Final Project: Research ProposalIn Weeks 1 through 9, you have created all the sections to be included in the research proposal. This week, you will collate all these sections and create the final dra

(2014) and Tufan -Kocak, Türkkan, Seren (2014), the attitudes of nursing students towards DV were negative, and t hey 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 clini cal 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 e t al., 2014; Karabulutlu, 2015). Ben Natan et al. (2016) found that normative beliefs, subjective norms, and behavioural beliefs affecte d 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 t o 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, rec ognize 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 egali tarian 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, a nd to create support for victims of violence ( Beccaria et al., 2 013 ). 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 f ollows: What is the impact of a gender equa lity 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 cou rse 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 participa ting 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 fr om 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 wer e excluded from the study. A f low 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 © 2018 Central European Journal of Nursing and Midwifery 842 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 co urse 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 comm enced. 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. Th e 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 struct ure, 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 N ormalization of Violence”, “The Generalization of Violence”, “The Causality of Violence”, an d “The Hiding of Violence”. The items of the Lik ert 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 © 2018 Central European Journal of Nursing and Midwifery 843 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 deve loped 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 Gend er Role”. The egalitarian attitude items of the Likert scale are rated as “absolutely dis agree” (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 consist ency 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 , 2008 b; World Healt h 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 desig ned 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 s ession Women’s rights in laws Sixth session Women in cultural context Seventh session Women in media Eighth s ession Women and religion Nineth s ession Definition, causes and types of DV Tenth s ession Effects of DV on women’s physical and mental helath Eleventh session Relationship between gender role and DV Twelfth s ession 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 re searcher 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. Durin g 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 researc h, the gender equality course was the independent variable, and the ATDV and GRA were dependent variables. The midwifery students’ demographic variables were evaluated using perce ntage distribution and mean. As the data showed a normal distribution, the re sults of the pre - and p ost -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 character istics are shown in Table 2. Of the 64 s tudents 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 © 2018 Central European Journal of Nursing and Midwifery 844 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 univers ity, 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 statistical ly 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) Demograp hic 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 v iolence 13.74 ± 1.5 14.18 ± 1.1 -1.785 0.079 Causality of v iolence 11.22 ± 1.7 11.81 ± 1.7 -2.708 0.009 Hiding of v iolence 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 th e 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 g ender role 35.86 ± 4.4 37.88 ± 2.4 -4.123 < 0.001 Female g ender 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 © 2018 Central European Journal of Nursing and Midwifery 845 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 attitude s 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 Ne w 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 ha d 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 cha nges in attit udes 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 cou rse, 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 revie w 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 determine d 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 f emale 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 i s not particularly effective in changing attitudes towards gender roles, and that these students require specialized training regarding gender roles . To transform g ender roles from traditional to equalitarian requires gender equality training. The differe nces 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 (201 7) 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. Secon d, the follow -up assessments of ATDV and GRA after the course had finished were not measured. Hence, we did not det erminate whether or not the effects of the course were long - term. Bahadir Yilmaz E. Cent Eur J Nurs Midw 2018;9(2):840 –847 © 2018 Central European Journal of Nursing and Midwifery 846 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 resul ts of this study suggest that a gender equality course should be integrated into the midwifery curriculum. After gender equality courses are integrated int o 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.

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