Quality of life of nursing students victims of gender violence

Abstract

Objective

To assess the quality of life of women Nursing students, victims of gender-based violence and to correlate the dimensions of quality of life with the types of violence.

Methods

A cross-sectional study with 91 Nursing students from a public university in the southeast region of Brazil between September 2019 and January 2020. A sociodemographic questionnaire, the World Health Organization Violence Against Women, section 10, and the Abbreviated Quality of Life (WHOQOL-BREF) were used.

Results

Most students were white (85%), single (87.9%), aged between 18 and 29 years (95.6%) and lived with family members (74.7%). About 41.8% suffered physical violence from the age of 15 years and 30.8% suffered sexual violence in the same period. Cases of sexual harassment before the age of 15 years occurred in 23.1% of the participants. There was no domain of quality of life with means classified as good or very good. The following domains had the lowest ratings: psychological (mean 3.148) and environment (mean 3.305). Sexual violence before the age of 15 years was associated with lower overall health satisfaction (p=0.034).

Conclusion

The quality of life of Nursing students who are victims of gender violence requires attention, given the absence of means classified as “good” or “very good” in the domains. The effects of gender violence go beyond physical harm and demand the implementation of public policies based on strategies to prevent and face this public health problem so the victims can have a better quality of life.

Violence against women; Gender-based violence; Students, nursing; Quality of life; Women’s health; Education

Resumo

Objetivo

Avaliar a qualidade de vida de mulheres estudantes de Enfermagem vítimas de violência de gênero e correlacionar as dimensões da qualidade de vida com os tipos de violência.

Métodos

Estudo transversal com 91 estudantes de Enfermagem de uma universidade pública da região Sudeste do Brasil entre setembro de 2019 e janeiro de 2020. Utilizou-se um questionário sociodemográfico, o World Health Organization Violence Against Women, seção 10, e o Abbreviated Quality of Life (WHOQOL-BREF).

Resultados

A maioria das estudantes eram brancas (85%), solteiras (87,9%), com idade entre 18 e 29 anos (95,6%) e residiam com familiares (74,7%). Cerca de 41,8% sofreu violência física desde os 15 anos e 30,8% violência sexual no mesmo período. Os casos de importunação sexual antes dos 15 anos ocorreram em 23,1% das participantes. Não houve domínio de qualidade de vida com médias classificadas como boas ou muito boas. Os domínios com menores classificações foram: psicológico (média 3,148) e meio ambiente (média 3,305). A violência sexual antes dos 15 anos esteve associada à menor satisfação geral com a saúde (p=0,034).

Conclusão

A qualidade de vida de estudantes de Enfermagem vítimas de violência de gênero requer atenção, tendo em vista a ausência de médias classificadas como “boa” ou “muito boa” nos domínios. Os efeitos da violência de gênero vão além dos danos físicos, tornando-se necessária a implementação de políticas públicas que se baseiam em estratégias de prevenção e enfrentamento desse problema de saúde pública para que as vítimas deste agravo possam ter uma melhor qualidade de vida.

Violência contra a mulher; Violência de gênero; Estudantes de enfermagem; Qualidade de vida; Saúde da mulher; Educação

Resumen

Objetivo

Evaluar la calidad de vida de mujeres estudiantes de enfermería víctimas de violencia de género y correlacionar las dimensiones de calidad de vida con los tipos de violencia.

Métodos

Estudio transversal con 91 estudiantes de enfermería de una universidad pública de la región sudeste de Brasil, entre septiembre de 2019 y enero de 2020. Se utilizó un cuestionario sociodemográfico, el World Health Organization Violence Against Women, sección 10, y el Abbreviated Quality of Life (WHOQOL-BREF).

Resultados

La mayoría de las estudiantes eran blancas (85 %), solteras (87,9 %), entre 18 y 29 años de edad (95,6 %) y residían con familiares (74,7 %). Cerca del 41,8 % sufrió violencia física desde los 15 años y el 30,8 % violencia sexual en el mismo período. Los casos de hostigamiento sexual antes de los 15 años ocurrieron en el 23,1 % de las participantes. No hubo dominio de calidad de vida con promedios clasificados como buenos y muy buenos. Los dominios con menores clasificaciones fueron: psicológico (promedio 3,148) y medio ambiente (promedio 3,305). La violencia sexual antes de los 15 años se relacionó con una menor satisfacción general con la salud (p=0,034).

Conclusión

La calidad de vida de estudiantes de enfermería víctimas de violencia de género requiere atención, considerando la ausencia de promedios clasificados como “buenos” o “muy buenos” en los dominios. Los efectos de la violencia de género van más allá de los daños físicos, lo que demuestra la necesidad de implementar políticas públicas que se basen en estrategias de prevención y enfrentamiento de este problema de salud pública para que las víctimas de este agravio puedan tener una mejor calidad de vida.

Violencia contra la mujer; Violencia de género; Estudiantes de enfermeira; Calidad de vida; Salud de la mujer; Educación

Introduction

Violence against women characterizes a phenomenon of varied and complex determinations, with occurrence of any gender-based act that results in physical and psychological damage or suffering for the woman with potential to interfere with the integrity of health and consequently, in the quality of life.(¹,²) This event is determined by gender and, although it has the potential to affect anyone, women are affected by the most harmful practices.(³,⁴) It is understood as a global public health problem in which nurses play a fundamental role in the identification, management and prevention of this condition.(⁵)

Note that Nursing is composed mostly by women, more than 80%,(⁶) that is, health professionals who are susceptible to this violence. In addition, students in this area are also part of this niche of possible victims. These professionals are often responsible for providing assistance to women victims of violence, and can also suffer from the same adversities. Studies show that Nursing practices can be loaded with marks and conceptions of gender that can facilitate or hinder the confrontation of this violence by the victim and the professional. Most of these professionals are aware of the care to be provided in these situations, although not all of them recognize the physical, moral and social consequences involved in this process that can affect the quality of life.(⁷-⁹) Nurses can be social agents to identify situations of gender violence and should use sensitivity and attention to situations that potentially suggest the existence of the problem, such as low self-esteem, distancing from family and friends imposed by intimate partners, silencing or disregarding needs and speeches of women, reports of situations of sexual harassment, psychological or moral aggression and even physical violence perpetrated by men associated with the assumption of superiority of the male gender.(⁸,⁹)

The concept of quality of life is closely linked to health-disease issues. Although there is no consensus on its definition, the description of quality of life is complex because it is related to diverse dimensions, such as emotional, genetic and biological aspects; habitual attitudes and behaviors and coping with everyday situations.(¹⁰) Quality of life involves aspects of biopsychosocial wellbeing, takes into account interpersonal relationships, conditions of education, housing, basic sanitation and lifestyle, and is affected by conditions of violence or violation of human rights.(¹¹)

A study of university students who suffered sexual violence in childhood showed that the quality of life in adulthood is intimately affected by aggression, especially in women. The scarcity of research on the various forms of violence, especially gender-based violence, is indicated in the study, which may represent a knowledge gap and imply in the lack of measures to face the phenomenon.(¹²) Other scholars mention that situations of sexual and gender violence experienced in childhood and youth can affect several aspects of adult life that are directly or indirectly related to some dimensions of quality of life. Some physical and sexual assaults, for example, can directly compromise the victim’s future affective experiences and safe and pleasurable sexual practices. Social relationships, which include contact with other people, exchange of experiences, creation of bonds and friendships, are usually strongly affected, as the victimized woman may create individual barriers as a result of the experiences of violence suffered. In addition, aspects of reproductive life can also be compromised given the severity of some sexual or psychological aggressions suffered, leading to situations such as infertility, fear of becoming pregnant or feeling unable to care for a baby after delivery.(¹³-¹⁶)

Thus, this article proposes to answer the following question: how is the quality of life of Nursing students who have suffered gender violence? The findings can contribute to increase the visibility of the theme and support reflections on measures to control the event and the care for Nursing student victims of gender-based violence. The information on the most affected dimensions of quality of life can support the planning of a line of comprehensive care for students, with safer and more effective participation of nurses in the identification of signs or symptoms and implementation of actions that exert positive impact on the wellbeing of this population. It is also expected that the study can contribute to support intersectoral policies for the prevention, embracement and confrontation of gender violence. Thus, the objectives of the study were to evaluate the quality of life of women Nursing students, victims of gender-based violence and correlate the dimensions of quality of life with the types of violence.

Methods

This is an exploratory-descriptive, cross-sectional study(¹⁷) guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement(¹⁸) conducted with nursing students from a public university in southeastern Brazil. Data were collected between September 2019 and January 2020 using instruments made available electronically. The Informed Consent form was also electronically accessed. A pre-test was performed with 241 women regularly enrolled in the four years of the course, and 173 reports of gender violence were identified. The sampling plan was based on this number and a 5% sampling error and 10% confidence level were considered in a homogeneous distribution, and a minimum sample of 87 participants was established. The invitation was made electronically (email or messaging application) by the main researcher.

The following inclusion criteria were adopted: being a woman (cis or transgender), a Nursing student regularly enrolled in any year of the course, 18 years of age or older, and having reported victimization by gender violence in the pre-test. Those who reported not having a minimum knowledge of computers to answer the data collection instruments were excluded. The reason for choosing Nursing students is the greater contact of researchers with students in this area as, according to the Research Ethics Committee, participants should be closely monitored after completing the questionnaires, because the theme was identified as sensitive and potentially uncomfortable or with psychosocial risks. The expansion of the study to students from other courses would require a larger team of researchers.

The questionnaires were sent electronically. The initial sample had 94 participants, but one student did not sign the informed consent form and two returned the instrument incomplete. Therefore, the final sample consisted of 91 women.

Data were collected using the WHOQOL-BREF questionnaire, the abbreviated version of the WHOQOL-100 developed by the World Health Organization (WHO) quality of life group, of the World Health Organization Violence Against Women (WHO VAW) instrument, section 10, “Other Experiences”, and a sociodemographic profile form.

The WHOQOL-BREF questionnaire is used worldwide, was validated in Brazil and can be applied to different populations, including health students.(¹⁹) It consists of 26 questions that assess the quality of life in physical, psychological, social relationships and environment domains.(²⁰) The WHO VAW tool, also developed by the World Health Organization, was validated in Brazil and has high reliability for investigating aspects related to violence against women.(²¹) Section 10 includes 13 questions that assess violence against women closely related to gender, especially physical and sexual violence from the age of 15 years and sexual harassment before the age of 15. The other sections were not used because they included variables that did not fit the object of this study. The instrument for analyzing the sociodemographic profile was composed of the variables: marital status, age, skin color, sexual orientation, family income, religion and living arrangements. The mean response time of the instruments was 25 minutes.

The answers to the questionnaires were tabulated in an Excel 97 spreadsheet. Descriptive and inferential statistical analysis were performed using the R software version 4.0.4. Quantitative variables were described as mean and standard deviation and qualitative variables as absolute and relative frequency. The results are presented in tables and descriptions. Data from the questionnaires developed by the WHO were analyzed according to the syntax provided by the study group that translated the document.(²¹) Spearman’s correlation was used to assess the relationship between the variables analyzed and the scores obtained. The significance level adopted was 5%, and p values ≤ 0.05 were considered significant.

The students were invited to voluntarily participate in the study, as explained in the Informed Consent form. The study was in accordance with norms of Resolution nº 466/2012 of the National Health Council and was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (process nº 3.528.234; CAAE:14791619.2.0000.5505). Despite the sensitivity of the topic, there were no manifestations of discomfort arising from the study nor requests for exclusion of participants.

Results

Most respondents were single (87.9%), aged between 18 and 29 years (95.6%), white (85%), heterosexual (71.4%) and had a family income of three to five minimum wages (19.7%). About 20.8% considered themselves as Catholic or non-active Catholics and most lived with a family member (74.7%) (Table 1).

Table 1
Sociodemographic characteristics of women Nursing students, victims of gender-based violence (n = 91)

Sociodemographic characteristics	n(%)
Marital status
Single	80(87.9)
Other	3(3.3)
Married/lives with partner	7(7.7)
Did not answer	1(1.1)
Age group (years)
18-29	87(95.6)
30-39	4(4.4)
Skin color
Yellow	3(3.3)
White	77(85)
Indigenous	3(3.3)
Black	8(8.7)
Sexual orientation
Bisexual	22(24.2)
Heterosexual	65(71.4)
Homosexual	3(3.3)
Did not answer	1(1.1)
Family income (minimum wages)
Up to 2	13(14.3)
2-3	9(9.9)
3-5	18(19.7)
5-7	14(15.4)
7-9	9(9.9)
More than 9	12(13.2)
Did not answer	16(17.6)
Religion
Agnostic	5(5.5)
Atheist/skeptical	5(5.5)
Catholic	19(20.8)
Christian	12(13.2)
Spiritist	16(17.6)
Evangelical	10(11)
No religion	14(15.4)
Tenrikyo	1(1.1)
Did not answer	9(9.9)
Living arrangements (with whom lives)
Family member/colleague	68(74)
Roomates	4(4.4)
Friend	2(2.2)
Partner/husband/boyfriend	8(8.8)
Alone	4(4.4)
Did not answer	5(5.5)

Regarding the type of gender-based violence suffered by women Nursing students, 41.8% were victims of physical violence from the age of 15 years, 30.8% suffered sexual violence from the same age and 23.1% suffered sexual harassment before the age of 15 years (Table 2). Note that more than one type of violence could be chosen in the instrument and a marked situation did not exclude the other, thus, the three forms of aggression were listed in 30.8% of the sample.

Table 2
Distribution of types of gender-based violence in women Nursing students (n=91)

Types of violence	n(%)
Physical violence from the age of 15 years
Yes	38(41.8)
No	51(56)
Did not answer	2(2.2)
Sexual violence from the age of 15 years
Yes	28(30.8)
No	63(69.2)
Sexual harassment before 15 years of age
Yes	21(23.1)
No	69(75.8)
Did not answer	1(1.1)

According to recommendations of the World Health Organization, the instrument used to assess quality of life had 24 questions that, grouped together, generated four domains, namely: physical domain, psychological domain, social relationships and environment. In addition, two questions evaluated the overall quality of life and participants’ satisfaction with their health. Answers were given in a 1-5 Likert scale, in which the higher the score the higher the quality of life. Only questions 3, 4 and 26 had to be recoded. In data analysis, there were no domains with means classified as “good” or “very good”. All domains were classified as regular, and the psychological domain had the lowest mean (3.148), with personal beliefs and negative feelings as items with the lowest scores (mean of 2.835 and 2.923, respectively). In the physical domain, dissatisfaction with activities of daily living (mean 2.725) and dependence on medicinal substances or medical aids (mean 2.857) stood out. In the social relationships domain, social support was the item with the lowest score (mean 3.111). Finally, home environment was the factor with the greatest negative impact in the environment domain (mean 2.890). Regarding overall perception of quality of life, participants indicated it as regular (mean 3.856), as well as their satisfaction with health (mean 3.318) (Table 3).

Table 3
Distribution of mean values of scores in quality of life domains of women Nursing students, victims of gender-based violence (n =91)

Domains	Mean (Standard deviation)
Physical health	3.380 (0.637)
Pain and discomfort	4.044 (0.982)
Energy and fatigue	3.956 (1.074)
Sleep and rest	2.824 (0.783)
Mobility	4.318 (0.867)
Activities of daily living	2.725 (1.136)
Dependence on medicinal substances or medical aids	2.857 (0.973)
Work capacity	2.911 (1.013)
Psychological domain	3.148 (0.699)
Positive feelings	3.297 (0.796)
Thinking, learning, memory and concentration	3.615 (0.975)
Self-esteem	3.144 (0.758)
Bodily image and appearance	3.011 (1.011)
Negative feelings	2.923 (0.991)
Personal beliefs and spirituality	2.835 (1.118)
Social relationships	3.341 (0.818)
Personal relationships	3.395 (0.917)
Social support	3.111 (1.258)
Sexual activity	3.527 (1.098)
Environment	3.305 (0.638)
Physical safety and protection	2.978 (0.829)
Home environment	2.890 (0.781)
Financial resources	2.912 (0.938)
Health and social care: accessibilty and quality	4.077 (0.778)
Opportunities for acquiring new information and skills	3.033 (1.016)
Participation in and opportunities for recreation/leisure	3.747 (1.235)
Physical environment: (pollution/noise/traffic/climate)	3.703 (1.110)
Transport	3.055 (1.266)
Overall perception of quality of life	3.856 (0.828)
Health satisfaction	3.318 (0.964)

In the statistical correlation between quality of life and the types of violence suffered by Nursing students, dissatisfaction with health was directly related to cases of sexual violence from the age of 15 years. When interpreting the frequencies of responses in each domain, only 18% of victims of physical violence from the age of 15 years reported good quality of life, 25% were dissatisfied with their personal relationships and 35% often had negative feelings such as bad mood, despair, anxiety and signs of depression. In cases of sexual violence, about 72.6% of participants who suffered this problem felt insecure in their daily lives. Physical violence from the age of 15 years also had a negative impact on students’ lives. Approximately 73.7% of them stated that some form of medical treatment was necessary to perform their daily activities (Table 4).

Table 4
Spearman’s correlation between domains of The World Health Organization Quality of Life (WHOQOL-BREF) and the types of gender-based violence of women Nursing students (n=91)

Domains	Sexual violence since age 15	Sexual harassment before age 15	Physical violence since age 15
Overall perception of quality of life	-0.062 (0.561)	0.099 (0.348)	-0.153 (0.147)
Health satisfaction	-0.176 (0.034)	-0.066 (0.535)	-0.016 (0.088)
Physical health	-0.135 (0.207)	-0.088 (0.407)	-0.129 (0.226)
Psychological	-0.123 (0.252)	-0.092 (0.388)	-0.069 (0.521)
Social relationships	-0.089 (0.405)	0.028 (0.789)	0.030 (0.778)
Environment	-0.124 (0.242)	0.028 (0.794)	-0.035 (0.741)

Discussion

Violence against women can generate physical, social and emotional damages such as post-traumatic stress disorder, stress, depression, in addition to altering behavioral responses and increasing the level of cortisol, which can cause several other damages to health in the medium and long term. Thus, violence against women constitutes an important public health problem and has high social and individual costs. Actions that prevent this problem and enable the development of strategies for better care for victims are necessary to improve the quality of life of victims.(¹²)

A study conducted in China showed that the relationship between violence against women and quality of life was mediated by depression, anxiety and stress.(²²) This highlights the importance of tracking and controlling symptoms among these women. Furthermore, specific interventions more focused on improving the appropriate cognitive, behavioral and coping skills are necessary to reduce the emotions triggered by this process.

Participants in this study were mostly single, young adult women, as those in a Finnish study that sought to measure the quality of life of women victims of gender-based violence compared to women who did not suffer violence.(²³) In such a study, the conclusion was that participants were more dissatisfied with their health than those who did not suffer violence, especially physical violence.

The need for medical care to maintain activities of daily living was an important finding and showed that gender-based violence can affect the health-disease process, increasing the need for help in daily activities. A study conducted in João Pessoa, Paraíba, correlated domestic violence against women and their quality of life and also pointed to an increase in the need for professional help so that victims could maintain their day-to-day tasks. Moreover, in the domain scores and in questions about overall quality of life, there was a statistical difference between women who suffered and did not suffer domestic violence; women who had never been victims of violent behavior by their partners showed a higher quality of life.(¹) Domestic violence also caused psychological consequences in victims’ lives, even in the long term, in line with the findings of the present study.

Violence perpetrated against women can cause health problems such as a reduction in women’s ability to concentrate, insomnia, nightmares, irritability, lack of appetite, and even the emergence of more serious mental illnesses such as depression, anxiety and suicidal ideation. As the motivating factor of violence is often sexism, most women feel incapable of defending themselves against something that seems so abstract, also considering that they do not always find support in society, especially in sexist cultures that believe in normative models for gender.(²²-²⁴)

The impairment of quality of life domains, such as physical health, psychological and social relationships domains, can also negatively impact the self-perception of health of women victims of gender-based violence. A national study of 24,376 women aged between 20 and 49 years showed that 80% of those who suffered interpersonal violence in the twelve months prior to the survey understood psychological and/or physical aggression as very serious, which, in most cases, led to a worse perception of health compared to women who had not been assaulted.(²⁵)

Thus, the impacts on the quality of life of women who have suffered violence may be greater than those identified by means of research instruments. This problem and its consequences in the multiple dimensions of women’s lives require a more in-depth analysis. In addition, follow-up, user embracement, attentive and qualified listening of health professionals are advised for early identification of disorders and reduction of damage to the integral health of victims. A study conducted in Rio de Janeiro sought to understand how nurses receive and serve this public, and the findings demonstrated that professionals offered user embracement to women in order to strengthen the conservation of vital energy, as they understood that violence provoked something deeper in women than physical pain and promoted changes in their vigor or mood. The researchers also mentioned that it is essential to encourage women by giving them the strength to react and offer guidance in relation to the health care network.(²⁶)

Nursing professionals must be prepared to help these victims, as health services are extremely important for problem detection, intervention and promotion of a better quality of life, in a professional and ethical way. Care based on personal beliefs and empirical generalizations can make it difficult or prevent the recognition of cases of violence against women and the embracement of victims.(²⁶,²⁷)

During their training, Nursing students must receive safe guidance on humanization, user embracement, surveillance of interpersonal violence, flows of care to victims and witnesses. In addition, they must also deal with their emotions in the assistance to the aggressor, in order to avoid further harm to the woman and/or family. Nursing professors should receive appropriate training in the subject to collaborate with a more appropriate training, encourage female students to express feelings and help them, whenever possible, in coping with their experiences associated with violence, so that the future nurses find self-protection mechanisms and maintain a good quality of life.(²⁷-²⁹)

Finally, in order to achieve the reduction of situations of gender-based violence and the consequent reduction of impacts, and promote a good quality of life for women, it is necessary to strengthen public policies aimed at dissemination, combat, prevention and continuing education of health professionals.(²⁸,²⁹)

Limitations included data collection in a single public university and the fact that participants were mostly young. Different results could possibly be found in samples composed of women Nursing students of older age or those attending private higher education institutions. In addition, the use of the cross-sectional design emphasizes data collection in a specific period of time, which does not allow a great depth of information. However, such limitations do not compromise the results and relevance of the topic, given the scarcity of materials on the subject and the possibility that the findings allow reflections on the magnitude of violence against women Nursing students.

The data obtained contribute to deepen the theoretical support that helps in the promotion of comprehensive health and in the planning of new interventions for victims. Furthermore, the study can help support public policies and strategies to mitigate the impact of gender-based violence on the quality of life of women Nursing students. Higher Education Nursing Institutions and professors should rethink training and seek to promote debates on the impact of violence on quality of life, with the ability to generate professionals with good conditions of care for others and themselves.

Conclusion

This study sought to characterize the quality of life of women Nursing students, victims of gender-violence and correlate the dimensions of quality of life with the violence suffered. Most participants experienced, in some way, changes in the quality of life resulting especially, from physical and sexual violence from the age of 15 years. Victims of gender-based violence experienced a higher level of stress and depression, which demonstrates that the subsequent effects caused by violence are not only physical and promotes reflections on the mental health of these women. In conclusion, the quality of life of women victims of gender violence requires intersectoral and multidisciplinary attention so that this public can enjoy better dignity. In addition, we emphasize the importance of the state guaranteeing the rights of these citizens and promoting prevention and coping policies that materialize in implemented strategies and measures that include educational institutions, families and society as a whole. It is expected that the study will encourage researchers to develop further studies on the phenomenon of quality of life after violence against women, filling existing gaps and expanding knowledge on the subject. This will also make it possible to give a voice to women, expand strategies to face the problem and favor a culture of peace.

Acknowledgements

The São Paulo Research Foundation (FAPESP), process number 2019/05267-1.

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Edited by

Associate Editor (Peer review process): Ana Lúcia de Moraes Horta (https://orcid.org/0000-0001-5643-3321) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  29 Aug 2022
• Date of issue
  2022

History

• Received
  08 July 2021
• Accepted
  19 Jan 2022