Intimate partner violence and substance abuse among minority women receiving care from an inner-city emergency department.

A woman's drug and alcohol use has been found to increase her risk of experiencing intimate partner violence (IPV). OBJECTIVE: The study describes the rates of lifetime and current IPV among women awaiting care in an emergency department and explores the association between IPV and having a drug abuse problem, and IPV and having an alcohol abuse problem, after controlling for demographic factors and history of childhood victimization. METHODS: Face-to-face interviews were conducted with 143 low-level triaged women recruited from an inner-city emergency department. RESULTS: Nearly one-half reported ever experiencing IPV, and over 18% reported IPV during the year before the interview. A higher proportion of abused women reported a history of regular crack, cocaine, or heroin use and visiting shooting galleries or crack houses. Participants who were physically abused by their partner during the past year (15%, n = 21) were more likely than nonabused women (85%, n = 122) to report higher scores on the Alcohol Use Disorders Identification Test (AUDIT) (4.9 vs. 2.4), a measure of alcohol-related problems, and the Drug Abuse Severity Test (DAST) (3.0 vs. 1.3), a measure of drug-related problems. Sexually abused women (6%, n = 9) were more likely than their counterparts (94%, n = 134) to have significantly higher AUDIT scores (6.4 vs. 2.5). The findings have implications for how the intersecting public health problems of IPV and substance abuse should be taken into consideration in research and patient care protocols in emergency departments.     

Healthcare utilization and costs for women with a history of intimate partner violence

OBJECTIVE: To determine the healthcare utilization and medical care costs of women with a history of intimate partner violence (IPV) compared to women without a history of IPV. DESIGN: Longitudinal cohort study. SETTING: Mixed-model health maintenance organization. PARTICIPANTS: Over 3000 (3333) women aged 18 to 64 years with > or = 3 year's cumulative enrollment prior to the survey, at least 1 year of which was after the 18th birthday. MAIN EXPOSURE: IPV since age 18 as determined from responses to telephone interview using questions from the Behavioral Risk Factor Surveillance System and also the Women's Experience with Battering Scale. OUTCOME MEASURES: Healthcare utilization and costs (from automated data) during the time that IPV occurred and following its cessation, compared to healthcare utilization for women who did not report IPV since age 18. RESULTS: A total of 1546 women reported IPV in their lifetime; at the time of interview, IPV had ceased in 87% of women, on average 16.0 years prior to interview. Healthcare utilization was higher for all categories of service during IPV compared to women without IPV, and decreased over time after cessation of IPV. However, healthcare utilization was still 20% higher 5 years after women's abuse ceased compared to women without IPV. Adjusted annual total healthcare costs were 19% higher in women with a history of IPV (amounting to $439 annually) compared to women without IPV. Based on prevalence for IPV of 44%, the excess costs due to IPV are approximately $19.3 million per year for every 100,000 women enrollees aged 18-64. CONCLUSIONS: Women with a history of IPV had significantly higher healthcare utilization and costs, continuing long after IPV ended. Given its high prevalence, IPV has a major impact on medical care resource utilization and efforts to prevent its occurrence and consequences are clearly indicated.     

Intimate Partner Violence/Abuse and Depressive Symptoms among Female Health Care Workers: Longitudinal Findings

Intimate partner violence and abuse (IPV/A) have been shown to have a major impact on mental health functioning. This study assessed the longitudinal association between recent IPV/A and depressive symptoms to identify potential targets for preventive interventions for women. Random effects models were used to examine four waves of data collected at 6-month intervals from a cohort of 1,438 female health care workers. IPV/A (e.g., sexual and physical violence, psychological abuse) in the past 5 years was associated with higher Center for Epidemiologic Studies Depression Scale (CES-D) 10 scores across four waves after adjustment for age, time, marital status, and childhood trauma. Women who reported IPV/A in the past 5 years had higher CES-D 10 scores (β, 1.31; 95% confidence interval, 0.79–1.82; p < .0001) than nonabused women. This association was generally constant with time, suggestive of a cross-sectional association across all four waves of data. Additionally, recent IPV/A was associated with change in depressive symptoms over time among the full cohort and those with CES-D 10 scores below 10 (the threshold for likely depression) at baseline. Recent IPV/A was independently associated with depressive symptoms both cross-sectionally and longitudinally. The longitudinal association was stronger among those not depressed at baseline. Implications for health care settings and workplace policies addressing IPV/A are discussed.     

Prevalence of intimate partner violence and health implications for women using emergency departments and primary care clinics.

OBJECTIVES: To determine prevalence of intimate partner violence (IPV) among women accessing health care, factors that influence rates of abuse, barriers to disclosure, and associated health problems and perceptions of safety. METHODS: A convenience sample of women seeking health care completed 1268 anonymous surveys (75 in Spanish) while at 1 of 24 urban, suburban, or rural emergency departments or primary care clinics. RESULTS: Of women in this study, 50-57% had experienced physical and/or emotional abuse and 26% reported sexual abuse in their lifetime. In the past year, 28% reported emotional abuse, 12% physical abuse, 6% severe physical abuse, and 4% sexual abuse. Logistic regression models found that younger, less-educated, less-affluent women presenting to urban emergency departments reported the highest rates of physical abuse. Although 83% welcomed abuse screening, only 25% ever had been asked and 86% would disclose abuse if asked directly, respectfully, and confidentially. Abused women reported significantly lower health status ratings than nonabused women (p < 0.001). Emotional abuse was as strongly associated with health problems as physical abuse. The majority (70-93%) of women with headaches, stomach problems, chronic pain, vaginal bleeding, substance abuse, depression, and suicidal thoughts had experienced lifetime physical/emotional abuse. CONCLUSIONS: Women experience many forms of abuse and present to a wide range of health care settings. The striking prevalence of IPV and associated emotional/physical health problems challenges providers to routinely assess for abuse in ways that minimize barriers to disclosure and enhance the development of an effective plan of care based on a patient's abuse experience.     

Cumulative abuse experiences, physical health and health behaviors

PURPOSE: Our purpose was to investigate the complex relationship between a range of lifetime abuse experiences with current physical health and health behaviors. METHODS: Between October 1998 and May 1999, interviews were conducted with 557 ethnically diverse women seen at two urban primary care centers. Seven forms of abuse were measured: childhood physical and sexual abuse, past physical and sexual intimate partner violence (IPV), and recent emotional, physical, and sexual IPV. Severity was measured for six of these forms. Multiple non-specific physical symptoms were measured with a modified PRIME-MD, and four health behaviors were ascertained. RESULTS: Approximately 10% of women never experiencing abuse reported multiple non-specific physical symptoms, compared with 25.8% to 78.4% of women reporting a range of abuse experiences. Increases in recent IPV, past IPV, child abuse, and economic hardship were associated with increases in reported symptoms. Women who experienced IPV were more likely to report smoking cigarettes, binge drinking, and having poor nutritional habits. CONCLUSIONS: Recent IPV is associated with physical symptoms and risky health behaviors beyond the effects of child abuse, past IPV, and economic disadvantage. Understanding a person's IPV experiences may inform interventions for health behaviors, such as smoking cessation programs.     

Discussions About Intimate Partner Violence During Prenatal Care in the United States: The Role of Race/Ethnicity and Insurance Status

Over 1.5 million women are physically, sexually, and emotionally abused by intimate partners in the U.S. each year. Despite the severe health consequences and costs associated with intimate partner violence (IPV), most health providers fail to assess patients for abuse. It was of interest to examine the occurrence of IPV discussions during prenatal care (PNC) visits among women who experienced IPV. This study analyzed data from the 2004–2008 National Pregnancy Risk Assessment Monitoring System which included 195,687 women who delivered a live birth in the U.S. IPV victimization was measured using four items that addressed physical abuse by a current or former husband/partner in the 12 months before or during pregnancy. Responses were categorized as preconception, prenatal, preconception and prenatal, and preconception and/or prenatal IPV. The outcome was IPV discussions by health providers during PNC. Separate logistic regression models provided odds ratios and 95 % confidence intervals. Women who reported prenatal IPV were less likely to have IPV discussions during PNC (OR = 0.81, 95 % CI = 0.70–0.94). Results were similar for women experiencing IPV during the prenatal and preconception periods. Among racial/ethnic minorities, women who experienced preconception IPV were less likely to have discussions about IPV during PNC. Further, Medicaid recipients who reported preconception and/or prenatal IPV were less likely to report IPV discussions (OR = 0.75, 95 % CI = 0.69–0.82). This study underscores a public health problem and missed opportunity to connect battered victims to necessary services and care. It elucidates the state of current clinical practice and better informs policies on incorporating universal IPV screening.     

Severity of spousal and intimate partner abuse to pregnant Hispanic women

Abuse to pregnant women can result in complications to maternal and child health. This study assessed the severity of intimate male partner abuse to Hispanic pregnant women receiving prenatal care at an urban public health department. The mean age of the 329 pregnant, abused Hispanic women was 24 years. The women had an average of eight years of education, annual incomes of less than $10,000, and most spoke only Spanish. In all, 30 percent of the women had been threatened with death, 18 percent had been threatened with a knife or gun, 80 percent had been shaken or roughly handled, 71 percent pushed or shoved, and 64 percent slapped on the face and head. Pregnant, abused Hispanic women experience abuse of sufficient severity to pose a risk to maternal and child health. Prenatal care provides a window of opportunity for routine abuse assessment and counseling for low-income, Hispanic pregnant women.     

Intimate partner violence among midlife and older women: a descriptive analysis of women seeking medical services

Although intimate partner violence (IPV) may occur throughout a woman's life course, there has been a paucity of research on the experiences of victimization among midlife and older women. This article examines both the prevalence of IPV among a sample of women ages 50 to 64 (N=620), who were recruited at an emergency department and primary care clinics in an urban setting, and the associated factors for the subsample of these women who reported IPV (n=34). More than 5 percent of the women reported experiencing some form of abuse by their partners within the past two years. Bivariate analyses comparing victims and nonvictims indicate that higher proportions of women who reported abuse had received public assistance and had a recent history of homelessness. In addition, victims of IPV reported higher frequencies of HIV risk factors than did nonvictims, including having a partner who insisted on sex without a condom, having sex with a man they knew or suspected was an IV drug user, and experiencing symptoms or receiving a diagnosis or treatment for a sexually transmitted infection. Significantly higher percentages of abused women reported being tested for HIV and being HIV seropositive. Implications of the findings for social workers are discussed.     

Partner violence and medical encounters: African-American women's perspectives

OBJECTIVE: To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Community-based, primary care center. PATIENTS: Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter. MEASUREMENTS: Patients' perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV "in the past year." RESULTS: Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers. CONCLUSIONS: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care.     

The influence of child abuse on the pattern of expenditures in women's adult health service utilization in Ontario, Canada

Childhood maltreatment is a common and serious problem for women, particularly in relation to impairment in adulthood. To our knowledge, no system-wide study has addressed the influence of childhood maltreatment on the cost of these women's adult health service utilization. This paper examines this relationship. The 1990 Ontario Health Survey (OHS) gathered information regarding determinants of physical health status and the use of health services. The 1991 Ontario Mental Health Supplement (OHSUP) examined a variety of childhood experiences as well as the prevalence of psychiatric disorders from a sample of OHS respondents. These were province-wide population health surveys of a probability-based sample of persons aged 15 years and older living in household dwellings in Ontario. The OHSUP randomly selected one member from each participating OHS household to be interviewed regarding personal experiences and mental health. This analysis used data from women aged 15-64 who participated in both the OHS and OHSUP. Self-reported health service utilization was collected in four groups of women--those who reported no history of child abuse, those with a history of physical abuse only, those who reported sexual abuse only, and those who reported both physical and sexual (combined) abuse. We hypothesized that a history of child abuse would result in greater adult health care costs. The results indicated that having a history of combined abuse nearly doubles mean annual ambulatory self-reported health care costs to 775 dollars (95% CI 504 dollars-1045 dollars) compared to a mean cost of 400 dollars with no abuse (95% CI 357 dollars-443 dollars). Median annual ambulatory self-reported health care costs were also increased in the combined abuse group, to 314 dollars (95% CI 220 dollars-429 dollars), compared to 138 dollars (95% CI 132 dollars-169 dollars) in those with no abuse. We conclude that child abuse in women is significantly associated with increased adult self-reported health care costs.     

How do women in Spain deal with an abusive relationship?

OBJECTIVES: To determine the different responses adopted by women in Spain who are victims of intimate partner violence (IPV); identify the different sociodemographic profiles associated with each response; analyse the factors contributing to adopting a response; and study the association between the different types of response and the different types of IPV. DESIGN: Cross sectional study. SETTING: 23 volunteer general practices in Spain. PARTICIPANTS: 1402 randomly selected women. MAIN OUTCOME MEASURE: Women's response to IPV: none, partner separation, reporting the case to the police, seeking help from healthcare professionals and seeking help from associations for battered women. RESULTS: Lifetime prevalence of any type of IPV (physical, psychological, and/or sexual) was 32%. Sixty three per cent of abused women took some kind of action to overcome IPV. Women who separated from their partners were mostly younger, with a smaller number of children and higher income and educational levels, compared with those abused women who reported the abuse to the police or sought help from healthcare professionals or associations for battered women. Independent factors associated with presenting a response to IPV were: being separated/divorced/widowed, having social support, having experienced IPV frequently, and having experienced physical and psychological abuse (compared with psychological abuse alone). Women who experienced the three types of abuse were also more likely to respond to violence. CONCLUSIONS: Identifying the factors that have an influence on the response adopted by abused women allows us to better understand the support needed by them to abandon an abusive relationship.     

Domestic violence and abuse, health status, and social functioning

BACKGROUND: Current and past history of domestic violence (DV), including physical, sexual, and emotional abuse is common among women patients seen in health care settings and is associated with a higher frequency of many health problems. However, the association of DV with self-assessed social functioning is less well known. METHODS: We administered a telephone survey to a random sample of 391 women HMO members seen for a routine annual check-up. The survey included questions about current and past physical, sexual, and emotional violence and self-assessed social functioning and health status from the SF-36. We included questions about attitudes toward routine DV screening, likelihood of disclosure, and the health care setting as a resource. RESULTS: Seven percent of the women reported recent DV and 34% reported lifetime abuse. Abuse was related to limitations in social functioning (adjusted OR = 2.26). Among women with no recent history of abuse, those with a history of past physical (adjusted OR = 1.90), sexual (adjusted OR = 2.04), or emotional (adjusted OR = 2.20) abuse reported significantly poorer social functioning. Emotional abuse, even in the absence of a history of physical or sexual abuse, was strongly associated with limitations in social functioning (adjusted OR = 4.95). Most women believed it appropriate for clinicians to inquire routinely about DV (87%) and 83% believed that the health care setting was a source of help. CONCLUSIONS: Current and past DV, including emotional abuse, adversely affect social functioning. Therefore, clinicians in the health care setting have a unique and important opportunity to assist women victims of DV and abuse.     

Partner violence and medical encounters: African-American women’s perspectives

Objective: To examine the relationship between intimate partner violence (IPV) victimization and patient satisfaction with medical encounters among an African-American population.Design: Cross-sectional, self-administered, anonymous survey.Setting: Community-based, primary care center.Patients: Consecutive African-American women recruited from an urban health center. A total of 102 women provided sufficient information to reveal whether they were currently experiencing IPV and to allow us to assess their experiences in their most recent primary care encounter.Measurements: Patients’ perceptions of their most recent encounter using questions adopted from the Medical Interview Satisfaction Scale and Consultation Satisfaction Questionnaire. We used the Conflicts Tactics Scale, supplemented with questions measuring sexual violence and emotional abuse, to assess IPV “in the past year.”Results: Women who reported current IPV rated several aspects of the encounter more negatively than did women who did not report current abuse. The IPV victims were less likely to report that they felt respected and accepted during the encounter, and they provided lower ratings of the quality of communication with their providers.Conclusions: It is unclear why victims of partner violence experience medical encounters as less satisfactory. Researchers need to expand studies of medical encounters as experienced by abused women to determine whether IPV status adversely affects general medical care.     

Women battering in primary care practice.

BACKGROUND: The organization of health care system to emphasize managed care has placed the primary care provider in an ideal position to assess the impact of intimate partner violence (IPV) on the health of women. Primary care practice provides a setting in which women can develop an ongoing relationship with their health care provider in which they feel safe to discuss IPV and possible options to improve their lives. Women's health and safety could be dramatically improved if primary care providers were prepared to assess, intervene and appropriately refer women who are in violent relationships. OBJECTIVES: The purpose of this article is to describe the prevalence of intimate partner violence in primary care populations and review the known physical, mental health and pregnancy consequences of abuse as well as discuss the implications of intimate partner violence on primary care practice.     

Intimate partner violence. A survey conducted in the primary care setting

OBJECTIVES: To determine the prevalence of intimate partner violence (IPV) in a sample of women attending primary care centers for any reason and to analyze the characteristics of this violence. METHODS: A cross sectional study was performed in 23 primary care centers in three regions of Spain (Andalusia, Madrid and Valencia). The sample included 1,402 randomly selected adult women aged between 18 and 65 years attending these centers. Among the variables collected through a self-administered questionnaire were the existence of physical, emotional or sexual abuse, and its timing, duration, and frequency. RESULTS: Overall, 32% had experienced some type of IPV. By type, 7% had experienced both physical and emotional IPV, 14% had experienced emotional IPV, 3% had experienced emotional and sexual IPV, and 6% had suffered all 3 types of IPV. Among the latter, 52% had experienced abuse for more than 5 years. Women who experienced abuse in a previous relationship had a greater probability of being abused by a new intimate partner (OR = 3.30; 95% CI, 2.10-5.18). CONCLUSIONS: These results show the scale of IPV in Spain. Health professionals play an important role in IPV, as they are in a privileged position to tackle this serious public health problem.     

Intimate partner violence among men prevalence, chronicity, and health effects

CONTEXT: The breadth and depth of intimate partner violence (IPV) experienced by men have not been fully documented. OBJECTIVES: To describe the prevalence, chronicity, and severity of IPV, and the health outcomes associated with IPV, in adult men with healthcare insurance. DESIGN: A retrospective telephone cohort study conducted from 2003 to 2005. The setting was an integrated healthcare system in Washington State and Idaho. PARTICIPANTS: English-speaking men aged 18 and older (N=420) enrolled in the healthcare system for 3 or more years. MAIN OUTCOME MEASURES: Physical, psychological, and sexual IPV were assessed using five questions from the Behavioral Risk Factor Surveillance Survey. Health was measured using the Short Form-36, version 2 (SF-36v2) survey, the Center for Epidemiological Studies Depression Scale, and the National Institute of Mental Health Presence of Symptoms Survey. RESULTS: Men experienced IPV at a rate of 4.6% in the past year, 10.4% in the past 5 years, and 28.8% over their lifetimes. While overall rates of physical and nonphysical IPV were similar, men aged 18-55 were twice as likely to be recently abused (14.2%, SE=2.6%) than were men aged 55 and older (5.3%, SE=1.6%). Abuse was typically nonviolent or mildly violent, occurred on multiple occasions, and was initiated by only one intimate partner. Compared to men with no IPV, older men who experienced IPV had more depressive symptoms (prevalence ratios=2.61 and 2.80 for nonphysical and physical abuse) and had lower SF-36v2 mental health subscales (range=-3.21 to -5.86). CONCLUSIONS: Men experience IPV at moderate rates, and poor mental health outcomes are associated with such experiences.     

EDITORIAL

We investigated the effects of physical, psychological, and sexual violence on the health status of women attending antenatal clinics at two tertiary hospitals in rural Thailand. We asked 421 pregnant women at 32 weeks gestation or later to complete a survey questionnaire. Participants reported high rates of psychological abuse (53.7%); threats, acts of physical abuse, or both (26.6%); and sexual violence (19.2%). Women abused during pregnancy had poorer health compared with nonabused women, in role emotional functioning, vitality, bodily pain, mental health, and social functioning. Given the high prevalence of violence and poor health status, routine screenings by maternity services is urgently required.     

Ascertainment of intimate partner violence in women seeking legal protection

BACKGROUND: Brief questions are necessary for identification of women seeking emergency professional services for intimate partner violence (IPV), and for initiating dialogue with women presenting for care who have previously reported abuse. We compare three questions that inquire about physical and psychological abuse to the Conflict Tactics Scale, version 2 (CTS-2) in a cohort of women seeking legal protection for IPV. METHODS: A total of 448 urban women reporting IPV to police or the court system completed surveys at 8 weeks (baseline), and 5 and 10 months after the incident to assess IPV. Sensitivity and specificity of brief questions on physical assault/abuse (one question) and psychological abuse (two questions) were assessed at baseline and in the periods between baseline and follow-up, using items from the CTS-2 reflecting minor and severe physical and psychological IPV as reference standards. RESULTS: Compared to the CTS-2 severe items, the physical abuse question at baseline detected 93% of abused women, and the two psychological abuse questions 94%. Sensitivity varied at follow-up (74% to 95% for physical, and 89% to 90% psychological), but remained higher when the severe versus minor CTS-2 items were reference standards. Specificity was reasonable for the physical question compared to the severe CTS-2 section (77% to 95%), but was more varied for the psychological questions (29% to 74%). CONCLUSIONS: Three brief questions reasonably identified women who experienced severe IPV and sought legal protection. The low specificity of the psychological questions suggests that women's abuse experience may not fit within the CTS-2 framework. The three questions should be considered for further testing in real-world settings as a tool for initiating conversation with women about abuse.