Abstract

Objective

To estimate prevalence and factors associated with intimate partner psychological violence against women in a rural area in the state of Rio Grande do Sul, in 2017.

Methods

This was a cross-sectional population-based study with women aged 18-49 years old and who had had an intimate partner in their lifetime. Questions from the World Health Organization Violence Against Women Study were administered. Poisson regression was used to estimate prevalence ratios (PR) and 95% confidence intervals (95%CI).

Results

971 women participated. Prevalence of lifetime psychological violence was 17.2% (95%CI 14.9;19.7). Those diagnosed with depression (PR=2.23 - 95%CI 1.70;2.91) and who had consumed alcohol in the last week were more likely to refer lifetime psychological violence (PR=1.53 - 95%CI 1.07;2.17). Single women were more likely to experience psychological violence than married women (PR=1.86 - 95%CI 1.32;2.63).

Conclusion

Psychological violence against woman in rural areas was related to mental health and alcohol use.

Keywords:
Violence Against Women; Intimate Partner Violence; Epidemiology; Rural Population; Cross-Sectional Studies

Introduction

Violence against women, in addition to violating rights, increases the demand for health care, characterizing a major challenge to Brazilian public health.¹1. Azambuja MPR, Nogueira C. Introdução à violência contra as mulheres como um problema de direitos humanos e de saúde pública. Saude Soc. 2008;17(3):101-12. doi: https://doi.org/10.1590/S0104-12902008000300011.
https://doi.org/10.1590/S0104-1290200800... One in seven women in Latin America and the Caribbean are estimated to have experienced physical and/or sexual violence perpetrated by an intimate partner.²2. Bott S, Guedes A, Ruiz-Celis AP, Mendoza JA. Intimate partner violence in the Americas: a systematic review and reanalysis of national prevalence estimates. Rev Panam Salud Publica. 2019 Mar 20;43:e26. doi: https://doi.org/10.26633/RPSP.2019.26.
https://doi.org/10.26633/RPSP.2019.26... This data becomes of even greater concern when lifetime exposure to psychological violence or emotional abuse is found to exist.³3. Vale SLL, Medeiros CMR, Cavalcanti CO, Junqueira CCS, Souza LC. Repercussões psicoemocionais da violência doméstica: perfil de mulheres na atenção básica. Rev RENE [Internet]. 2013 [acesso 23 ago. 2021];14(4):683-93. Disponível em: http://www.revistarene.ufc.br/revista/index.php/revista/article/download/1123/pdf
http://www.revistarene.ufc.br/revista/in...

Psychological violence is characterized by any action or omission that causes or seeks to cause harm to a person’s self-esteem, identity or development.⁴4. Ministério da Saúde (BR). Violência intrafamiliar: orientações para a prática em serviço. Brasília, DF: MS; 2002. (Série cadernos de atenção básica, n. 8). It is considered to be one of the most frequent forms of aggression in the domestic environment, despite being underreported and more difficult for the victim to identify, since often women do not realize they are suffering aggression.⁵5. Silva LL, Coelho EBS, Caponi SNC. Violência silenciosa: violência psicológica como condição da violência física doméstica. Interface (Botucatu). 2007;11(21):93-103. doi: https://doi.org/10.1590/S1414-32832007000100009.
https://doi.org/10.1590/S1414-3283200700... There is wide variation in the global literature on the prevalence of intimate partner psychological violence against women, including those who live in rural areas⁶6. Habib SR, Abdel Azim EK, Fawzy IA, Kamal NN, El Sherbini AM. Prevalence and effects of violence against women in a rural community in Minia Governorate, Egypt. J Forensic Sci. 2011;56(6):1521-7. doi: https://doi.org/10.1111/j.1556-4029.2011.01886.x.
https://doi.org/10.1111/j.1556-4029.2011... ^,77. Moura LBA, Gandolfi L, Vasconcelos AMN, Pratesi R. Intimate partner violence against women in an economically vulnerable urban area, Central-West Brazil. Rev Saude Publica. 2009;43(6):944-53. doi: https://doi.org/10.1590/s0034-89102009005000069.
https://doi.org/10.1590/s0034-8910200900... The main factors associated with the occurrence of this form of violence are being married,⁸8. Mathias AKRA, Bedone AJ, Osis MJD, Fernandes AMS. Prevalência da violência praticada por parceiro masculino entre mulheres usuárias da rede primária de saúde do estado de São Paulo. Rev Bras Ginecol e Obstet. 2013;35(4):185-91. doi: https://doi.org/10.1590/s0100-72032013000400009.
https://doi.org/10.1590/s0100-7203201300... low level of schooling,⁹9. Vieira LJES, Ferreira RC, Moreira GAR, Gondim APS, Araujo MAL, Silva RM. Factors associated to the imposition of types of violence against women informed in sentry services. Rev Lat Am Enfermagem. 2013;21(4):920-7. doi: https://doi.org/10.1590/S0104-11692013000400013.
https://doi.org/10.1590/S0104-1169201300... ^,1010. Vameghi R, Akbari SAA, Majd HA, Sajedi F, Sajjadi H. The comparison of socioeconomic status, perceived social support and mental status in women of reproductive age experiencing and not experiencing domestic violence in Iran. J Inj Violence Res. 2018;10: 35-44. doi: https://doi.org/10.5249/jivr.v10i1.983.
https://doi.org/10.5249/jivr.v10i1.983... low family income,¹¹11. Caballero J, Alfaro M, Nuñez Y, Torres H. Violencia psicológica contra la mujer por su pareja en el Perú, 2004-2007 [Internet]. Rev PeruEpidemiol. 2009 [acesso 23 de ago 2021];13:1-7. Disponível em https://www.redalyc.org/articulo.oa?id=203120367006.
https://www.redalyc.org/articulo.oa?id=2... ^,1212. Khalifeh H, Hargreaves J, Howard LM, Birdthistle I. Intimate partner violence and socioeconomic deprivation in England: findings from a national cross-sectional survey. Am J Public Health. 2013;103(3):462-72. doi: https://doi.org/10.2105/AJPH.2012.300723.
https://doi.org/10.2105/AJPH.2012.300723... being over 30 years old¹³13. Sanz-Barbero B, López Pereira P, Barrio G, Vives-Cases C. Intimate partner violence against young women: prevalence and associated factors in Europe. J Epidemiol Community Health. 2018;72(7):611-6. doi: https://doi.org/10.1136/jech-2017-209701.
https://doi.org/10.1136/jech-2017-209701...

14. Sandoval-Jurado L, Jiménez-Báez MV, Rovira Alcocer G, Vital Hernandez O, Pat Espadas FG. Violencia de pareja: tipo y riesgos en usuarias de atención primaria de salud en Cancún, Quintana Roo, México. Aten Primaria. 2017;49(8):465-72. doi: https://doi.org/10.1016/j.aprim.2016.09.013.
https://doi.org/10.1016/j.aprim.2016.09.... ^-1515. Gokler ME, Arslantas D, Unsal A. Prevalence of domestic violence and associated factors among married women in a semi-rural area of western Turkey. Pak J Med Sci. 2014;30(5):1088-93. doi: https://doi.org/10.12669/pjms.305.5504.
https://doi.org/10.12669/pjms.305.5504... and diagnosis of depression.¹⁶16. Sapkota D, Bhattarai S, Baral D, Pokharel PK. Domestic violence and its associated factors among married women of a village development committee of rural Nepal. BMC Res Notes. 2016 Mar 19;9(1):178. doi: https://doi.org/10.1186/s13104-016-1986-6.
https://doi.org/10.1186/s13104-016-1986-...

A pioneer population-based study conducted in Brazil, in the city of São Paulo and in 15 municipalities located in the Zona da Mata region of Pernambuco, between 2000 and 2001, identified that the prevalence of psychological violence occurring at least once during lifetime was 41.8% [95% confidence interval (95%CI) 38.7;45.1] in São Paulo and 48.9% (95%CI 45.9;51.7) in the Zona da Mata region of Pernambuco (without separating the overlap existing between physical, psychological or sexual violence).¹⁷17. Schraiber LB, D'Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saude Publica. 2007;41(5):797-807. doi: https://doi.org/10.1590/S0034-89102007000500014.
https://doi.org/10.1590/S0034-8910200700... The same study found that prevalence of reporting having suffered psychological violence alone during lifetime was 17.5% for women living in São Paulo and 17.3% for those living in Zona da Mata region of Pernambuco.¹⁷17. Schraiber LB, D'Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saude Publica. 2007;41(5):797-807. doi: https://doi.org/10.1590/S0034-89102007000500014.
https://doi.org/10.1590/S0034-8910200700...

Life in rural areas is marked by being distant from support networks and services¹⁸18. Arboit J, Costa MC, Silva EB, Colomé ICS, Prestes M. Violência doméstica contra mulheres rurais: práticas de cuidado desenvolvidas por agentes comunitários de saúde. Saude Soc. 2018;27(2):506-17. doi: https://doi.org/10.1590/S0104-12902018169293.
https://doi.org/10.1590/S0104-1290201816... , and even from networks of affection, favoring the silencing and invisibility of violence. Therefore, this study sought to describe a panorama of psychological violence in a rural area, a context still little explored, as well as among subgroups in which it occurs more, thus contributing to highlighting possible paths in the fight for the guarantee of women’s rights, giving visibility to the theme and the need to break the silence when faced with situations of violation of human rights.

The objective of this study was to estimate prevalence and factors associated with intimate partner psychological violence against women living in a rural area.

Methods

This is a population-based cross-sectional study, developed within the Federal University of Rio Grande Master’s Degree Program in Public Health joint research initiative entitled ‘Health of the Rural Population of Rio Grande’. Located in the extreme south of the state of Rio Grande do Sul, Brazil, the municipality of Rio Grande has a total territorial extension of 2,709.5 km² and in 2017 had a population of around 209,000 inhabitants, 4% of whom lived in the rural area.¹⁹19. Instituto Brasileiro de Geografia e Estatística. Atlas do censo demográfico 2010 [Internet]. Rio de Janeiro]: IBGE; 2013. Disponível em: http://censo2010.ibge.gov.br/apps/atlas/
http://censo2010.ibge.gov.br/apps/atlas...

In this study, we included women (of the female sex) between 18 and 49 years old, living permanently in rural areas of the municipality and who reported having had at least one intimate partner in their lifetime, regardless of sexual orientation. Institutionalized women and those who were not physically and/or mentally able to participate in the interview without assistance were excluded.

The sample size was calculated to meet the research objectives, whereby the largest sample size needed was 931 women, considering association between psychological violence and schooling. The sample size calculation was estimated by taking prevalence of psychological violence as being approximately 45%, a 95% confidence level and a margin of error of 3 percentage points. When calculating the sample size for associated factors, we considered a 95% confidence level, power of 80%, a prevalence ratio of 1.5, and 25% minimum prevalence of intimate partner psychological violence against women for the unexposed groups.

The sampling process was systematic and reached 83.1% of the households in the rural area of the municipality. To do so, a number between 1 and 5 was drawn, so that the number drawn corresponded to the household that was ‘skipped’. Thus, if number 2 was drawn, every second household within a sequence of five was not sampled, but rather skipped. This procedure ensured that four out of every five households were sampled.

Data collection occurred between April and October 2017, at home. A questionnaire was administered using tablets programmed with REDCap^® (Research Electronic Data Capture) software. The data collected were transferred to an internet server, reviewed by the study supervisors, and then stored at the Federal University of Rio Grande. The interviewers were selected and trained beforehand, and had constant supervision and daily monitoring in the field, to clarify possible doubts and other necessary guidance. Subsequently, quality control was carried out by randomly repeating 5% of the interviews.

In order to assess the prevalence of intimate partner psychological violence against women, this being the main outcome of the study, we used a questionnaire from the World Health Organization Violence Against Women Study (WHO-VAW Study) which had been translated and validated in Portuguese.²⁰20. Schraiber LB, Latorre MRDO, França-Jr I, Segri NJ, D'Oliveira AFPL. Validity of the WHO VAW study instrument for estimating gender-based violence against women. Rev Saude Publica. 2010;44(4):658-66. doi: https://doi.org/10.1590/s0034-89102010000400009.
https://doi.org/10.1590/s0034-8910201000... This instrument assesses psychological violence through four items/questions asking whether intimate partners: (i) Insulted you or made you feel bad about yourself? (ii) Belittled or humiliated you in front of others? (iii) Did things to intimidate or scare you on purpose? (iv) Threatened to hurt you or someone you care about?

A participant who answered affirmatively to at least one of the four questions above was considered a victim of psychological violence. As the study aimed to assess prevalence of intimate partner psychological violence against women, first of all the participants answered a filter question about whether they had had an intimate partner in their lifetime. An intimate partner was defined as a male person with whom the participant had had sexual relations at some point in her lifetime. With the intention of not making the participants feel embarrassed, we chose to ask about the occurrence of violence in all intimate relationships they had had up until the date of data collection and not necessarily a situation experienced in their current relationships.

The independent variables were collected by administering the socioeconomic variables block of the questionnaire, as follows: age (in years: 18-29; 30-39; 40-49); self-reported race/skin color (white; black; brown); schooling (in years of study: 0-4; 5-8; 9 or more); current marital status (married or has a partner; single; separated, divorced or widowed); work status at the time of the interview (yes or no); family income (amount received by all household residents in the month prior to the interview, ranked based on quintiles); self-reported lifetime depression diagnosed by a doctor or psychologist (yes or no); religious belief (yes or no); use of alcoholic beverages in the past week (yes or no); tobacco smoking (never smoked; former smoker; smoker); and number of children (none; one; two; three or more).

After performing the descriptive analyses, the prevalence rates of intimate partner psychological violence against women and their respective 95%CIs were calculated. Poisson regression with robust variance adjustment was used in the crude and adjusted analyses to estimate prevalence ratios (PR) and their respective 95%CIs.

A four-level hierarchical model (Figure 1) was used in the adjusted analysis to control for possible confounding factors. In this model, the variables that were on an equal or higher hierarchical level were considered to be possible confounders in the relationship with the outcome of the study, namely: the ‘age’, ‘race/skin color’ and ‘schooling’ variables on the first level of analysis; the ‘marital status’, ‘family income’, ‘work’ and ‘number of children’ on the second level; self-reported diagnosis of ‘depression’ and ‘religious belief’ on the third level; and behavioral variables such as ‘use of alcohol’ and ‘tobacco smoking’ on the fourth level. The backward variable selection method was used, and the variables corresponding to each hierarchical level were included on them jointly. All associations that had a p-value <0.20 in the Wald test for heterogeneity or in the linear trend test were kept in the analysis, and variables with a p-value <0.05 were considered to be statistically significant. All analyses were performed using Stata/IC^® version 14.

The study project was approved by the Federal University of Rio Grande Health Research Ethics Committee, as per Opinion No. 51/2017, issued on April 27^th 2017: File No. 23116.009484/2016-26. Data confidentiality and voluntary participation in the research were guaranteed, whereby it was possible to withdraw from the study at any time without needing to provide justification. All participants signed a Free and Informed Consent form before the questionnaires were administered. At the end of the study, they received a folder with addresses and telephone numbers of public health, social work and safety services for women.

Results

In the 2,669 households with permanent residents in the rural area of the municipality of Rio Grande, we identified 1,391 women of childbearing age, from 15 to 49 years old, and 1,199 were sampled. Of these, 103 women were not found after the third attempt (losses) and 17 did not want to take part in the study (refusals), 83 did not meet the age inclusion criterion, 20 had had no intimate partner in their lifetime, and 5 had missing information regarding the outcome variable, resulting in 971 valid observations. Among these, 167 (17.2% - 95%CI 14.9;19.7) reported having experienced at least one occurrence of intimate partner psychological violence in their lifetime.

Table 1 describes the characteristics of the sample studied. More than half of the women had five years schooling or more, 85.9% (821/956) were White, 84.7% (822/971) were married or living with a partner, 37.7% (366/971) were working, 26.8% (260/970) reported having received diagnosis of depression by a psychologist or physician during their lifetime, 67.2% (652/971) had religious beliefs, 68.4% (665/971) had never smoked and 90.2% (876/971) reported not having used alcoholic beverages in the last week.

Different manifestations of psychological violence were identified. Approximately 12.0% (95%CI 10.1;14.3) reported insults, 10.5% (95%CI 8.7;12.6) humiliation or belittlement, 10.1% (95%CI 8.3;12.2) intimidation, and 9.5% (95%CI 7.8;11.5) threats (Table 2). One hundred fifty of 167 women who reported the occurrence of intimate partner psychological violence in their lifetime reported that the abusive relationship they mentioned had lasted for one year or more.

In Table 3 it can be seen that in the adjusted analysis, single women (PR=1.86 - 95%CI 1.32;2.63) and separated, divorced and widowed women (PR=1.96 - 95%CI 1.23;3.13) were significantly more likely to be victims of intimate partner psychological violence compared to those who were married or living with a partner. The likelihood of intimate partner psychological violence was also found to be higher for women who had self-reported depression diagnosed by a psychologist or physician over their lifetime (PR=2.23 - 95%CI 1.70;2.91), and for those who had used alcoholic beverages in the past week (PR=1.53 - 95%CI 1.07;2.17).

Discussion

Around one in five women participating in this study reported experiencing at least one episode of intimate partner psychological violence in their lifetime. Single, separated, divorced, or widowed women were more likely to have experienced intimate partner psychological violence in their lifetime, compared to those who were married or living with a partner. Participants who reported diagnosis of depression and those who had used alcoholic beverages in the past week were more likely to have been victims of intimate partner psychological violence, compared to those who did not report diagnosis of depression or use of alcohol. These findings contribute to evidence that women from rural areas and from different subgroups identified within them, suffer this type of violence, pointing to the need for public policies and health services, among others, that offer the necessary support in face of the issue.

Prevalence of intimate partner psychological violence against women was lower than that found in women from the Zona da Mata region of Pernambuco, although it is similar to the report of psychological violence alone, at least once during lifetime, identified in the same study.¹⁷17. Schraiber LB, D'Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saude Publica. 2007;41(5):797-807. doi: https://doi.org/10.1590/S0034-89102007000500014.
https://doi.org/10.1590/S0034-8910200700... Psychological violence has been highlighted in the records of specialized care services for women. A study conducted in Paraíba in 2015 found that 80% of reported cases involved psychological violence.²¹21. Costa MS, Serafim MLF, Nascimento AR. Violência contra a mulher: descrição das denúncias em um centro de referência de atendimento à mulher de Cajazeiras, Paraíba, 2010 a 2012. Epidemiol Serv Saude. 2015;24(3):551-8. doi: https://doi.org/10.5123/S1679-49742015000300022.
https://doi.org/10.5123/S1679-4974201500... Although violence is identified in various locations, rural areas tend to have higher rates of violence against women than urban areas.²⁰20. Schraiber LB, Latorre MRDO, França-Jr I, Segri NJ, D'Oliveira AFPL. Validity of the WHO VAW study instrument for estimating gender-based violence against women. Rev Saude Publica. 2010;44(4):658-66. doi: https://doi.org/10.1590/s0034-89102010000400009.
https://doi.org/10.1590/s0034-8910201000... Some authors attribute this fact to gender relations being more unequal in rural areas than in urban areas, since the support service infrastructure for women living in more isolated places is generally poorer and they are less engaged in movements related to gender issues.¹⁷17. Schraiber LB, D'Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saude Publica. 2007;41(5):797-807. doi: https://doi.org/10.1590/S0034-89102007000500014.
https://doi.org/10.1590/S0034-8910200700... ^,2222. Sinha A, Mallik S, Sanyal D, Dasgupta S, Pal D, Mukherjee A. Domestic violence among ever married women of reproductive age group in a slum area of Kolkata. Indian J Public Health. 2012;56(1):31-6. doi: https://doi.org/10.4103/0019-557X.96955.
https://doi.org/10.4103/0019-557X.96955... ^,2323. Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med. 2002;55(9):1603-17. doi: https://doi.org/10.1016/s0277-9536(01)00294-5.
https://doi.org/10.1016/s0277-9536(01)00... These data corroborate the ecological model that addresses multiple factors associated with occurrence of violence.²⁴24. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: WHO; 2002. Chapter 4, Violence by intimate partners; p. 87-113. Women’s socioeconomic and behavioral characteristics may not by themselves explain psychological violence with precision, since the socio-environmental context of the victims, the characteristics of their partners and cultural issues may also influence the occurrence of aggression.²2. Bott S, Guedes A, Ruiz-Celis AP, Mendoza JA. Intimate partner violence in the Americas: a systematic review and reanalysis of national prevalence estimates. Rev Panam Salud Publica. 2019 Mar 20;43:e26. doi: https://doi.org/10.26633/RPSP.2019.26.
https://doi.org/10.26633/RPSP.2019.26... ^,55. Silva LL, Coelho EBS, Caponi SNC. Violência silenciosa: violência psicológica como condição da violência física doméstica. Interface (Botucatu). 2007;11(21):93-103. doi: https://doi.org/10.1590/S1414-32832007000100009.
https://doi.org/10.1590/S1414-3283200700...

According to our findings, women who reported having been diagnosed with depression at some time in their lives were 123% more likely to have experienced psychological violence. A review study suggests that depressive symptoms are associated with perpetration of psychological violence and, in some cases, are predictors of it.²⁵25. Capaldi DM, Knoble NB, Shortt JW, Kim HK. A systematic review of risk factors for intimate partner violence. Partner Abuse. 2012;3(2):231-80. doi: https://doi.org/10.1891/1946-6560.3.2.231.
https://doi.org/10.1891/1946-6560.3.2.23... However, as this study has a cross-sectional design, caution is recommended when extrapolating this result, since the data were collected simultaneously. Therefore, it is not possible to meet the temporality criterion needed to confirm, with precision, what was expected: diagnosis of depression or having experienced a situation of domestic violence; and what is cause or effect in such a relationship.

Use of alcoholic beverages was also a statistically significant associated factor, thus corroborating the findings of other studies.¹³13. Sanz-Barbero B, López Pereira P, Barrio G, Vives-Cases C. Intimate partner violence against young women: prevalence and associated factors in Europe. J Epidemiol Community Health. 2018;72(7):611-6. doi: https://doi.org/10.1136/jech-2017-209701.
https://doi.org/10.1136/jech-2017-209701... ^,2626. Kaysen D, Dillworth TM, Simpson T, Waldrop A, Larimer ME, Resick PA. Domestic violence and alcohol use: trauma-related symptoms and motives for drinking. Addict Behav. 2007;32(6):1272-83. doi: https://doi.org/10.1016/j.addbeh.2006.09.007.
https://doi.org/10.1016/j.addbeh.2006.09... The social role and self-esteem of women who experience psychological violence is harmed,⁵5. Silva LL, Coelho EBS, Caponi SNC. Violência silenciosa: violência psicológica como condição da violência física doméstica. Interface (Botucatu). 2007;11(21):93-103. doi: https://doi.org/10.1590/S1414-32832007000100009.
https://doi.org/10.1590/S1414-3283200700... and use of alcohol can be a strategy for coping with this situation.²⁷27. Garcia LP, Silva GDM. Violência por parceiro íntimo: perfil dos atendimentos em serviços de urgência e emergência nas capitais dos estados brasileiros, 2014. Cad Saude Publica. 2018;34(4):e00062317. doi: https://doi.org/10.1590/0102-311X00062317.
https://doi.org/10.1590/0102-311X0006231... Harmful alcohol use is a public health problem linked to violence. There is evidence of association between alcohol use and situations of victimization, although the relationships between them are not clear. In this study, we only investigated alcohol use by women. Recent research suggests alcohol intake by the aggressor should also be assessed,²⁷27. Garcia LP, Silva GDM. Violência por parceiro íntimo: perfil dos atendimentos em serviços de urgência e emergência nas capitais dos estados brasileiros, 2014. Cad Saude Publica. 2018;34(4):e00062317. doi: https://doi.org/10.1590/0102-311X00062317.
https://doi.org/10.1590/0102-311X0006231... and that other factors should be measured, such as antisocial behavior and use of other psychoactive substances.²⁴24. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: WHO; 2002. Chapter 4, Violence by intimate partners; p. 87-113.

The finding that single, divorced, separated or widowed women were more likely to be victimized than married or cohabiting women diverges from other studies, in which prevalence of intimate partner psychological violence against women was more prevalent among married women when compared to single women.³3. Vale SLL, Medeiros CMR, Cavalcanti CO, Junqueira CCS, Souza LC. Repercussões psicoemocionais da violência doméstica: perfil de mulheres na atenção básica. Rev RENE [Internet]. 2013 [acesso 23 ago. 2021];14(4):683-93. Disponível em: http://www.revistarene.ufc.br/revista/index.php/revista/article/download/1123/pdf
http://www.revistarene.ufc.br/revista/in... ^,2828. Leite FMC, Amorim MHC, Wehrmeister FC, Gigante DP. Violence against women, Espírito Santo, Brazil. Rev Saude Publica. 2017 Apr 10;51:33. doi: https://doi.org/10.1590/S1518-8787.2017051006815.
https://doi.org/10.1590/S1518-8787.20170... It is possible to list some hypotheses for this result. A first hypothesis in this sense would be that psychological violence within spousal relationships may be difficult to recognize.⁵5. Silva LL, Coelho EBS, Caponi SNC. Violência silenciosa: violência psicológica como condição da violência física doméstica. Interface (Botucatu). 2007;11(21):93-103. doi: https://doi.org/10.1590/S1414-32832007000100009.
https://doi.org/10.1590/S1414-3283200700... ^,88. Mathias AKRA, Bedone AJ, Osis MJD, Fernandes AMS. Prevalência da violência praticada por parceiro masculino entre mulheres usuárias da rede primária de saúde do estado de São Paulo. Rev Bras Ginecol e Obstet. 2013;35(4):185-91. doi: https://doi.org/10.1590/s0100-72032013000400009.
https://doi.org/10.1590/s0100-7203201300... It is also believed that women who are not in a spousal relationship may have more partners, thus increasing the likelihood of meeting a violent partner; and that they may be more aware, so as to be able to recognize and put an end to the violent relationship; however, these aspects need to be studied in greater depth. A study based on data from the Federal District retrieved from the Notifiable Health Conditions Information System (SINAN) for the period 2009 to 2012, identified that almost one third of women who had suffered violence were single.²⁹29. Silva LEL, Oliveira MLC. Características epidemiológicas da violência contra a mulher no Distrito Federal, 2009 a 2012. Epidemiol Serv Saude. 2016;25(2):331-42. doi: https://doi.org/10.5123/S1679-49742016000200012.
https://doi.org/10.5123/S1679-4974201600... Given that the present study investigated occurrence of intimate partner violence during lifetime, it may be possible that the differences with regard to findings of other studies demonstrate that women with a history of abusive relationships were able to end them at some point. However, this did not always happen quickly. In this study, approximately 90% of the women who were victims of psychological violence stated that this abusive relationship lasted for more than a year. This information leads us to reflect on the initial stages of relationships, when the couple is more willing to integrate and adapt the conjugal models they learned in the families in which they grew up,³⁰30. Falcke D, Boeckel MG, Wagner A. Violência conjugal: mapeamento do fenômeno no Rio Grande do Sul. Psico. 2017;48(2):120-9. doi: https://doi.org/10.15448/1980-8623.2017.2.25148.
https://doi.org/10.15448/1980-8623.2017.... even if those models were dysfunctional. A literature review study found that witnessing domestic violence committed by parents and family members as a child may be a risk factor for involvement in violent relationships in the future.²⁵25. Capaldi DM, Knoble NB, Shortt JW, Kim HK. A systematic review of risk factors for intimate partner violence. Partner Abuse. 2012;3(2):231-80. doi: https://doi.org/10.1891/1946-6560.3.2.231.
https://doi.org/10.1891/1946-6560.3.2.23...

The present study did not focus on evaluating the current situation of intimate partner psychological violence against women, but rather on its occurrence during lifetime. The reason for adopting this premise was the understanding that exposure of this magnitude can have consequences for a woman’s life, not just in the short term.²⁴24. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: WHO; 2002. Chapter 4, Violence by intimate partners; p. 87-113. However, the limitations of the measurement of this cannot be ruled out. It is important to consider possible recall bias and information bias, besides the possibility of the outcome being underreported due to women having difficulties in reporting situations of psychological violence they experience. Another limitation is having obtained data on use of alcohol only in the last week and not identifying abusive use.

Despite the limitations mentioned, this is a population-based study conducted as a household survey, with a low percentage of losses and refusals, investigating the rural area of a municipality with full Family Health Strategy coverage. Measuring prevalence of psychological violence using an instrument validated for the Brazilian population²²22. Sinha A, Mallik S, Sanyal D, Dasgupta S, Pal D, Mukherjee A. Domestic violence among ever married women of reproductive age group in a slum area of Kolkata. Indian J Public Health. 2012;56(1):31-6. doi: https://doi.org/10.4103/0019-557X.96955.
https://doi.org/10.4103/0019-557X.96955... and which is widely used in other countries,²2. Bott S, Guedes A, Ruiz-Celis AP, Mendoza JA. Intimate partner violence in the Americas: a systematic review and reanalysis of national prevalence estimates. Rev Panam Salud Publica. 2019 Mar 20;43:e26. doi: https://doi.org/10.26633/RPSP.2019.26.
https://doi.org/10.26633/RPSP.2019.26... besides favoring understanding of possible associated factors, enables new prevention and primary health care strategies to be planned aimed at decreasing the occurrence of events of violence, as well as mitigating their impact on the lives of those women who have experienced episodes of rights violations. As for the women being able to understand the questions contained in the WHO-VAW Study questionnaire, no limitation was identified that could have compromised the development of the research. The women interviewed understood the questions and showed no difficulties in talking about the theme. Being able to master the questionnaire as well as its practicality corroborates what was described in a study which intended to validate the instrument in the Portuguese language by applying it in urban and rural areas of the country.²⁰20. Schraiber LB, Latorre MRDO, França-Jr I, Segri NJ, D'Oliveira AFPL. Validity of the WHO VAW study instrument for estimating gender-based violence against women. Rev Saude Publica. 2010;44(4):658-66. doi: https://doi.org/10.1590/s0034-89102010000400009.
https://doi.org/10.1590/s0034-8910201000...

The conclusion is reached that psychological violence against women is present in the rural area of the municipality of Rio Grande, RS, and shows a relationship with depression and use of alcohol, besides affecting different subgroups. It is interesting to note that the prevalence rates of the different forms of psychological violence identified were lower than those found in the pioneer study to validate the instrument used,²⁰20. Schraiber LB, Latorre MRDO, França-Jr I, Segri NJ, D'Oliveira AFPL. Validity of the WHO VAW study instrument for estimating gender-based violence against women. Rev Saude Publica. 2010;44(4):658-66. doi: https://doi.org/10.1590/s0034-89102010000400009.
https://doi.org/10.1590/s0034-8910201000... and which was conducted more than a decade ago. However, it should be noted that a heterogeneous country like Brazil needs improvements in the organization of health actions and services that meet its regional peculiarities. Rural areas have specific contexts, and women living there may feel that it is a greater challenge for them to report situations of violence and seek support.¹⁷17. Schraiber LB, D'Oliveira AFPL, França-Junior I, Diniz S, Portella AP, Ludermir AB, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saude Publica. 2007;41(5):797-807. doi: https://doi.org/10.1590/S0034-89102007000500014.
https://doi.org/10.1590/S0034-8910200700... ^,2222. Sinha A, Mallik S, Sanyal D, Dasgupta S, Pal D, Mukherjee A. Domestic violence among ever married women of reproductive age group in a slum area of Kolkata. Indian J Public Health. 2012;56(1):31-6. doi: https://doi.org/10.4103/0019-557X.96955.
https://doi.org/10.4103/0019-557X.96955... ^,2323. Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med. 2002;55(9):1603-17. doi: https://doi.org/10.1016/s0277-9536(01)00294-5.
https://doi.org/10.1016/s0277-9536(01)00...

Finally, the study highlights the importance of regarding violence against women as a public health problem that is also present in rural areas. As it is a multifactorial issue, as presumed by the ecological model,²⁴24. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: WHO; 2002. Chapter 4, Violence by intimate partners; p. 87-113. it is important to reflect on the use of alcohol and depression in their complex - and not unidirectional - relationship with domestic violence in the rural context. Intersectoral and integrated policies and actions need to be planned, in rural regions, in order to promote gender equality, mental health and reduction of use of alcohol and other drugs, expanding the health and social work network in the rural context, as well as decentralizing and reducing bureaucracy in accessing it.

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