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Cumulative Abuse Experiences, Physical Health and Health Behaviors
Cumulative Abuse Experiences, Physical Health and Health Behaviors LOUISE-ANNE MCNUTT, PhD, BONNIE E. CARLSON, PhD, MICHELE PERSAUD, MPH, AND JUDY POSTMUS, MSW
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. Ann Epidemiol 2002;12:123–130. © 2002 Elsevier Science Inc. All rights reserved. KEY WORDS: Domestic Violence, Spouse Abuse, Child Abuse, Health Behaviors, Signs and Symptoms, Stress, Smoking Cessation, Primary Care.
INTRODUCTION The health of young women is influenced by physical symptoms that can affect the ability to function daily and health behaviors that may impact future well being. According to the National Ambulatory Medical Care Survey, women aged 25–44 years have an average of about three physician office visits each year, often for non-specific physical symptoms including headaches, stomach pain and cramps, back symptoms, and chest pain (1). The Behavioral Risk Factor Surveillance System (BRFSS) reports that more than 30% of young women have at least one poor physical health day each month, more than half of this group reporting three or more in a month (2). Also prevalent among young women are health behaviors, such as smoking, excessive alcohol consumption, and poor nutrition, that can lead to chronic diseases later in life. For example, about a quarter of young women smoke
From the Department of Epidemiology, School of Public Health, (L.A.M., M.P.), and the School of Social Welfare (B.E.C., J.P.), University at Albany, Rensselaer, NY. Address correspondences to: Louise-Anne McNutt, PhD, Assistant Professor of Epidemiology, School of Public Health, University at Albany, SUNY, 1 University Place, Room 125, Rensselaer, NY 12144. Received December 20, 2000; revised March 22, 2001; accepted April 6, 2001. © 2002 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
despite wide-ranging public health efforts to reduce smoking prevalence (3, 4). A growing literature suggests that intimate partner violence (IPV) may be an important risk factor for multiple physical symptoms that affect overall health (5–13). While some physical assaults clearly cause traumatic injuries (5, 6, 14–17), studies suggest that many common non-specific physical symptoms, such as stomach pain, gastrointestinal symptoms, and frequent and severe headaches, are strongly associated with IPV (5–10, 13, 16, 18). And though the effect of IPV on health behaviors has not been well studied, Coker and colleagues have identified associations between IPV and cardiovascular conditions that may be a result of poor health behaviors, suggesting that poor health behaviors may mediate the relationship (19). Studies of IPV published in the medical literature tend to utilize limited measures of recent IPV, typically only recent physical violence, often suggesting that the main risk to health is physical assault. And yet many women in abusive relationships experience emotional and sexual abuse, too (20–21). In addition, IPV prior to the previous year may have lingering but unmeasured health effects (22–24). Moreover, studies have identified child physical and sexual abuse as risk factors for IPV (25, 26), health behaviors (27), and overall adult health (28–30). Child abuse may thus confound or effect modify measures of association between IPV and health. 1047-2797/02/$–see front matter PII S1047-2797(01)00243-5
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Selected Abbreviations and Acronyms CTS Conflict Tactics Scale IPV intimate partner violence BRFSS Behavioral Risk Factors Surveillance System HMD Health Maintenance Organization PRIME-MD Primary Care Evaluation of Mental Disorders
The purpose of this article is to discuss the relationship between child abuse and IPV with physical symptoms and health behaviors. Because our primary interest is the development of IPV intervention programs, we were particularly interested in understanding health effects associated with recent IPV for women with different risk backgrounds.
METHODS A women’s health study was conducted at two primary care sites of a health maintenance organization (HMO). Both were located in northeastern cities and served ethnically diverse populations. The analyses described in this report use information obtained during a telephone survey. Women were eligible for the study if they had a medical appointment between October 1998 and May 1999, spoke English or Spanish, were 18 to 44 years old, could be reached by telephone, and were willing to participate. A letter explaining the study, including a phone number to call if the subject did not want to be contacted, was provided during an office visit. Only two women asked not to be called. Of the 1978 women seen, 969 (49.0%) were reachable by telephone; of those reachable, 584 (60.3%) agreed to participate in the study (Council of American Survey Research Organizations [CASIO] response rate 43.5%). No compensation was provided. This report focuses on the 557 women who had a male partner or no recent partner and provided complete information on child abuse questions. The survey was administered by trained interviewers knowledgeable about IPV. The study and protocol were approved by the Institutional Review Boards of the HMO and authors’ university. IPV and Child Abuse Measures We measured seven different forms of abuse, five in adulthood (recent physical, sexual, and emotional, and past physical and sexual) and two in childhood (physical and sexual). Severity for six of the seven types of abuse was ascertained and categorized as none (0), lower level (1) and higher level (2). The physical aggression portion of the Conflict Tactics Scale (CTS) was used to measure recent physical violence. The CTS is the most commonly used measure of the frequency and severity of physical violence by a partner during
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the past year, and has established validity and reliability (32–34). In accordance with the CTS design, a severity value of 2 was assigned if any “major” act of physical aggression was reported (e.g., beaten) and 1 if physical aggression was limited to “minor” acts (e.g., pushed, slapped). For recent sexual violence, women reporting being forced to have sex against their will during the past year were given a value of 2, those reporting feeling afraid or being uncomfortable during sexual relations but not forced to have sex were given a value of 1, and women reporting neither received a value of 0. Recent emotional abuse was assessed through seven questions that parsimoniously tapped the various domains, including ridicule, jealousy, threats to harm of self and children, destruction of property, and isolation from others during the past year (Cronbach’s alpha 0.82) (35). Possible responses included “not at all,” “a little bit,” “quite a bit,” and “a lot.” Women reporting being put down, insulted, falsely accused of having an affair, or having their partner behave excessively jealous “a little” received a score of 1; all other emotionally abusive/controlling behaviors (e.g., threats of harm) or the listed behaviors occurring more frequently resulted in a score of 2. This scale is strongly associated with the verbal aggression portion of the CTS which was assess on a subset of 225 women participating in a follow-up interview (p 0.001). Physical and sexual partner violence occurring more than a year ago were ascertained. For past physical IPV, scores were assigned to women experiencing none (0), physical acts perceived as “not at all” or “somewhat” violent (1), and acts perceived as “moderately” or “severely” violent (2). For past sexual IPV, 0 was assigned for women reporting none, and a value of 2 was assigned for women reporting forced sex against her will. Child abuse was measured with 14 modified items from the Child Maltreatment Interview Schedule (36). Child physical abuse was measured with the question “Before age 17, did a parent, stepparent, or other adult in charge of you ever do something on purpose to you (for example, hit or punch or push you down) that gave you bruises, broke bones or teeth, or made you bleed?” This is a conservative definition that excludes most moderate forms of discipline. Women reporting physical abuse were asked how often it happened, the ages when it started and stopped, whether authorities were notified, and whether medical treatment was sought for injuries. Child sexual abuse was ascertained using the question: “Before you were age 17, did an adult ever touch your body in a sexual way or make you touch their sexual parts?” Women reporting sexual abuse were asked to identify the perpetrator(s), the age of first and last occurrence, the number of times it happened, if oral, anal, or vaginal intercourse happened, or if objects were placed in her anus or vagina. Scores were assigned by an approach
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that incorporated the detailed information obtained (available from the authors). Child physical and sexual abuse measures both used a 0, 1, 2 scale, with 2 representing the most severe forms of abuse. Physical Symptoms and Health Behaviors Measures Fifteen non-specific physical symptoms included in the somatization scale of the PRIME-MD were queried (37). Besides upper respiratory infection, these symptoms are the most common physical complaints reported by primary care patients (38). Consistent with the PRIME-MD criteria used for somatoform disorder screening, women reporting three or more symptoms occurring “a lot” during the past month were considered to have multiple physical symptoms (37). Four of the seven health behaviors associated with poor physical health status and increased mortality investigated in the Alameda County Human Population Laboratory were included (smoking cigarettes, sleeping fewer or more than 7 to 8 hours, not eating breakfast and excessive use of alcohol) (39, 40). Data Management and Statistical Analysis Data were double entered and verified using EPIINFO (41), and statistical analysis conducted using SAS (42, 43). Frequencies and percentages were computed for demographic characteristics by abuse history. The relationships between recent IPV with specific components of IPV and child abuse were assessed with percentages and, for those who reported the specific type of abuse, with mean frequency/severity score. Logistic regression analysis was used to assess the association between recent IPV, past IPV, and child abuse with multiple non-specific physical symptoms, adjusted for demographic factors and primary care center. We used a classical epidemiology approach to model selection. We first assessed interaction terms hypothesized to be significant (e.g., recent IPV and child abuse). We then determined if demographic factors confounded the association between abuse experiences and multiple physical symptoms by removing these factors and assessing the effect on the parameter estimates of the exposure variables of interest (44). Because odds ratios are poor estimates of prevalence ratios for common outcomes, prevalence ratios were estimated directly from the predicted probabilities. The associations between IPV and health behaviors were assessed separately for women who reported child abuse and those who did not.
RESULTS Sample Description Women participating in this study were between 18 to 44 years old by study design. Approximately 65.8% were
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White, 22.7% African-American, and 11.5% from other race/ethnic groups. Most women (86.4%) were high school graduates, and 53.7% obtained some post-high school education. Economic status was mixed. While about a quarter of study participants had household incomes over $50,000, 38% had incomes less than $20,000 a year. About 30% reported some level of economic hardship, and 31.4% were insured by Medicaid. Demographic characteristics by abuse history are presented in Table 1. Women who reported a history of abuse were more likely to report economic challenges than were women reporting no abuse. Abuse Experiences Of the 557 women studied, 262 (47.0%) met the general study definition of recent IPV. Of these 262 women, 43 (16.4%) reported higher levels of recent IPV scores (4–6), requiring at least two forms of IPV with one form at a severe level. The relationships between recent IPV severity with types of recent IPV, past IPV, and child abuse are shown in Table 2. Not only did almost all physically or sexually abused women report emotional abuse, increasing levels of physical abuse were accompanied by increasing levels of emotional and sexual abuse (data not shown), making it impossible to disentangle the health effects of emotional, physical, and sexual abuse. Women who reported recent IPV also were more likely than those who did not to report past IPV and child abuse. In general, an exposure-response association was seen between child abuse (and its severity) and past IPV with recent IPV. Lifetime Abuse Experiences and Non-specific Physical Symptoms Of the 164 women who reported no lifetime abuse, 9.8% reported three or more non-specific physical symptoms occurring “a lot” during the past month. In contrast, between 25.8% and 72.4% of women who reported some lifetime abuse reported multiple physical symptoms, the proportion depending on the types and amount of abuse experienced. Logistic regression modeling indicated that increases in recent IPV, past IPV, and child abuse were associated with increases in the likelihood of women reporting multiple physical symptoms (Table 3). Based on this model, women who experienced abuse in the home were approximately 1.4 to 8.2 times more likely to report multiple physical symptoms, compared to women reporting no lifetime abuse and no economic hardship, depending on the types and severity of abuse and the presence of current economic hardship. The exposure-response association between recent IPV and multiple non-specific physical symptoms existed after adjusting for past IPV and child abuse. Each factor was modeled using categorical variables because the continuous forms of the scales did not meet the logistic model assumptions. The analysis was adjusted for socioeconomic hard-
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TABLE 1. Demographic characteristics of study sample, by lifetime abuse experiences
Child Abuse Onlya (N 39)
No Abuse (N 164) Factors Age 18–24 years 25–34 years 35–44 years Race/Ethnicity White African-American Latina Other Missing Education No high school diploma High school diploma Post high school education Employment None 1 to 34 hours 35 or more hours Missing Economic Hardship Not at all A little Somewhat to extreme Missing Income $20,000 $20,001–$30,000 $30,001–$50,000 $50,000 Missing Lives with Male Partner Yes No Children in the home Yes No Payer of HMO membership Job Medicaid Male partner Other Nonmember
number
%
number
%
32 73 59
19.5 44.5 36.0
4 16 19
10.3 41.0 48.7
116 30 9 8 1
71.2 18.4 5.5 4.9
27 9 3 0 —
23 55 86
14.0 33.5 52.5
42 40 81 1
Partner Violence Onlyb (N 219) number
Both Child Abuse and Partner Violence (N 135) p-valuec
%
number
%
58 79 82
26.5 36.1 37.4
27 62 46
20.0 45.9 34.1
0.125
63.2 23.1 7.7 0
142 56 17 3 1
65.1 25.7 7.8 1.4
80 31 16 8 —
59.3 23.0 11.8 5.9
0.182
3 11 25
7.7 28.2 64.1
29 77 113
13.2 35.2 51.6
21 39 75
15.6 28.9 55.5
0.637
25.8 24.5 49.7
11 7 21 —
28.2 18.0 53.8
54 36 129 —
24.7 16.4 58.9
35 30 69 1
26.1 22.4 51.5
0.535
139 11 13 1
85.3 6.7 8.0
26 3 9 1
68.4 7.9 23.7
156 27 35 1
71.5 12.4 16.1
79 25 30 1
59.0 18.6 22.4
0.001
46 18 36 49 15
30.9 12.1 24.1 32.9
13 8 5 13 —
33.3 20.5 12.8 33.3
76 35 45 44 19
38.0 17.5 22.5 22.0
61 22 25 14 13
50.0 18.0 20.5 11.5
0.004
87 77
53.0 47.0
22 17
56.4 43.6
110 109
50.2 49.8
63 72
46.7 53.3
0.784
102 62
62.2 37.8
25 14
64.1 35.9
148 71
67.6 32.4
93 42
68.9 31.1
0.379
58 42 34 23 7
36.9 26.8 21.7 14.7
18 13 4 0 4
51.4 37.2 11.4 0
83 69 29 23 15
40.7 33.8 14.2 11.3
49 50 14 12 10
39.2 40.0 11.2 9.6
0.063
a
Any physical or sexual child abuse. Any past physical or sexual abuse or recent physical, sexual, or emotional abuse by an intimate partner. c Chi-square test for general association, adjusted for study site. b
ship; adjusting the model for other potential confounders, such as age and education, did not substantively alter the findings. Adding interaction terms between types of lifetime abuse experiences did not identify effect modification in this multiplicative model. Race/ethnicity did not confound the association between lifetime abuse and symptoms; however, insufficient data ex-
ists to obtain precise estimates for African-American women and Latinas separately. For all race/ethnic groups, an increase in lifetime abuse scores was associated with an increased report of physical symptoms; however, the prevalence ratios were smaller for African-Americans and Latinas, primarily because a larger proportion of never-abused minority women reported multiple physical symptoms.
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TABLE 2. Relationship between recent intimate partner violence score and lifetime abuse experiences Recent Partner Violence Score No Partner (N 61)
Recent emotional/controlling behavior Recent physical violence Recent sexual violence Past partner physical violence Past partner sexual violence Child physical abuse Child sexual abuse a b
None (N 234)
Low-Moderate Level (N 219)
High Level (N 43)
%a
xb
%a
xb
%a
xb
%a
xb
— — — 31.2 18.0 19.7 19.7
— — — — — 7.1 8.8
— — — 25.6 12.4 12.8 15.8
— — — — — 5.5 7.7
97.7 13.7 4.6 41.6 24.7 21.0 28.3
2.5 1.9 2.5 — — 6.0 8.0
100 95.4 51.2 39.5 34.9 32.6 37.2
8.7 44.9 4.3 — — 7.6 7.9
Percentage of women reporting specific type of abuse. Mean score restricted to women who reported the specific type of abuse. For emotional/controlling behaviors items were summed with values not at all (0), a little bit (1), quite a bit (2), and a lot (3) (possible values 1–21), child physical abuse (possible values 1–12), and child sexual abuse (possible values 1–12). For physical violence the mean score is the mean Conflict Tactics Scale score which incorporates both frequency and severity of abuse (32–34). For recent sexual violence the score represents the average frequency of being forced to have sex against her will during the past year.
Health Behaviors Our data suggest that an association may exist between IPV and health behaviors associated with chronic disease development (Table 4). Among women reporting no physical or sexual child abuse, women who experienced high levels of IPV (either recent, past, or both) were more likely to be current smokers and have poorer dietary habits than women reporting no IPV or lower levels. Among women who reported child abuse, IPV was associated with current smoking and poorer dietary habits, but this latter association did not reach statistical significance.
DISCUSSION This study of women seen in primary care settings found that lifetime abuse experiences were associated with current physical symptoms and health behaviors that could af-
fect future health. Previous studies of recent or lifetime IPV also have found an association with physical symptoms (5, 7, 8, 10, 13, 19), but few have adjusted for child abuse and previous IPV or incorporated information about severity of IPV. Our results suggest that recent IPV is associated with an increased risk of poor health beyond the risk associated with past abuse. Although our cross-sectional survey cannot establish a temporal association between lifetime IPV and health symptoms, Sullivan and colleagues found that severely battered women’s physical health improved when the abuse stopped, suggesting a causal relationship between IPV and physical health (13). Recent physical and sexual violence were almost always accompanied by emotional abuse, and increased frequency and severity of physical or sexual violence were strongly associated with increased emotional abuse. Additionally, women who experience sexual violence typically reported more severe levels of physical violence than did women
TABLE 3. Association between recent and past IPV, child abuse, and economic hardship with multiple non-specific physical symptoms (parameter estimates from logistic regression) Factor Intercept Recent IPVa—low/moderate Recent IPVa—high Past IPV Child Abuseb—moderate Child Abuseb—high Economic hardship Study site
Parameter Estimate
Standard Error
Wald Chi-square p-value
2.1207 0.5532 0.9184 0.7440 0.3878 1.4437 1.0153 0.1120
0.2353 0.2215 0.3723 0.2118 0.2372 0.3778 0.2599 0.2099
0.001 0.013 0.014 0.001 0.102 0.001 0.001 0.594
Adjusting for demographic factors, such as age and education and primary care center did not substantively alter the parameter estimates. Hosmer-Lemeshow Goodness-of-Fit Test p 0.828. a For recent IPV, the types and average severity of IPV women experienced in each group are described in Table 2. b For child abuse, moderate level included women reporting either physical abuse or sexual abuse, or the lowest measured forms of both physical and sexual abuse. High level included women experiencing both physical and sexual abuse with at least one form at a severe level (e.g., needing medical attention). The referent group was no child abuse, low levels of child abuse were not measured in this study.
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TABLE 4. Relationship between IPV and health behaviors (by child abuse experiences) Lifetime Intimate Partner Violencea,b Chi-square p-valuec
Health Practices
None (%)
Low (%)
Moderate/High (%)
No child abuse reported Risky Health Behaviors 0 1–2 3–4
N 164
N 124
N 95
31.7 57.3 11.0
21.0 64.5 14.5
13.7 64.2 22.1
0.008
26.2 41.5 42.1 5.5
29.8 44.4 42.7 12.1
42.1 55.8 49.5 16.8
0.017 0.066 0.627 0.014
N 39
N 53
N 82
33.3 48.7 18.0
18.9 62.2 18.9
12.2 58.5 29.3
0.080
30.8 43.6 41.0 7.7
35.9 56.6 50.9 5.7
53.7 61.0 61.0 9.8
0.057 0.303 0.068 0.720
Currently smokes cigarettes Eats breakfast 50% of days or less Sleeps more or less than 7–8 hours Binge drinks (5 drinks in a day) Child abuse reported Risky Health Behaviors 0 1–2 3–4 Currently smokes cigarettes Eats breakfast 50% of days or less Sleeps more or less than 7–8 hours Binge drinks (5 drinks in a day) a
Lifetime IPV scores of 1–2 grouped as low, and scores of 3–10 grouped as moderate to high. Note: Small sample sizes prevented looking at past and recent IPV separately. c Chi-square test for general association (adjusted for study site). b
never sexually assaulted. Thus, attributing non-specific physical symptoms and health behaviors to a specific form of abuse must be done with caution. While the causal mechanism between IPV and physical health may be clear for acute traumatic injuries, it is not as clear for the more common non-specific physical symptoms. The two likely mechanisms for physical symptoms are the direct and indirect effects from physical trauma and stress. For example, the delayed results of physical violence may be chronic injuries causing headaches, vision and hearing difficulties, chronic neck and back pain, and arthritis (5, 19, 23, 24). Physical, sexual and emotional IPV also may cause physical symptoms and disease through the indirect mechanism of stress on which a substantial literature exists. A leading theory is that stress causes increased secretions of catecholamines, prolactin, and releases of natural opiates (45). These hormonal changes have been linked to cardiovascular diseases, cancer and immunocompromise (46–50). Little hormonal research has specifically focused on IPV, but Larkin and colleagues found that increased catecholamine levels were associated with IPV (51). Other studies have identified stress as a risk factor for behaviors, such as smoking, substance abuse and poor nutrition (52–57), with wellknown adverse health effects. Because IPV is associated with the primary behavioral risk factors for heart disease mortality, IPV interventions may decrease morbidity and mortality by targeting health behaviors. For example, women who experienced IPV were more likely to currently smoke. Those who report no child
abuse or IPV had a current smoking prevalence of 26.2%, similar to the national average for women aged 18 to 44 years (3). Women reporting IPV had a smoking prevalence between 29.8% and 53.7%, depending on the severity of IPV and whether a history of child abuse existed or not. Population-based studies also have found that IPV is associated with smoking (58, 59), and additionally that abused women are heavier smokers than non-abused women (58). While most smokers want to quit, only about 2% of smokers manage to successfully quit each year (4). IPV intervention may be one method to improve these modest results, yet it is rarely discussed as a strategy in chronic disease prevention. While this study had several methodologic strengths, some caveats are noteworthy. First, the study had a crosssectional design and thus we cannot determine temporal sequence between IPV with physical symptoms and health behaviors. Second, the response rate was low. Because telephone surveys are heavily used in IPV research, we have conducted studies to assess the impact of low response rates. Our findings suggest two important points: 1. The prevalence of recent IPV reported through telephone surveys is likely an overestimate (60); however, 2. measures of association between IPV and health are likely to be biased toward the null (61). Additionally, in fall 1999 we enrolled 76 women into a substudy conducted on-site at one of the centers specifically to enroll women not included in the telephone survey. The measures of association in this small sample were
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consistent with those in this report. Third, like all measures of IPV, and particularly measures of IPV severity, misclassification of some women’s experiences probably occurred; however, it is likely that misclassification of IPV was nondifferential with respect to health measures. Fourth, self-report interviews using the same types of Likert scales to measure exposure and disease may slightly overestimate the associations (62). The likely combined impact of these limitations is a slight underestimate of the true associations between IPV with health and health behaviors. Last, forms of child maltreatment besides physical and sexual abuse were not measured and thus could not be evaluated in this study. The relationship between lifetime abuse—childhood and adult, emotional, physical and sexual—and health is complex and still poorly understood. This study found that recent IPV is associated with non-specific health symptoms and risky health behaviors over and above the effects of child abuse, past adult abuse, and economic disadvantage. These findings can potentially inform IPV intervention programs and provide insight into the types of services individuals may need to reduce risk in their lives and ultimately improve health. Understanding a person’s IPV experiences also may help inform interventions for health behaviors, such as smoking cessation programs. This study was funded by the Preventive Health and Health Services Block Grant, New York State Department of Health. The authors thank the staff of Kaiser Permanente Northeast for their assistance.
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47. Cohen S, Williamson GM. Stress and infectious disease in humans. Psychol Bull. 1991;109:5–24. 48. Rabin BS, Cohen S, Ganguli R, Lysle DT, Cunnick JE. Bidirectional interaction between the central nervous system and the immune system. Crit Rev Immunol. 1989;9:279–312. 49. Herbert TB, Cohen S, Marsland AL, Bachen EA, Rabin BS, Muldoon MF, et al. Cardiovascular reactivity and the course of immune response to an acute psychological stressor. Psychosom Med. 1994;56:337–344. 50. Kiecolt-Glaser JK, Cacioppo JT, Malarkey WB, Glaser R. Acute psychological stressors and short-term immune changes: What, why, for whom, and to what extent? Psychosomatic Med. 1992;54:680–685. 51. Inslicht SS, Larkin GL, Hyman KB, Baum A. Intimate partner violence and platelet catecholamine levels. Acad Emerg Med 2000; 7(abs.):11. 52. Cohen S, Williamson GM. Perceived stress in a probability sample of the United States. In: Spacapan S, Oscamp S, eds. The Social Psychology of Health. Newbury Park, CA: Sage; 1988:31–67. 53. Conway TL, Vickers RR Jr, Ward HW, Rahe RH. Occupational stress and variation in cigarette, coffee, and alcohol consumption. J Health Soc Behav. 1981;22:155–165. 54. Keuthen NJ, Niaura RS, Borrelli B, Goldstein M, DePue J, Murphy C, et al. Comorbidity, smoking behavior and treatment outcome. Psychother Psychosom. 2000;69:244–250. 55. Acierno R, Kilpatrick DG, Resnick H, Saunders B, De Arellano M, Best C. Assault, PTSD, family substance use, and depression as risk factors for cigarette use in youth: Findings from the National Survey of Adolescents. J Trauma Stress. 2000;13:381–396. 56. Lundberg U. Stress responses in low-status jobs and their relationship to health risks: musculoskeletal disorders. Ann N Y Acad Sci. 1999; 896:162–172. 57. Calderon R Jr, Schneider RH, Alexander CN, Myers HF, Nidich SI, Haney C. Stress, stress reduction and hypercholesterolemia in African Americans: A review. Ethn Dis. 1999;9:451–462. 58. Hathaway JE, Mucci LA, Silverman JG, Brooks DR, Mathews R, Pavlos CA. Health status and health care use of Massachusetts women reporting partner abuse. Am J Prev Med. 2000;19:302–307. 59. Verhoek-Oftedahl W, Pearlman DN, Coutu Babcock JC. Improving surveillance of intimate partner violence by use of multiple data sources. Am J Prev Med. 2000;19:308–315. 60. McNutt LA, Lee R. Intimate partner violence prevalence estimation using telephone surveys: Understanding the effect of nonresponse bias. Am J Epidemiol. 2000;152:438–441. 61. Lee R, McNutt LA. Nonresponse bias in telephone surveys: Effect on the measure of association between intimate partner violence and health. Annual American Public Health Association Meeting Abstract #4189. Boston, MA, 2000. 62. Cohen S, Kessler RC, Gordon LU. Strategies for measuring stress in studies of psychiatric and physical disorders. In: Cohen S, Kessler RC, Gordon LU, eds. Measuring Stress: A Guide for Health and Social Scientists. New York: Oxford University Press; 1997:3–28.
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. Ann Epidemiol 2002;12:123–130. © 2002 Elsevier Science Inc. All rights reserved. KEY WORDS: Domestic Violence, Spouse Abuse, Child Abuse, Health Behaviors, Signs and Symptoms, Stress, Smoking Cessation, Primary Care.
INTRODUCTION The health of young women is influenced by physical symptoms that can affect the ability to function daily and health behaviors that may impact future well being. According to the National Ambulatory Medical Care Survey, women aged 25–44 years have an average of about three physician office visits each year, often for non-specific physical symptoms including headaches, stomach pain and cramps, back symptoms, and chest pain (1). The Behavioral Risk Factor Surveillance System (BRFSS) reports that more than 30% of young women have at least one poor physical health day each month, more than half of this group reporting three or more in a month (2). Also prevalent among young women are health behaviors, such as smoking, excessive alcohol consumption, and poor nutrition, that can lead to chronic diseases later in life. For example, about a quarter of young women smoke
From the Department of Epidemiology, School of Public Health, (L.A.M., M.P.), and the School of Social Welfare (B.E.C., J.P.), University at Albany, Rensselaer, NY. Address correspondences to: Louise-Anne McNutt, PhD, Assistant Professor of Epidemiology, School of Public Health, University at Albany, SUNY, 1 University Place, Room 125, Rensselaer, NY 12144. Received December 20, 2000; revised March 22, 2001; accepted April 6, 2001. © 2002 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
despite wide-ranging public health efforts to reduce smoking prevalence (3, 4). A growing literature suggests that intimate partner violence (IPV) may be an important risk factor for multiple physical symptoms that affect overall health (5–13). While some physical assaults clearly cause traumatic injuries (5, 6, 14–17), studies suggest that many common non-specific physical symptoms, such as stomach pain, gastrointestinal symptoms, and frequent and severe headaches, are strongly associated with IPV (5–10, 13, 16, 18). And though the effect of IPV on health behaviors has not been well studied, Coker and colleagues have identified associations between IPV and cardiovascular conditions that may be a result of poor health behaviors, suggesting that poor health behaviors may mediate the relationship (19). Studies of IPV published in the medical literature tend to utilize limited measures of recent IPV, typically only recent physical violence, often suggesting that the main risk to health is physical assault. And yet many women in abusive relationships experience emotional and sexual abuse, too (20–21). In addition, IPV prior to the previous year may have lingering but unmeasured health effects (22–24). Moreover, studies have identified child physical and sexual abuse as risk factors for IPV (25, 26), health behaviors (27), and overall adult health (28–30). Child abuse may thus confound or effect modify measures of association between IPV and health. 1047-2797/02/$–see front matter PII S1047-2797(01)00243-5
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Selected Abbreviations and Acronyms CTS Conflict Tactics Scale IPV intimate partner violence BRFSS Behavioral Risk Factors Surveillance System HMD Health Maintenance Organization PRIME-MD Primary Care Evaluation of Mental Disorders
The purpose of this article is to discuss the relationship between child abuse and IPV with physical symptoms and health behaviors. Because our primary interest is the development of IPV intervention programs, we were particularly interested in understanding health effects associated with recent IPV for women with different risk backgrounds.
METHODS A women’s health study was conducted at two primary care sites of a health maintenance organization (HMO). Both were located in northeastern cities and served ethnically diverse populations. The analyses described in this report use information obtained during a telephone survey. Women were eligible for the study if they had a medical appointment between October 1998 and May 1999, spoke English or Spanish, were 18 to 44 years old, could be reached by telephone, and were willing to participate. A letter explaining the study, including a phone number to call if the subject did not want to be contacted, was provided during an office visit. Only two women asked not to be called. Of the 1978 women seen, 969 (49.0%) were reachable by telephone; of those reachable, 584 (60.3%) agreed to participate in the study (Council of American Survey Research Organizations [CASIO] response rate 43.5%). No compensation was provided. This report focuses on the 557 women who had a male partner or no recent partner and provided complete information on child abuse questions. The survey was administered by trained interviewers knowledgeable about IPV. The study and protocol were approved by the Institutional Review Boards of the HMO and authors’ university. IPV and Child Abuse Measures We measured seven different forms of abuse, five in adulthood (recent physical, sexual, and emotional, and past physical and sexual) and two in childhood (physical and sexual). Severity for six of the seven types of abuse was ascertained and categorized as none (0), lower level (1) and higher level (2). The physical aggression portion of the Conflict Tactics Scale (CTS) was used to measure recent physical violence. The CTS is the most commonly used measure of the frequency and severity of physical violence by a partner during
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the past year, and has established validity and reliability (32–34). In accordance with the CTS design, a severity value of 2 was assigned if any “major” act of physical aggression was reported (e.g., beaten) and 1 if physical aggression was limited to “minor” acts (e.g., pushed, slapped). For recent sexual violence, women reporting being forced to have sex against their will during the past year were given a value of 2, those reporting feeling afraid or being uncomfortable during sexual relations but not forced to have sex were given a value of 1, and women reporting neither received a value of 0. Recent emotional abuse was assessed through seven questions that parsimoniously tapped the various domains, including ridicule, jealousy, threats to harm of self and children, destruction of property, and isolation from others during the past year (Cronbach’s alpha 0.82) (35). Possible responses included “not at all,” “a little bit,” “quite a bit,” and “a lot.” Women reporting being put down, insulted, falsely accused of having an affair, or having their partner behave excessively jealous “a little” received a score of 1; all other emotionally abusive/controlling behaviors (e.g., threats of harm) or the listed behaviors occurring more frequently resulted in a score of 2. This scale is strongly associated with the verbal aggression portion of the CTS which was assess on a subset of 225 women participating in a follow-up interview (p 0.001). Physical and sexual partner violence occurring more than a year ago were ascertained. For past physical IPV, scores were assigned to women experiencing none (0), physical acts perceived as “not at all” or “somewhat” violent (1), and acts perceived as “moderately” or “severely” violent (2). For past sexual IPV, 0 was assigned for women reporting none, and a value of 2 was assigned for women reporting forced sex against her will. Child abuse was measured with 14 modified items from the Child Maltreatment Interview Schedule (36). Child physical abuse was measured with the question “Before age 17, did a parent, stepparent, or other adult in charge of you ever do something on purpose to you (for example, hit or punch or push you down) that gave you bruises, broke bones or teeth, or made you bleed?” This is a conservative definition that excludes most moderate forms of discipline. Women reporting physical abuse were asked how often it happened, the ages when it started and stopped, whether authorities were notified, and whether medical treatment was sought for injuries. Child sexual abuse was ascertained using the question: “Before you were age 17, did an adult ever touch your body in a sexual way or make you touch their sexual parts?” Women reporting sexual abuse were asked to identify the perpetrator(s), the age of first and last occurrence, the number of times it happened, if oral, anal, or vaginal intercourse happened, or if objects were placed in her anus or vagina. Scores were assigned by an approach
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that incorporated the detailed information obtained (available from the authors). Child physical and sexual abuse measures both used a 0, 1, 2 scale, with 2 representing the most severe forms of abuse. Physical Symptoms and Health Behaviors Measures Fifteen non-specific physical symptoms included in the somatization scale of the PRIME-MD were queried (37). Besides upper respiratory infection, these symptoms are the most common physical complaints reported by primary care patients (38). Consistent with the PRIME-MD criteria used for somatoform disorder screening, women reporting three or more symptoms occurring “a lot” during the past month were considered to have multiple physical symptoms (37). Four of the seven health behaviors associated with poor physical health status and increased mortality investigated in the Alameda County Human Population Laboratory were included (smoking cigarettes, sleeping fewer or more than 7 to 8 hours, not eating breakfast and excessive use of alcohol) (39, 40). Data Management and Statistical Analysis Data were double entered and verified using EPIINFO (41), and statistical analysis conducted using SAS (42, 43). Frequencies and percentages were computed for demographic characteristics by abuse history. The relationships between recent IPV with specific components of IPV and child abuse were assessed with percentages and, for those who reported the specific type of abuse, with mean frequency/severity score. Logistic regression analysis was used to assess the association between recent IPV, past IPV, and child abuse with multiple non-specific physical symptoms, adjusted for demographic factors and primary care center. We used a classical epidemiology approach to model selection. We first assessed interaction terms hypothesized to be significant (e.g., recent IPV and child abuse). We then determined if demographic factors confounded the association between abuse experiences and multiple physical symptoms by removing these factors and assessing the effect on the parameter estimates of the exposure variables of interest (44). Because odds ratios are poor estimates of prevalence ratios for common outcomes, prevalence ratios were estimated directly from the predicted probabilities. The associations between IPV and health behaviors were assessed separately for women who reported child abuse and those who did not.
RESULTS Sample Description Women participating in this study were between 18 to 44 years old by study design. Approximately 65.8% were
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White, 22.7% African-American, and 11.5% from other race/ethnic groups. Most women (86.4%) were high school graduates, and 53.7% obtained some post-high school education. Economic status was mixed. While about a quarter of study participants had household incomes over $50,000, 38% had incomes less than $20,000 a year. About 30% reported some level of economic hardship, and 31.4% were insured by Medicaid. Demographic characteristics by abuse history are presented in Table 1. Women who reported a history of abuse were more likely to report economic challenges than were women reporting no abuse. Abuse Experiences Of the 557 women studied, 262 (47.0%) met the general study definition of recent IPV. Of these 262 women, 43 (16.4%) reported higher levels of recent IPV scores (4–6), requiring at least two forms of IPV with one form at a severe level. The relationships between recent IPV severity with types of recent IPV, past IPV, and child abuse are shown in Table 2. Not only did almost all physically or sexually abused women report emotional abuse, increasing levels of physical abuse were accompanied by increasing levels of emotional and sexual abuse (data not shown), making it impossible to disentangle the health effects of emotional, physical, and sexual abuse. Women who reported recent IPV also were more likely than those who did not to report past IPV and child abuse. In general, an exposure-response association was seen between child abuse (and its severity) and past IPV with recent IPV. Lifetime Abuse Experiences and Non-specific Physical Symptoms Of the 164 women who reported no lifetime abuse, 9.8% reported three or more non-specific physical symptoms occurring “a lot” during the past month. In contrast, between 25.8% and 72.4% of women who reported some lifetime abuse reported multiple physical symptoms, the proportion depending on the types and amount of abuse experienced. Logistic regression modeling indicated that increases in recent IPV, past IPV, and child abuse were associated with increases in the likelihood of women reporting multiple physical symptoms (Table 3). Based on this model, women who experienced abuse in the home were approximately 1.4 to 8.2 times more likely to report multiple physical symptoms, compared to women reporting no lifetime abuse and no economic hardship, depending on the types and severity of abuse and the presence of current economic hardship. The exposure-response association between recent IPV and multiple non-specific physical symptoms existed after adjusting for past IPV and child abuse. Each factor was modeled using categorical variables because the continuous forms of the scales did not meet the logistic model assumptions. The analysis was adjusted for socioeconomic hard-
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TABLE 1. Demographic characteristics of study sample, by lifetime abuse experiences
Child Abuse Onlya (N 39)
No Abuse (N 164) Factors Age 18–24 years 25–34 years 35–44 years Race/Ethnicity White African-American Latina Other Missing Education No high school diploma High school diploma Post high school education Employment None 1 to 34 hours 35 or more hours Missing Economic Hardship Not at all A little Somewhat to extreme Missing Income $20,000 $20,001–$30,000 $30,001–$50,000 $50,000 Missing Lives with Male Partner Yes No Children in the home Yes No Payer of HMO membership Job Medicaid Male partner Other Nonmember
number
%
number
%
32 73 59
19.5 44.5 36.0
4 16 19
10.3 41.0 48.7
116 30 9 8 1
71.2 18.4 5.5 4.9
27 9 3 0 —
23 55 86
14.0 33.5 52.5
42 40 81 1
Partner Violence Onlyb (N 219) number
Both Child Abuse and Partner Violence (N 135) p-valuec
%
number
%
58 79 82
26.5 36.1 37.4
27 62 46
20.0 45.9 34.1
0.125
63.2 23.1 7.7 0
142 56 17 3 1
65.1 25.7 7.8 1.4
80 31 16 8 —
59.3 23.0 11.8 5.9
0.182
3 11 25
7.7 28.2 64.1
29 77 113
13.2 35.2 51.6
21 39 75
15.6 28.9 55.5
0.637
25.8 24.5 49.7
11 7 21 —
28.2 18.0 53.8
54 36 129 —
24.7 16.4 58.9
35 30 69 1
26.1 22.4 51.5
0.535
139 11 13 1
85.3 6.7 8.0
26 3 9 1
68.4 7.9 23.7
156 27 35 1
71.5 12.4 16.1
79 25 30 1
59.0 18.6 22.4
0.001
46 18 36 49 15
30.9 12.1 24.1 32.9
13 8 5 13 —
33.3 20.5 12.8 33.3
76 35 45 44 19
38.0 17.5 22.5 22.0
61 22 25 14 13
50.0 18.0 20.5 11.5
0.004
87 77
53.0 47.0
22 17
56.4 43.6
110 109
50.2 49.8
63 72
46.7 53.3
0.784
102 62
62.2 37.8
25 14
64.1 35.9
148 71
67.6 32.4
93 42
68.9 31.1
0.379
58 42 34 23 7
36.9 26.8 21.7 14.7
18 13 4 0 4
51.4 37.2 11.4 0
83 69 29 23 15
40.7 33.8 14.2 11.3
49 50 14 12 10
39.2 40.0 11.2 9.6
0.063
a
Any physical or sexual child abuse. Any past physical or sexual abuse or recent physical, sexual, or emotional abuse by an intimate partner. c Chi-square test for general association, adjusted for study site. b
ship; adjusting the model for other potential confounders, such as age and education, did not substantively alter the findings. Adding interaction terms between types of lifetime abuse experiences did not identify effect modification in this multiplicative model. Race/ethnicity did not confound the association between lifetime abuse and symptoms; however, insufficient data ex-
ists to obtain precise estimates for African-American women and Latinas separately. For all race/ethnic groups, an increase in lifetime abuse scores was associated with an increased report of physical symptoms; however, the prevalence ratios were smaller for African-Americans and Latinas, primarily because a larger proportion of never-abused minority women reported multiple physical symptoms.
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TABLE 2. Relationship between recent intimate partner violence score and lifetime abuse experiences Recent Partner Violence Score No Partner (N 61)
Recent emotional/controlling behavior Recent physical violence Recent sexual violence Past partner physical violence Past partner sexual violence Child physical abuse Child sexual abuse a b
None (N 234)
Low-Moderate Level (N 219)
High Level (N 43)
%a
xb
%a
xb
%a
xb
%a
xb
— — — 31.2 18.0 19.7 19.7
— — — — — 7.1 8.8
— — — 25.6 12.4 12.8 15.8
— — — — — 5.5 7.7
97.7 13.7 4.6 41.6 24.7 21.0 28.3
2.5 1.9 2.5 — — 6.0 8.0
100 95.4 51.2 39.5 34.9 32.6 37.2
8.7 44.9 4.3 — — 7.6 7.9
Percentage of women reporting specific type of abuse. Mean score restricted to women who reported the specific type of abuse. For emotional/controlling behaviors items were summed with values not at all (0), a little bit (1), quite a bit (2), and a lot (3) (possible values 1–21), child physical abuse (possible values 1–12), and child sexual abuse (possible values 1–12). For physical violence the mean score is the mean Conflict Tactics Scale score which incorporates both frequency and severity of abuse (32–34). For recent sexual violence the score represents the average frequency of being forced to have sex against her will during the past year.
Health Behaviors Our data suggest that an association may exist between IPV and health behaviors associated with chronic disease development (Table 4). Among women reporting no physical or sexual child abuse, women who experienced high levels of IPV (either recent, past, or both) were more likely to be current smokers and have poorer dietary habits than women reporting no IPV or lower levels. Among women who reported child abuse, IPV was associated with current smoking and poorer dietary habits, but this latter association did not reach statistical significance.
DISCUSSION This study of women seen in primary care settings found that lifetime abuse experiences were associated with current physical symptoms and health behaviors that could af-
fect future health. Previous studies of recent or lifetime IPV also have found an association with physical symptoms (5, 7, 8, 10, 13, 19), but few have adjusted for child abuse and previous IPV or incorporated information about severity of IPV. Our results suggest that recent IPV is associated with an increased risk of poor health beyond the risk associated with past abuse. Although our cross-sectional survey cannot establish a temporal association between lifetime IPV and health symptoms, Sullivan and colleagues found that severely battered women’s physical health improved when the abuse stopped, suggesting a causal relationship between IPV and physical health (13). Recent physical and sexual violence were almost always accompanied by emotional abuse, and increased frequency and severity of physical or sexual violence were strongly associated with increased emotional abuse. Additionally, women who experience sexual violence typically reported more severe levels of physical violence than did women
TABLE 3. Association between recent and past IPV, child abuse, and economic hardship with multiple non-specific physical symptoms (parameter estimates from logistic regression) Factor Intercept Recent IPVa—low/moderate Recent IPVa—high Past IPV Child Abuseb—moderate Child Abuseb—high Economic hardship Study site
Parameter Estimate
Standard Error
Wald Chi-square p-value
2.1207 0.5532 0.9184 0.7440 0.3878 1.4437 1.0153 0.1120
0.2353 0.2215 0.3723 0.2118 0.2372 0.3778 0.2599 0.2099
0.001 0.013 0.014 0.001 0.102 0.001 0.001 0.594
Adjusting for demographic factors, such as age and education and primary care center did not substantively alter the parameter estimates. Hosmer-Lemeshow Goodness-of-Fit Test p 0.828. a For recent IPV, the types and average severity of IPV women experienced in each group are described in Table 2. b For child abuse, moderate level included women reporting either physical abuse or sexual abuse, or the lowest measured forms of both physical and sexual abuse. High level included women experiencing both physical and sexual abuse with at least one form at a severe level (e.g., needing medical attention). The referent group was no child abuse, low levels of child abuse were not measured in this study.
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TABLE 4. Relationship between IPV and health behaviors (by child abuse experiences) Lifetime Intimate Partner Violencea,b Chi-square p-valuec
Health Practices
None (%)
Low (%)
Moderate/High (%)
No child abuse reported Risky Health Behaviors 0 1–2 3–4
N 164
N 124
N 95
31.7 57.3 11.0
21.0 64.5 14.5
13.7 64.2 22.1
0.008
26.2 41.5 42.1 5.5
29.8 44.4 42.7 12.1
42.1 55.8 49.5 16.8
0.017 0.066 0.627 0.014
N 39
N 53
N 82
33.3 48.7 18.0
18.9 62.2 18.9
12.2 58.5 29.3
0.080
30.8 43.6 41.0 7.7
35.9 56.6 50.9 5.7
53.7 61.0 61.0 9.8
0.057 0.303 0.068 0.720
Currently smokes cigarettes Eats breakfast 50% of days or less Sleeps more or less than 7–8 hours Binge drinks (5 drinks in a day) Child abuse reported Risky Health Behaviors 0 1–2 3–4 Currently smokes cigarettes Eats breakfast 50% of days or less Sleeps more or less than 7–8 hours Binge drinks (5 drinks in a day) a
Lifetime IPV scores of 1–2 grouped as low, and scores of 3–10 grouped as moderate to high. Note: Small sample sizes prevented looking at past and recent IPV separately. c Chi-square test for general association (adjusted for study site). b
never sexually assaulted. Thus, attributing non-specific physical symptoms and health behaviors to a specific form of abuse must be done with caution. While the causal mechanism between IPV and physical health may be clear for acute traumatic injuries, it is not as clear for the more common non-specific physical symptoms. The two likely mechanisms for physical symptoms are the direct and indirect effects from physical trauma and stress. For example, the delayed results of physical violence may be chronic injuries causing headaches, vision and hearing difficulties, chronic neck and back pain, and arthritis (5, 19, 23, 24). Physical, sexual and emotional IPV also may cause physical symptoms and disease through the indirect mechanism of stress on which a substantial literature exists. A leading theory is that stress causes increased secretions of catecholamines, prolactin, and releases of natural opiates (45). These hormonal changes have been linked to cardiovascular diseases, cancer and immunocompromise (46–50). Little hormonal research has specifically focused on IPV, but Larkin and colleagues found that increased catecholamine levels were associated with IPV (51). Other studies have identified stress as a risk factor for behaviors, such as smoking, substance abuse and poor nutrition (52–57), with wellknown adverse health effects. Because IPV is associated with the primary behavioral risk factors for heart disease mortality, IPV interventions may decrease morbidity and mortality by targeting health behaviors. For example, women who experienced IPV were more likely to currently smoke. Those who report no child
abuse or IPV had a current smoking prevalence of 26.2%, similar to the national average for women aged 18 to 44 years (3). Women reporting IPV had a smoking prevalence between 29.8% and 53.7%, depending on the severity of IPV and whether a history of child abuse existed or not. Population-based studies also have found that IPV is associated with smoking (58, 59), and additionally that abused women are heavier smokers than non-abused women (58). While most smokers want to quit, only about 2% of smokers manage to successfully quit each year (4). IPV intervention may be one method to improve these modest results, yet it is rarely discussed as a strategy in chronic disease prevention. While this study had several methodologic strengths, some caveats are noteworthy. First, the study had a crosssectional design and thus we cannot determine temporal sequence between IPV with physical symptoms and health behaviors. Second, the response rate was low. Because telephone surveys are heavily used in IPV research, we have conducted studies to assess the impact of low response rates. Our findings suggest two important points: 1. The prevalence of recent IPV reported through telephone surveys is likely an overestimate (60); however, 2. measures of association between IPV and health are likely to be biased toward the null (61). Additionally, in fall 1999 we enrolled 76 women into a substudy conducted on-site at one of the centers specifically to enroll women not included in the telephone survey. The measures of association in this small sample were
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consistent with those in this report. Third, like all measures of IPV, and particularly measures of IPV severity, misclassification of some women’s experiences probably occurred; however, it is likely that misclassification of IPV was nondifferential with respect to health measures. Fourth, self-report interviews using the same types of Likert scales to measure exposure and disease may slightly overestimate the associations (62). The likely combined impact of these limitations is a slight underestimate of the true associations between IPV with health and health behaviors. Last, forms of child maltreatment besides physical and sexual abuse were not measured and thus could not be evaluated in this study. The relationship between lifetime abuse—childhood and adult, emotional, physical and sexual—and health is complex and still poorly understood. This study found that recent IPV is associated with non-specific health symptoms and risky health behaviors over and above the effects of child abuse, past adult abuse, and economic disadvantage. These findings can potentially inform IPV intervention programs and provide insight into the types of services individuals may need to reduce risk in their lives and ultimately improve health. Understanding a person’s IPV experiences also may help inform interventions for health behaviors, such as smoking cessation programs. This study was funded by the Preventive Health and Health Services Block Grant, New York State Department of Health. The authors thank the staff of Kaiser Permanente Northeast for their assistance.
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