosure

The authors declare that they have no competing interests.

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