Research Paper (Gender Roles)

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Cent Eur J Nurs Midw 2018;9(2):840–847

doi: 10.15452/CEJNM.2018.09.0013

ORIGINAL PAPER

THE EFFECTIVENESS OF A GENDER EQUALITY COURSE IN CHANGING

UNDERGRADUATE MIDWIFERY STUDENTS’ ATTITUDES TOWARDS DOMESTIC

VIOLENCE AND GENDER ROLES

Emel Bahadir Yilmaz

Department of Midwifery, Health Sciences Faculty, Giresun University, Piraziz, Giresun, Turkey

Received September 18, 2017; Accepted March 17, 2018. Copyright: This is an open access article distributed under the terms of the

Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

Abstract

Aim: The aim of the study is to evaluate the effectiveness of a gender equality course in changing undergraduate midwifery

students’ attitudes towards domestic violence and gender roles. Design: A one-group before-after quasi-experimental design

was used. Methods: First-year undergraduate midwifery students (n = 64) were pre- tested and post- tested for their attitude to

domestic violence and gender roles using “The Attitudes Towards Domestic Violence Scale”, and “The Gender Roles

Attitudes Scale”. Data were collected from a health science faculty in Giresun, Turkey. The pre- and post-test results were

compared using a paired samples t-test. Results: While the mean score of the attitudes towards domestic violence was

55.23 ± 5.84 before the gender equality course, it increased to 57.71 ± 5.07 after the course. The increase in scores was

statistically significant (p < 0.001). For attitudes to gender roles, the mean total score increased from 154.65 ± 14.16 to

164.72 ± 13.65 after the course (p < 0.001). Conclusion: The gender equality course helped students develop more positive

attitudes towards domestic violence and gender roles. We achieved the aim of the study. We recommend that gender equality

courses be integrated into the midwifery curriculum.

Keywords: domestic violence, gender equality, gender roles, midwifery students.

Introduction

The pregnancy and postpartum period are associated

both with the initiation of violence within

a relationship, or with an increase in the severity or

frequency of domestic violence (DV) (Marchant et

al., 2001). However, these periods provide many

potential opportunities for midwives to identify and

help women experiencing DV (Bacchus et al., 2004;

Stenson, Sidenvall, Heimer, 2005; McLachlan et al.,

2011). Therefore, midwives are crucial in identifying

affected women, in providing appropriate care and

support (Hindin, 2006; Lauti, Miller, 2008).

Sensitivity to DV should also be developed in all

midwives, and they should be provided with adequate

knowledge and skills (Prime Ministry Directorate

General on the Status of Women, 2008a).

DV has negative effects on sexual and reproductive

health, as well as on the physical and mental health

of women. Some of the effects related to sexual and

reproductive health include gynaecological disorders,

Corresponding author: Emel Bahadir Yilmaz, Department of

Midwifery, Health Sciences Faculty, Giresun University, Erenler

Street and No: 25, Giresun, Turkey; e-mail:

[email protected]

trauma, unintended and unwanted pregnancy,

abortion, HIV and other sexually transmitted

infections, maternal mortality, miscarriage, stillbirth,

and babies born with low birth weight (World Health

Organization, 2012; International Confederation

of Midwives, 2014). Midwives also play a crucial

role in identifying and managing DV due to women’s

frequent contact with them. However, they have

difficulties in recognising DV because of a limited

knowledge of the most common signs and symptoms

of violence, lack of training, education, and

confidence, time constraints, safety issues, staff

shortages, cultural taboos, unwillingness of victims to

disclose abuse, lack of privacy for screening, and

midwives’ personal experiences of DV (Mezey et al.,

2003; McCosker-Howard et al., 2005; Lazenbatt,

Taylor, Cree, 2009; Finnbogadóttir, Dykes, 2012;

Mauri et al., 2015; Pitter, 2016).

A number of studies have been conducted on

undergraduate students receiving education in the

health field. Kaynar-Tunçel, Dündar, Peşken (2007)

pointed out that while a significant number of nursing

and midwifery students had positive attitudes, as

many as half were undecided on the appropriateness

of questioning women about whether they were being

Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840–847

exposed to violence. According to Kaplan et al.

(2014) and Tufan-Kocak, Türkkan, Seren (2014), the

attitudes of nursing students towards DV were

negative, and they had adopted traditional gender

roles. According to some studies, nursing and

midwifery students also lacked confidence

in recognizing and responding to abuse (Bradbury-

Jones, Broadhurst, 2015), were ill-prepared to deal

with domestic violence in clinical practice (Beccaria

et al., 2013), and had not received sufficient training,

practical skills, and classroom knowledge to

effectively manage abuse against women (Majumdar,

2004).

Some studies have indicated that attitudes to gender

roles of healthcare students are in line with traditional

views, with adverse effects on attitudes towards DV

(Kanbay et al., 2012; Kaplan et al., 2014;

Karabulutlu, 2015). Ben Natan et al. (2016) found

that normative beliefs, subjective norms, and

behavioural beliefs affected nursing students’

inclinations to screen women for DV (24). Coleman

and Stith’s (1997) study measured nursing students’

attitudes towards victims of DV. They found that

students with more egalitarian beliefs regarding

gender roles were more sympathetic to victims

of abuse than those with more traditional attitudes to

gender roles.

There is no evidence regarding the effectiveness

of midwifery students’ training in attitudes towards

gender roles and DV. However, there is some

evidence regarding the effectiveness of midwives’

training in DV. Jayatilleke et al. (2015) conducted

a training program for public health midwives.

The training program significantly improved

midwives’ practices, perceived responsibility, and

self-confidence in identifying and assisting DV

sufferers. Berman, Barlow, Koziol-McLain (2005)

interviewed midwives who had participated in the

Family violence prevention education programme in

the Auckland region, 2002. Most spoke of their

increased motivation and emphasized the importance

of knowledge in encouraging changes in attitudes.

Midwives who have positive attitudes towards DV

report greater understanding of DV, recognize signs

of DV, ask women what would be helpful for them,

and support those who have been abused (Protheroe,

Green, Spiby, 2004; Baird et al., 2017). Thus,

training in DV is very important, and is associated

with gender roles, since midwives with egalitarian

attitudes towards gender roles are more likely to have

positive attitudes towards DV.

Undergraduate education is also a critical time for

developing attitudes towards DV and attitudes to

gender roles necessary to identify, prevent, and

manage DV, and to create support for victims

of violence (Beccaria et al., 2013). Hence, this study

evaluated the effectiveness of a gender equality

course on the attitudes of undergraduate midwifery

students towards DV and gender roles. The research

question was as follows: What is the impact

of a gender equality course on the attitudes

of undergraduate midwifery students towards DV and

gender roles?

Aim

The aim of this study was to evaluate the

effectiveness of a gender equality course in changing

the attitudes of undergraduate midwifery students

towards DV and gender roles. Objectives:

1. To evaluate the effectiveness of a gender equality course in changing attitudes of

undergraduate midwifery students towards DV.

2. To evaluate the effectiveness of a gender equality course in changing the attitudes of

undergraduate midwifery students towards

gender roles.

Methods

Design

A one-group before-after quasi-experimental design

was used to evaluate the effectiveness of a gender

equality course in changing attitudes

of undergraduate midwifery students towards DV and

gender roles.

Sample

Convenience sampling was used. All the participants

were enrolled in the first-year of a Bachelor

of Midwifery Degree at the University of Giresun

in the academic year 2015–2016. 64 students who

participated in the gender equality course in the fall

semester were eligible to participate in the study.

Students were given the option of participating and

assured that their participation was voluntary. The

inclusion criteria for the study included: 1) taking the

gender equality course, 2) voluntary participation,

and 3) competence in understanding and speaking

Turkish. The criteria for exclusion from the study

were: 1) Non-participation in two or more sessions,

and 2) lack of competence in understanding or

speaking Turkish. Two students did not have

sufficient competence in Turkish, and six students

who did not participate in two or more courses were

excluded from the study. A flow diagram of the

phases of the study is shown in Figure 1. 64 students

who participated in the gender equality course in the

fall semester were eligible to participate in the study.

Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840–847

Figure 1 The flow diagram of the study

All were female, and their average age was

18.34 ± 0.80.

Data collection

The study was conducted between September 2015

and January 2016. During the study, the data were

collected at two different time points. Before the

course started, measurements from the ATDV and

GRA scales were taken by a researcher, and

the second measurements were collected one week

after the course had finished. Official written

permission was received from the school

management before the study commenced. Students

were then informed about the study, and data

collection forms were distributed to the students who

had voluntarily agreed to participate in the study,

during classes. The completion of the data collection

forms took about 15–20 minutes.

The data was collected with the “Demographic

Information Form (DIF)”, “The Attitudes Towards

Domestic Violence Scale (ATDV)”, and “The

Gender Roles Attitudes Scale (GRA)”. The DIF

included demographic information about the students

such as age, family structure, number of siblings, area

they lived in, socio-economic status, parents’

educational status, and parents’ professions.

The ATDV Scale was developed by Şahin, Dişsiz

(2009). The ATDV Scale, which consists of 13 items,

and assesses interiorized labelling, has four

subscales: “The Normalization of Violence”,

“The Generalization of Violence”, “The Causality

of Violence”, and “The Hiding of Violence”.

The items of the Likert scale are rated as “absolutely

disagree” (1 point), “disagree” (2 points),

“undecided” (3 points), “agree” (4 points), and

“completely agree” (5 points). The highest possible

All first year midwifery students (n = 72) were selected

The Gender Equality Course that consisted of 12 sessions and each

session lasted two hours

8 students were excluded (2 students did not understand or speak

Turkish well, and 6 students did not participate in at least two sessions)

Filled out the ATDV and the GRAS

Filled out the ATDV and the GRAS (n = 64)

Analysis

Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840–847

score from the scale was 65, and the lowest was 13.

Higher scores indicated that attitudes towards

domestic violence were positive. The instrument’s

total Cronbach alpha internal consistency coefficient

was found to be 0.72. For this study, the Cronbach

alpha internal consistency coefficient was found to be

0.75.

The GRA was developed by Zeyneloğlu and

Terzioğlu (2011). The GRA Scale, which consists

of 38 items, and assesses interiorized labelling, has

five subscales: “Egalitarian Gender Role”, “Female

Gender Role”, “Marriage Gender Role”, “Traditional

Gender Role”, and “Male Gender Role”.

The egalitarian attitude items of the Likert scale are

rated as “absolutely disagree” (1 point), “disagree”

(2 points), “undecided” (3 points), “agree” (4 points)

and “completely agree” (5 points). The traditional

attitudes items of the Scale are rated inversely.

The highest possible score from the scale was 190,

and the lowest was 38. Higher scores from the scale

indicated that the students had more egalitarian

attitudes towards gender roles. The instrument’s total

Cronbach alpha internal consistency coefficient was

found to be 0.92. For this study, the Cronbach alpha

internal consistency coefficient was found to be 0.86.

Gender Equality Course

The gender equality course consisted of two parts.

The first part, which related to gender roles, was

structured based on the related literature (World

Health Organization, 2006; Prime Ministry

Directorate General on the Status of Women, 2008b;

World Health Organization, 2009; Ecevit et al., 2011;

Dökmen, 2016). The second part related to DV was

structured based on the related literature also

(Berman, Barlow, Koziol-McLain, 2005; Jayatilleke

et al., 2015; Crombie, Hooker, Reisenhofer, 2016).

The course was designed to improve the attitudes

of undergraduate midwifery students towards

domestic violence and gender roles. A summary

of the course content is shown in Table 1.

Table 1 The topics of the gender equality course

Sessions Topics

First session Preparatory

Second session Gender, gender role and related theories

Third session Women in politics

Fourth session Gender inequality in education

Fifth session Women’s rights in laws

Sixth session Women in cultural context

Seventh session Women in media

Eighth session Women and religion

Nineth session Definition, causes and types of DV

Tenth session Effects of DV on women’s physical and mental helath

Eleventh session Relationship between gender role and DV

Twelfth session Closing

The course spanned ten sessions, and each session

lasted two hours. The course was delivered by

a researcher, assistant professor in Midwifery

Department of Health Science Faculty at the

University of Giresun, a RN with advanced education

in psychiatric nursing, with a PhD in domestic

violence. Using case reports and making visual

presentations, the researcher discussed how to define

the signs of domestic violence, and improved their

awareness and level of knowledge. The researcher

debated on the agenda related to DV and gender

equality. The students were allowed to share their

sexist experiences. During the course, the researcher

gave the students written notes about each of the

session’s content.

Data analysis

The Statistical Package for Social Sciences (SPSS,

Chicago, IL) for Windows version 16.0 was used for

data entry and analysis. In this research, the gender

equality course was the independent variable, and

the ATDV and GRA were dependent variables.

The midwifery students’ demographic variables were

evaluated using percentage distribution and mean.

As the data showed a normal distribution, the results

of the pre- and post-tests were compared using

a paired samples t-test. The significance level of the

statistical tests was set to 0.05 (p < 0.05).

Results

The sample characteristics are shown in Table 2.

Of the 64 students that commenced the study, 75.0%

came from a nuclear family structure, 42.2%

Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840–847

previously lived in a town, and 37.5% previously

lived in the country. 82.8% of the students perceived

their socio-economic status as moderate. Only 14

(21.9%) of the students’ mothers worked outside

the home, and 20.3% of them had graduated from

high school or university. Nearly a third of students’

fathers (35.9%) had graduated from high school or

university, and most (82.8%) were in work.

As indicated in Table 3, the mean ATDV total score

of students was 55.23 ± 5.84 before the gender

equality course. It increased to 57.71 ± 5.07 one

week after the final session. The increase in the

scores was statistically significant (t = -4.829,

p = 0.000). There were statistically significant

increases in ATDV subscale mean scores one week

after the last session (t = -5.116, p = 0.000 for

normalization of violence; t = -2.708, p = 0.009 for

causality of violence; t = -2.797, p = 0.007 for hiding

of violence). However, there was no statistically

significant increase in generalization of violence

subscale mean scores one week after the final session

(t = -1.785, p = 0.079).

Table 2 Sample characteristics (n = 64)

Demographic information n %

Family structure nuclear 48 75.0

extended 14 21.9

divorced 2 3.1

Place of living country 24 37.5

town 27 42.2

village 13 20.3

Socio-economic status high 9 14.1

moderate 53 82.8

low 2 3.1

Mother’s educational

level

illiterate 5 7.8

< high school 46 71.9

≥ high school 13 20.3

Mother’s working status working 14 21.9

not working 50 78.1

Father’s educational level < high school 41 64.1

≥ high school 23 35.9

Father’s working status working 53 82.8

not working 11 17.2

Table 3 Distribution of students’ ATDV subscale mean scores according to pre- and post-test measures (n = 64)

Pretest

X ± SD

Posttest

X ± SD t value p value

Normalization of violence 21.50 ± 2.5 23.07 ± 2.1 -5.116 < 0.001

Generalization of violence 13.74 ± 1.5 14.18 ± 1.1 -1.785 0.079

Causality of violence 11.22 ± 1.7 11.81 ± 1.7 -2.708 0.009

Hiding of violence 8.05 ± 1.8 8.59 ± 1.8 -2.797 0.007

Total score 55.23 ± 5.8 57.71 ± 5.0 -4.829 < 0.001 X – arithmetic mean; SD – standard deviation

Table 4 shows the students’ GRA scores across

the subscales. The students’ mean “eqalitarian gender

role”, “female gender role”, “marriage gender role”,

“traditional gender role”, and “male gender role”

subscale scores increased significantly one week after

the final session compared to the scores before the

course (egalitarian gender role t = -4.123, p = 0.000;

female gender role t = -5.400, p = 0.000; marriage

gender role t = -2.733, p = 0.008; traditional gender

role t = -5.440, p = 0.000; male gender role

t = -4.177, p = 0.000). In the GRA, the mean total

score before the course was 154.65 ± 14.16.

It increased significantly to 164.72 ± 13.65 one week

after the final session (t = -6.633, p = 0.000).

Table 4 Distribution of students’ GRA subscale mean scores according to pre- and post-test measures (n = 64)

Pretest

X ± SD

Posttest

X ± SD

t value p value

Egalitarian gender role 35.86 ± 4.4 37.88 ± 2.4 -4.123 < 0.001

Female gender role 26.83 ± 4.5 29.30 ± 4.9 -5.400 < 0.001

Marriage gender role 36.63 ± 2.8 37.56 ± 2.2 -2.733 0.008

Traditional gender role 29.45 ± 4.5 32.37 ± 4.3 -5.440 < 0.001

Male gender role 25.41 ± 2.6 27.12 ± 2.6 -4.177 < 0.001

Total score 154.65 ± 14.1 164.72 ± 13.6 -6.633 < 0.001 X – arithmetic mean; SD – standard deviation

Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840–847

Discussion

The higher scores in the ATDV subscales one week

after the last session indicated that the gender

equality course was helpful in improving attitudes

towards DV. This result provides empirical support

for the suggestion that the course promotes

improvement in attitudes towards DV of the students.

Similar results to our study were obtained in another

study consisting of 26 midwives, evaluating the

impact on midwives of a training programme

designed to increase their awareness and

understanding of violence against women (Protheroe,

Green, Spiby, 2004). It was demonstrated that after

training, the midwives reported greater understanding

of DV, and an increased likelihood of identifying and

supporting victims of DV. According to Berman,

Barlow, Koziol-McLain (2005), The New Zealand

College of Midwives organized a workshop to train

midwives in how to integrate screening and referral

for family violence into their care. Participants later

asserted that the training had been of value to their

midwifery practice. They described an increasing

sense of confidence in routinely screening their

clients, and related strategies for doing this safely.

Jayatilleke et al. (2015) reported that a DV training

programme for public health midwives improved

identification of and assistance for DV victims in Sri

Lanka. They also suggested that the training

programme had the potential to improve midwives’

skills in preventing DV.

A study by McLachlan et al. (2011), which evaluated

an educational intervention for midwives in order to

identify and support women with psychosocial issues

during the postnatal period, revealed different results

to our study. In this case, the programme did little to

change attitudes to DV. However, the reason for the

failure of this educational intervention may be that it

did not directly attempt to change knowledge of and

attitudes to DV. In another study by Ritchie et al.

(2013) it was determined that the training and

documentation had led to improved assessment

of female victims of assault presenting at

an emergency department. However, the training

alone did not account for the changes. Supporting

processes such as a standardized documentation form

are required in addition to training. Alongside

training, a systematic approach is necessary to

promote changes in attitudes towards DV

in midwives.

As illustrated in Table 4, it was determined that

students’ mean “egalitarian gender role”, “female

gender role”, “marriage gender role”, “traditional

gender role” and “male gender role” subscale scores

increased significantly after the gender equality

course, compared to the scores before the course.

These results indicated that the gender equality

course contributed to students’ more positive

attitudes to gender roles. There were no intervention

studies related to gender roles in the literature. Our

review of the related literature found that the studies

aimed either to assess the association between

students’ gender roles and undergraduate education,

or to determine students’ gender roles. Results

of a recent study by Kömürcü et al. (2016) which

determined the attitudes of first and fourth year

nursing and midwifery students to gender roles

revealed that attitudes regarding male, female,

marriage and traditional gender roles of the students

did not change during their nursing and midwifery

education. Adana et al. (2011) reported that male

nursing students had social gender roles which

supported violence against women by men, and that

nursing education did not affect the social gender

roles of the students. In another study, the attitudes to

gender roles of first and fourth year nursing and

midwifery female students were compared.

A statistically significant difference was found

between the two groups (Atış, Alan, 2010).

The results of these studies suggest that

undergraduate nursing and midwifery education is

not particularly effective in changing attitudes

towards gender roles, and that these students require

specialized training regarding gender roles.

To transform gender roles from traditional

to equalitarian requires gender equality training.

The differences in these studies may be due to

differences in the nursing and midwifery curriculum.

Therefore the curriculum in nursing and midwifery

schools should be restructured. A review study by

Crombie, Hooker, Reisenhofer (2017) demonstrated

that undergraduate DV education for

nursing/midwifery staff and students was inadequate

and unsatisfactory. In accordance with these results,

DV education should examine gender roles and the

effects of traditional gender roles on attitudes towards

DV. A study by Jayatilleke et al. (2015) emphasized

that gender roles were an integral part of DV training

programmes.

Limitation of study

This study had two limitations. Firstly, the design did

not include a control group. For this reason, it was

not possible to establish causality between the course

and the results. Second, the follow-up assessments

of ATDV and GRA after the course had finished

were not measured. Hence, we did not determinate

whether or not the effects of the course were long-

term.

Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840–847

Conclusion

The results of our study confirmed that the gender

equality course was successful in improving attitudes

towards both gender roles and DV. Aspects

influencing the effectiveness of gender equality

courses include presenting case reports, making

visual presentations, discussion of an agenda related

to DV and gender equality, and the length of the

training (twelve days, twenty four hours). A final

factor might be the integration of DV and gender

equality. The results of this study suggest that

a gender equality course should be integrated into the

midwifery curriculum. After gender equality courses

are integrated into the midwifery curriculum,

the outcomes of courses should be assessed and

shared in scientific environments.

Ethical aspects and conflict of interest

Ethical issues were taken into consideration during

all phases of the study. Written consent was obtained

from the Dean of Health Sciences Faculty. The study

was conducted according to the ethical guidelines set

out in the Declaration of Helsinki. Students were

informed regarding the aim and design of the study.

They were invited to participate, and verbal and

written consent was received from the students.

The author has no conflicts of interest to disclose.

Acknowledgement

We would like to thank the those who participated in

this study.

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