A correlational cross-sectional study was conducted in suburban women of Zahedan, Iran in 2016. The Cochran’s formula (n= z²p(1-p)/d²) was used to determine the sample size [17]. In this formula with assuming the maximum variability, which is equal to 50% (p=0.5) and taking 95% confidence level with ±5% precision and z=1.96 sample size calculated 348. To ensure further, 400 subjects participated in the study. Zahedan has four suburban areas. To determine the number of sample in each area, the proportion of households in each region to total households in suburban area was multiplied in the total number of samples. In this study, the inclusion criteria were being married, being in reproductive ages (15-49 years) and living in informal settlements of Zahedan, while the exclusion criteria were women with known physical or mental issues. Samples were collected using random cluster sampling method. To do this, healthcare centers throughout the marginalised areas were defined as clusters (10 healthcare centers) and then, four healthcare centers were randomly selected from them. Then, all women in each of the four centers, who desired to participate in the study, were recruited until saturation was reached. The sampling continued for six months from July 2016 to December 2016.

The instruments used in this study included the GHQ-28 and sexual and physical violence Questionnaire that were completed through Individual interviews [18,19].

The physical and sexual violence section of the Sexual Reproductive Health Needs Assessment questionnaire was used in order to study the physical and sexual violence among the target population. The reliability and validity of the English version of the questionnaire were examined in 2008 by United Nations Population Fund (UNFPA) [20]. In Iran, the face and content validity as well as reliability of the questionnaire and each of the subscales were assessed by Khani S et al., [19]. The Intraclass Correlation Coefficient (ICC) of the physical and sexual violence subscale was also evaluated as 0.6, proving to be sufficiently reliable [19]. In the present study, the content validity of the questionnaire was confirmed and its ICC was 0.78. The items in the questionnaire were including recognition of local women and girls who are physically and sexually abused, physical and sexual violence against women, violence abusers and report the violence. The questionnaire items were in the nominal level.

The GHQ-28 is a 28-item questionnaire, incorporating four subscales of somatic symptoms, anxiety, insomnia, social dysfunction and severe depression scored on a four point Likert-type scale from zero to three. The GHQ was first developed by Goldberg DP (1972) and later, the 28-item version of the questionnaire was constructed by Goldberg DP and Hiller VF (1979) [21], the items of which were extracted from the initial 60-item version based on a factor analysis. The scores of the items in each subscale were added together to calculate each subscale score, and the total score was obtained by the sum of the scores of the items in all the four subscales. In this method, the maximum score of a subject in the questionnaire was 84. The Persian version of the questionnaire was utilised in this study, as developed by Nazifi M et al., who investigated its validity and reliability. The Cronbach’s alpha coefficients for the subscales and overall scale of the GHQ-28 was in the range of 0.74-0.92 [18]. The cut-off point of the GHQ-28 is 23. Score of zero to 22 indicates a healthy state and ≥23 indicates an unhealthy state [22].

The ethical approval of the research project (code: IR.SBMU.RETECH.REC.1395.244) was received from the research Ethics Committee of the Shahid Beheshti University of Medical Sciences and all the necessary permits were taken. Further, the sampling was performed after explaining the significance, objectives, implication of the results and promising the confidentiality of information to the participants as well as obtaining written consent from them.

Frequencies, percent frequencies, mean, and standard deviation were used to describe demographic variables, mental health score, physical and sexual violence status. Independent t-tests and linear regression analysis were used to assess the association between the physical and sexual violence status and GHQ-28 score. The statistical significance level was set at p<0.05. Statistical analysis was performed by SPSS version 19.0.

This cross-sectional, correlational study was conducted on 400 marginalised women with the mean age of 26.72±6.45 years. Demographic characteristics of the subjects under the study are summarised in [Table/Fig-1].

The mean mental health score of the study subjects was 30.05±16.66. Among the subscales, the highest mean score was related to the somatic symptoms subscale, whereas the lowest mean score was related to the severe depression subscale [Table/Fig-2]. Moreover, the highest percentage of the study subjects was in unhealthy condition in terms of somatic symptoms (62.8%), anxiety and insomnia (54.5%) and overall mental health (62%), but was in healthy condition in terms of social dysfunction (52.5%) and severe depression (70.2%) [Table/Fig-2].

In total, 125 (31.2%) of the subjects knew women or girls in their neighbourhood who were beaten and also, 72 of the subjects was beaten in the past year. In most of the cases, the assailant was the intimate partner (97.2%) and the physically abused women had not reported (79.2%). Further, fear about destroying the relationship and more violence was the reason why the majority of the subjects (43.8%) had not reported such assaults. In addition, 27 (6.8%) of the subjects knew women or girls in their neighbourhood who had experienced sexual coercion. In addition, 63 women were worried about sexual violence by someone other than her husband. However, in fact and real life, for none of the women had sexual violence by someone other than her husband. 156 (39%) subjects were coerced into sex by their husband; also, the majority of cases had not reported the intimate partner sexual coercion (94.2%), because they thought it to be normal and felt no need for any follow up (40.8%) [Table/Fig-3].

The results of the independent t-test indicated that the GHQ-28 scores, in total and in each of the subscales, were significantly higher in the physically abused group than in the group with no history of physical violence [Table/Fig-4].

Moreover, the GHQ-28 overall score as well as the scores of all its subscales were higher in the group of subjects with history of sexual violence than in the group with no history of sexual violence. The results of the independent t-test showed the differences to be significantly meaningful in the subscales of somatic symptoms, severe depression and overall score (p=0.04, p=0.04 and p=0.03, respectively) [Table/Fig-4].

The simple linear regression was used to determine the effects of physical and sexual violence on the mental health.

The standardised regression coefficient of physical violence is significantly positive and thus, can directly predict the GHQ-28 score [Table/Fig-5].

Similarly, the standardised regression coefficient of sexual violence is significantly positive and thus, can directly predict the GHQ-28 score [Table/Fig-6].

The aim of this study was to investigate the status of mental health as well as sexual and physical violence and also, to assess the relationship between sexual and physical violence with mental health of the marginalised women in the south east of Iran. The main goal of the study was to assess women at reproductive age. According to the Statistical Center of Iran, this age group has the largest population in women [24]. Also, age is a factor affecting domestic violence and mental disorders [25]. In reproductive age, hormonal changes and important events such as pregnancy and childbirth are associated with violence and mental disorders [26,27].

The results of this study showed that the majority of the subjects were at a disadvantage in terms of mental health. Further, physical and sexual violence were respectively experienced by 18% and 39% of the subjects over the past year, the relationship between physical/sexual violence and the GHQ-28 score was observed to be significantly positive.

The study conducted in Gorgan by Ghaffari E et al., showed that 40.4% of the subjects were suspected to have mental disorders, while 26.4% of the subjects suffered depression, 32% suffered anxiety and 22.7% suffered social dysfunction [28]. In the current study, however, 62% of the subjects were in the group of mental disorders, depression, anxiety and social dysfunction. The overall scores were greater than the relevant scores observed in Ghaffari E et al.’s study.

It is reported in Korean suburban, marginalisation and depression symptoms had significant relation [29]. Mumford D et al., in their study on the marginalised population in Pakistan reported the prevalence of depression and anxiety disorders as 10% among men and 25% among women [30]. According to the study by Muthukumar K and Bharatwaj RS, the prevalence of depression was 22.8% among the marginalised population in Chennai [31]. However, in this study, the prevalence of severe depression was 29.8% among the marginalised women, which is more than the rate of depression among the marginalised women in some other countries.

Sexual and physical violence are among factors affecting mental health [16]. The prevalence of physical and sexual violence was observed to be 60% and 32.9% among the women in Marivan [9], 34.4% and 34.2% among the 15–50-year-old women in Ahvaz [32] and 13% and 21% among the rural women in Khorramdarreh County, respectively [6].

The results of the studies show that physical and sexual violence is significantly associated with lowered mental health [33]. Lagdon S et al., showed PTSD, anxiety and depression as consequences of domestic violence [34]. Similarly, depression, anxiety, drug abuse and smoking increased among abused women in Kentucky [35]. In another study, in urban residents of Washington state and northern Idaho reported increased mild to severe depression and reduced social performance in women with history of physical and sexual violence [36]. Overall, eating and sleeping disorders, alcohol and drug abuse, feelings of shame and guilt, depression and anxiety, suicidal behaviour and self-injury, fear and panic disorders, PTSD, poor self-esteem, psychosomatic disorders, unsafe sexual behaviour, smoking and physical inactivity are among the mental effects of domestic violence [37].

Factors such as early marriage, alcohol abuse by spouse, unemployment, observation of violence, multiple children, less education level and economic security lead to face with enormous social, economic and physical stresses and increase the violence against women and mental disorders [33].

Receiving healthcare and counselling services can reduce the effects of violence. However, the results of the study by Nasrabadi AN et al., on women in Ahvaz showed that 84% of the abused women in Ahvaz had never been referred for counselling services [32]. The results in this study also show that 79.2% of women with a history of physical violence and 94.2% of women with a history of sexual violence remained silent and never received any counselling services, as they feared compromising their marital relationship and believed in naturalness of violence and thus, no need for any follow up. This is despite free counselling services offered in the comprehensive healthcare centers in marginalised areas. Future research is recommended to focus on resolving issues impeding the use of such services and proposing strategies to facilitate and enhance their use.

Regarding personal, environmental and cultural characteristics in marginalised areas that provide the ground for violence, further studies are recommended to be performed in this regard so that basis could be created to modify programs, develop gender-sensitive programs and increase the efficiency of services in these areas.

The limitation of this study was the use of cross-sectional method which lacked the ability to assess the causal relationships and long-term consequences of violence. Therefore, cohort studies are recommended to be carried out in this regard. Furthermore, qualitative studies are also helpful in complementing the information and also, in designing interventions and programs.

The marginalised women in Zahedan experience sexual violence more than physical violence. However, the rate of both physical and sexual violence is lower among them as compared to marginalised populations in some countries. Moreover, the marginalised women in Zahedan suffer low mental health, as it is influenced by physical and sexual violence. However, counselling services were rarely used by this population. Therefore, it is urgent to implement some policies and plans to reduce violence and promote mental health among this group of people as well as to provide more acceptable services for them.