Disclosure and Health Seeking Behavior of Domestic Violence Survivors of Women attending the National Guard Primary Healthcare Centers in the Western Region, Saudi Arabia, 2020
2 King Abdullah International Medical Research Center. Jeddah, Saudi Arabia
3 King Saud Bin Abdulaziz University of Health Sciences, Jeddah, Saudi Arabia
Citation: Razaz M Wali, Disclosure and Health Seeking Behavior of Domestic Violence Survivors of Women attending the National Guard Primary Healthcare Centers in the Western Region, Saudi Arabia, 2020. Ann Med Health Sci Res. 2021;11:S1 05-11
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Background: Domestic violence is prevalent in Saudi Arabia, and the help-seeking behavior of domestic violence survivors (DVS) vary in terms of the demographic factors, type of domestic violence, and cultural norms. The objective of the study was to explore disclosure and help-seeking behavior and the association with demographic factors of women attending the National Guard Primary Healthcare Centers in the Western Region of Saudi Arabia. Methods: A cross-sectional study was conducted with women who previously experienced domestic violence and attending a National Guard Primary Health Care Center in the Western Region of Saudi Arabia from January to May 2020. A non-probability convenient sampling method was used. In total, 1845 participants were invited to complete a validated, self-administered Arabic version of the Norvold Domestic Abuse Questionnaire (NORAQ) to determine the help-seeking behavior of survivors of domestic violence. All women between 18-65 years who met the inclusion criteria were included. The data were analyzed using SPSS (Statistical Package Social Sciences) version 24.0. Results: Only a third 34.3% of the domestic violence survivors attempted to find assistance. Although most of the DVS were not scared of disclosure, only 28.4% went to a formal sector, such as the police or a social agency. Financial dependence on the caregiver as well as living in the city was significantly associated with disclosure and help-seeking behaviors. Conclusion: Despite the prevalence of domestic violence, most domestic violence survivors do not seek assistance. Some disclosed the violence to their physicians, but very few reported it to the police or a social agency. Help-seeking behavior in Saudi Arabia needs to be supported, and awareness of the legal rights and reporting channels should be emphasized. Many formal and non-formal services are available; however, the information about these services should be accessible to women.
Domestic violence; Help seeking behavior; Disclosure; Women abuse; Primary health care; Saudi Arabia
Domestic Violence (DV) is a major public health concern in Saudi Arabia and globally. The prevalence of DV in the Western Region of Saudi Arabia is 33.24%, indicating that one in every three women is victims of abuse. [1,2] Abused women suffer from physical and mental health consequences ; however, Domestic Violence Survivors (DVS) find it difficult to disclose or seek assistance for such events. Inherent in disclosing, is a psychological burden for the women being abused, which can delay the process of seeking assistance. Reasons for the delay could be cultural norms, social control, healthcare system, or social institution regulations. [4,5]
If women decide to disclose being abused, she has two resources. Informal resources such as friends, neighbors, and families, are most frequently accessed; few would disclose to formal resources such as health personnel, social services, or the police in severe cases. Some do not disclose being abused at all. 
Factors contributing to DV disclosure are the severity of the abuse, the involvement of children, and trust in the healthcare or social system. Women tend to seek assistance from family before they approach more formal resources, in non-severe cases, and when finding other no familial resources were ineffective. 
The clinical presentation depends on the type of abuse. DV is not easy to identify, especially if it is not suspected during the clinical consultation.  Primary Healthcare Centers (PHC) is the first line of contact with the patient, where women usually present with both acute and chronic symptoms of DV. It is the most suitable place where women can disclose abuse. Still, unfortunately, women tend not to reveal because of the perception that the medical, social, and governmental services cannot protect her.  A better understanding of the DVS’s disclosure and help-seeking behaviors can facilitate planning and designing preventive, screening, and curative services and reaching women who would not voluntarily disclose being abused. The behavior of DVS to disclose being abused is not widely researched in Saudi Arabia, and the study aimed to assess the help-seeking practices of DVS in Saudi Arabia with women attending the National Guard Primary Health Care Centers in Jeddah, Saudi Arabia.
Materials and Methods
A cross-sectional survey was conducted with a non-probability convenient sample of women aged 14-65 years. The sample attended the Primary Health Care Clinics during 2019-2020. Five Primary Health Care Centers were included, namely Iskan clinic, Specialized Poly Clinic, Bahra Clinic, Sharaee Clinic, and Iskan Taif Clinic.
The sample size was calculated at a 95% Confidence Interval (CI) level with a 50% response distribution and a margin of error of ± 5%. The required sample size was determined to be 1845 using Raosoft software (http://www.raosoft.com/samplesize.html). The data was collected with a self-administered questionnaire, the validated Arabic version of the Norvold Domestic Abuse Questionnaire (NORAQ).  The NORAQ measures the prevalence of three types of abuse, physical, psychological, and sexual, and explores the severity and help-seeking behaviors of abused victims. The questionnaire consists of three sections; the first section consists of demographic information, the second section explores the incidence of violence, the severity, and type of abuse and the third section is related to the help-seeking behavior, the objective of this study.
Women, complying with the inclusion criteria, were invited to participate and complete the questionnaire. In the case of illiteracy, a data collector assisted in the process. The data collectors were available all the time to answer any question. Women who were sick or had an emergency condition were excluded from the study.
Ethical approval was obtained from the Institutional Review Board (IRB) at King Abdullah International Medical Research Center (KAIMRC). Ethical principles were maintained throughout the research process; all participants signed a consent form and were informed about their right to withdraw from the study any time with no consequence. Anonymity and confidentiality were assured during the research process.
The data were entered and stored in a workplace computer, accessed by the Author only. The data were analyzed using SPSS (Statistical Package Social Sciences) version 24.0. Continuous variables were presented as mean and standard deviation and the categorical variables as frequency and percentage. For inferential statistics, Pearson’s Chi-square was used to test the association between help-seeking behavior and the qualitative independent variables. A t-test was used to test the relationship between help-seeking behavior and quantitative independent variables. A p-value<0.05 was considered significant.
A sample of 1845 participants completed the questionnaire. All were Saudi females and Muslims. The mean age was 32.24 ± 10.92 years. The majority 71.96% (n=1304) were married with 22.41% (n=406) single, 2.54% (n=56) widowed, and 2.54 % (n=46) divorced. The mean age at marriage was 16.86 ± 9.442 years, and the mean duration of marriage was 1.801 ± 1.152 years [Table 1].
|Age at marrige (n=1703)||16.86||9.442|
|Duration of marriage (n=1717)||1.801||1.152|
Table 1: Demographic characteristics of the sample.
Most of the sample lived in the city 83.13% (n=1503), with 15.76% (n=285) living in a village. The majority 77.65% (n=1074) were financially dependent on their caregiver. Regarding the educational level, 45.66% (n=826) were undergraduate, 42.56% (n=707) postgraduate, and 10.06% (n=182) were illiterate. Most of the sample (n=1813) were housewives 85.27% (n=1546) and a small proportion 14.23% (n=258) were employed. Regarding the income status, for more than half 64.58% (n=1165), the monthly income was more than 5000 SR [Table 2]. Just more than half of the sample, 52.2% (n=942) visited the hospital 1-3 times in the last year, and the majority 87.6% (n=1578) had a positive experience with their doctors. Regarding admission to the hospital for any reason in the last year, the majority 79.4% (n=1438) were not admitted to the hospital [Table 2].
|Financially dependent (n=1383)|
|Marital status (n=1812)|
|Education level (n=1808)|
|Employment status (n=1813)|
|Less than 5000||639||35.42|
|More than 5000||1165||64.58|
|Number of hospital visits (last year)|
|More than 7||402||22.3|
|Experience with the doctor visit last year|
|Negative with some positive||152||8.4|
|Positive with some negative||805||44.7|
|Hospital admission last year (n=1810)|
Table 2: Demographic characteristics of the sample.
Disclosure and help-seeking behavior of domestic violence survivors
From Table 3, domestic violence survivors were 599. Only a third 34.3% (n=173) attempted to find help by herself after being abused [Figure 1]. A smaller proportion 2.8% (n=17) actually contacted a formal or non-formal resource. Less than half 37.6% (n=225) decided to tell somebody about being abused, and 47.6% (n=285) told their treating physician [Figure 2]. An only a smaller proportion (0.2%, n=1) disclosed the whole event of the abuse to anybody at any time. In terms of where to go in case of a DV event, 33.6% (n=167) knew the relevant resources [Figure 3]. Although most of the DVS were not scared of disclosure 67.69% (n=308), only 28.4% (n=170) went to the formal sector, such as the police or a social agency. Of the group who went to the police/social agency, 36.6% (n=11) indicated that nothing was done, 16.6% (n=5) the case was investigated then closed, and 13.3 % (n=4), the claim was judged, but nothing was done.
|Try to find help (all) (n=504)|
|Tried actually for help (n=599)|
|Tell anybody (n=599)|
|Tell the doctor (n=599)|
|Disclose being abused (n=599)|
|Know where to go in case of abuse (n= 497)|
|Scared of informing (n= 455)|
|Tell the police/ social agency (n=599)|
|Results of telling the police (n=30)|
|Investigated, no judge||4||13.3|
|Action was taken||1||3.3|
|I closed the case||6||20|
Table 3: Disclosure and help-seeking behavior of domestic violence survivors.
Comparison of disclosure and help-seeking behaviors among different types of abuse
Table 4 indicates that, for all types of abuse, the DVS disclosed the violence after one year of the mean age of the first DV event. The age of the DVS at the first incident of abuse was as follows: psychological 13.07 ± 11.27, physical 12.79 ± 10.094, and sexual abuse 9.92 ± 7.633. The majority of DVS of all three types of violence did not seek help. More than half of the DVS for all types of violence did not disclose being abused (psychological; 55.29%, physical; 54.51%, and sexual; 65.18%). Regarding disclosure to a medical practitioner, the majority of the DVS did not disclose the event (84.78%; 80.44% and 87.5% for psychological, physical, and sexual abuse. However, a small proportion did disclose the event when the physician inquired (7.39%; 11.17%; 8.92%), respectively.
|Variables||Psychological abuse (n=460)||Physical abuse||Sexual abuse|
|Age at first abuse||13.07||11.27||12.79||10.094||9.92||7.633|
|Age of disclosure||14.85||11.63||13.62||10.572||11.92||8.492|
|Abuse last year|
|Disclosure of abuse to anybody|
|Yes (partially, all)||203||44.72||146||45.47||47||34.81|
|Disclosure to a medical practitioner|
|Yes, she knows||5||2.17||3||1.67||1||1.78|
|Yes, when she asked||17||7.39||20||11.17||5||8.92|
Table 4: Comparison of disclosure and help-seeking behaviors among different types of abuse.
The relationship between disclosure and helpseeking behaviors and demographic factors
This study showed no significant association between help-seeking behavior and demographic factors such as educational level, home type, place of residence, and family income. There was also no association with social status, marriage duration, and the number of hospital visits. The only statistically significant factor was the association between disclosure and help-seeking behavior and being financially dependent on the caregiver (p ≤ 0.05) [Table 5].
|Variable||No||Asked for help||Did not ask for help||*Chi-||p-value|
|No (%)||No (%)||square|
|Illiterate||39||10 (5.8)||29 (8.8)|
|Undergraduate||221||70 (40.5)||151 (54.6)|
|Graduate||233||90 (52)||143 (43.2)|
|Postgraduate||11||3 (1.7)||8 (2.4)|
|Unknown||8||2 (1.2)||6 (1.8)|
|City||399||144 (83.2)||255 (77)|
|Village||79||27 (15.6)||70 (21.1)|
|Owned||319||103 (59.5)||216 (65.5)|
|Rent||184||70 (40.5)||114 (34.5)|
|< SAR 5000||190||69 (39.9)||121 (36.7)|
|> SAR 5000||313||104 (60.1)||209 (63.3)|
|Single||134||42 (24.30)||92 (27.8)|
|Married||327||116 (67.1)||211 (63.7)|
|Divorce||25||12 (6.9)||13 (3.9)|
|Widow||18||3 (1.7)||15 (5.5)|
|< 5 years||100||31 (19.4)||69 (20.9)|
|5-10 years||87||35 (21.9)||52 (15.8)|
|≥ 10 years||176||61 (38.1)||115 (34.8)|
|No||250||83 (65.9)||167 (71.1)|
|109||43 (34.1)||66 (28.3)|
|No of hospital visits||2.353||0.312|
|1-3||231||75 (43.3)||156 (47.1)|
|4-6||153||60 (34.7)||93 (28.1)|
|More than 7||120||38 (22.0)||82 (24.8)|
Table 5: The relationship between disclosure and help-seeking behaviors and demographic factors.
The relationship between disclosure and helpseeking behavior by type of abuse
There was a significant association between the educational level and help-seeking behaviors in the psychological and physical DVS groups (p ≤ 0.05) but not in sexual abuse. The type of residence was significantly associated with physical abuse. Social status and financial dependency on the caregiver were associated considerably with help-seeking of all types of abuse (p ≤ 0.05). However, family income, home type, age at marriage, and duration of the marriage, had no association with disclosure and help-seeking behaviors to any kind of abuse [Table 6].
|Variable||Psychological abuse||Physical abuse||Sexual abuse|
|Residence (city, urban)||0.887||0.188||0.377||0.291||5.477||0.486|
|Home type (rent,own)||0.502||0.974||13.984||0.002||0.836||0.99|
|Age at marriage||113.479||0.004||38.697||0.265||85.753||0.588|
Table 6: The relationship between disclosure and help-seeking behavior by type of abuse.
Despite the high prevalence of DV in women attending the National Guard Primary Healthcare Centers, the help-seeking prevalence is low.  More than half of the sample did not disclose DV. However, disclosing DV is multi-factorial; many cultural taboos and norms play a role. [11,12]
The literature review indicated that women could get assistance from formal resources such as health institutions, social workers, police, or domestic violence agencies, as well as informal resources, including friends and families. 
The current study indicated that most of the DVS did not try to find assistance from any resource, although more than half of the DVS disclosed the event of abuse to an informal resource such as friends or family. Possible reasons could be personal, complicated nature of the process or unclear helpseeking channels. Some DVS are afraid to disrupt their marital relationship, loss of their children, rejection by the family, or divorce. These results are similar to a study indicated that the DVS did not disclose being abused to their family or friend unless they were victims of abuse as well.  A qualitative study indicated that the barriers for women to disclose an event of abuse are related to four categories: the social context, family, individual, and the expectation from the health/community system including, feelings of shame and guilt, preservation of the unity of the family and upholding the gender role. From another perspective, the women thought that physicians are inexperienced in dealing with DV or had a negative past experience with their physician. 
Although DVS were not scared of informing and some were familiar with the available protection resource, almost none of the DVS disclosed the whole abuse event to anybody. The finding is similar to a study conducted in Pakistan, where women who screened positive for DV, chose to remain silent due to reasons such as the stigma of abuse, fear of the partner, distrust in the formal system, and the acceptance of violence.  DVS usually present to their primary care physician with their abusive experience, which could be direct or indirect, and almost no one disclosed or discussed the experience during the clinical consultation. A small group did not disclose being abused because they thought their doctor knew, few disclosed the event only when the doctor asked, and only one revealed the whole event. A study reported similar findings that survivors of abuse did not disclose DV to a healthcare practitioner even though they visited the health facility in the same period for health concerns such as mental health problems, including anxiety, depression, and insomnia. Possible explanations could be that the healthcare institution lacked policies, procedures, and trained personal in screening for DV or to individual factors such as fear, breach of confidentiality, or lack of trust in the healthcare system. The finding is supported by a Malaysian study highlighting barriers for DV disclosure to primary care physicians as the privacy of DV and the male gender role in the community. 
Current family medicine services in Saudi Arabia fail to recognize DV due to the lack of policy guidelines and screening programs. In the present study, the disclosure of DV to the medical practitioners was similar. The majority did not disclose or thought the doctor knew. The question is, why would the patient believe that the doctor knew? Could it be related to a long-term relationship with the primary care physician or because the patient presented many times with the same issue? A study emphasized that physicians avoided or were not willing to discuss DV, the basis of the two main barriers, namely a negative past experience with the healthcare system or the unknown role of the healthcare provider.  Another study demonstrated that a DVS did not seek assistance from the primary care physician because of their perception that health care services are not appropriate for their needs, are not practical or, finally, not trained to manage cases of DV. The same study reports that women needed support and guidance from informal groups to access the formal support system. 
Less than half of the DVS in the current study reported the abuse event to the police, possibly due to the lack of proper channels, awareness programs, and information on the role of each sector. Most importantly, the unknown consequence of reporting in terms of the victim’s safety and confidentiality. Two studies reported that women do not disclose being abused unless it is severe or their children suffered, because they are unsure about the consequences, they consider the abuse event as over or because they do not trust the attitude of the institutions. [17,18]
The relationship between disclosure and helpseeking behavior and demographic factors
The current study indicated a significant association between disclosure of DV and financial dependence on the abuser. This could explain the fear of reporting as they may endanger the financial support from the abuser, or they have no other place to go. These results are in line with a Canadian study reporting that financial independence is positively associated with women’s help-seeking behavior. 
The current study also did not reveal a significant association with the educational level, home type, and place of residence, social status, and the duration of the marriage. In contrast, a study conducted in India reported that women tend to report abuse if they were severely abused, educated, married after the age of 21 years, or have no children. 
The relationship between help-seeking behavior and different kind of abuse
Based on the findings of the current study, the educational level is significantly associated with psychological and physical abuse, but not with sexual abuse, because women with higher educational levels tend to report violence. In contrast, sexually abused women felt shame and guilt. This finding is supported by a study revealing that survivors of sexual assault do not disclose the event because of the perceived support and the adverse reaction from the community. 
Another significant association, women living in the city tend to disclose physical abuse, possibly due to a higher level of independence and easier access to formal resources such as the police and hospitals. However, for psychological and sexual abuse, the same situation did not apply. Similar findings were presented in a Dhaka study. 
The prevalence of DV in Saudi Arabia is high; unfortunately, most DVS does not attempt to obtain assistance or disclose the DV to informal resources. Only a minority of DVS in this study approached the police or formal protection services. Several barriers to disclosure have been identified, including personal, related to the community, or related to the healthcare system. DVS approach formal or informal sectors for assistance for physical or physiological abuse, but not sexual abuse. Some demographic factors are associated with disclosure of DV, including financial dependence on the caregiver or living in the city, but no other demographic factors.
The cycle of domestic violence must be broken; however, this cannot be achieved without collaboration between different sectors. Women should be empowered to disclose DV without the feeling of guilt or shame, be aware of her legal rights, the consequence of reporting, and the penalty for the abuser in a safe, confidential manner. The community and families have to be educated and allow non-stigmatization, non-judgmental decisions for battered women. A unified health-based policy should be introduced to all health sectors. This policy should include procedures for screening, transportation, and management of such cases. In addition, healthcare providers should be trained in the aspects of interviewing, examination, and documentation.
It is suggested that broader community outreach programs are required to challenge and change norms and cultural taboos, to ensure that family and friends can provide appropriate support for women in abusive relationships who are seeking assistance. The non-formal facilities should be strengthened to facilitate the transition from the non-formal sector to the formal sector through ongoing awareness programs in the school, universities, and shopping malls. An example is a program empowering women to finish their education and find employment to release them from the financial dependency on the caregiver. It is also recommended that all DVS should be aware of their legal rights should they decide to leave the partner and her power to keep her children.
The effect of different awareness programs and the implementation of a national health policy related to helpseeking behaviors require in-depth research.
Limitations of the study
This study was conducted with the DVS attending the Primary Health Care Centers in the Western Region of Saudi Arabia, limiting the generalizability of the findings. Due to the nature of quantitative research, the reasons and opinions of the DVS were not explored. In addition, the expectations from the formal and non-formal resources were not explored. The study may also suffer from recall or social bias due to the sensitive nature of the topic.
Implications for practice and research
This study showed that domestic violence survivors did not disclose the violent event, based on this study; it is a good chance for policymakers to review current recommendations and protocols in dealing with such cases.
This study is a call for more detailed studies in a broader population, including a qualitative approach to highlight what could be added to current domestic violence services from the victim’s perspective. Besides, this study revealed that DVS would not disclose being abused unless they were asked by a health care provider, which calls for a national policy and screening programs.
This is the first Saudi study that shows that women in abusive relationships may choose to stay silent because of the lack of a wide-base national program that can empower the women to ask for help from the appropriate channels.
Ethics approval and consent to participate
Ethical approval was obtained from the Institutional Review Board of King Abdullah International Medical Research Center with a reference number RJ20/ 024/ J. Ethical principles were maintained throughout the research process. All participants signed informed consent, and confidentiality and anonymity assured as no personal identifiers were used. All data were stored on workplace computers with access to study personal only.
Consent to publish
Written informed consent for publication was obtained.
Availability of data and materials
All data generated or analyzed during this study are included in this published article.
The Author declares that they have no competing interests.
This research is self-funded.
The Author contributed to all the parts, proposal writing, data collection, data analysis, and writing the discussion.
The correspondence author (R.M.W) is the owner of the intellectual idea, analysis, writing the result, and the discussion section and final review.
We want to thank all women who participated in this study and data collectors (Bayader Shami, Razan Alharbi, Danah Bakhallagi, Haneen Falata, Esraa Alfayoumi, Amal Almutairi, Hadeel Guhal, Raghad AlQurashi, Amal Alnemare, Bashaier AlQahtani, Asayel Alwthenani, Duaa Sabri, and Omnia Wawi) for their contribution to the success of this research.
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