Depressive Symptoms and Interpersonal Victimization Among African American Women Attending an Urban STD Clinic

Women’s Health Issues 18 (2008) 375–380

DEPRESSIVE SYMPTOMS AND INTERPERSONAL VICTIMIZATION AMONG AFRICAN AMERICAN WOMEN ATTENDING AN URBAN STD CLINIC Makeda J. Williams, PhD, MPH, CHESa*, and Diane M. Grimley, PhDb a

b

National Cancer Institute, Bethesda, Maryland Department of Health Behavior, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama Received 17 May 2007; revised 30 May 2008; accepted 24 June 2008

Objectives. This study evaluated the association of depressive symptom levels and interpersonal victimization. The sample was comprised of 455 African American women attending an urban sexually transmitted disease clinic. Interpersonal victimization was defined as whether a woman was forced to have sexual intercourse and whether a woman was ever hit, slap or physically hurt by a boyfriend, girlfriend, or spouse in the past 12 months. Methods. Using audio computer-assisted self-interviewing (ACASI), women responded to questions regarding interpersonal victimization and depressive symptom levels (e.g., depression, sadness, loneliness and crying in the past week). Results. Results indicated that women with a history of interpersonal victimization were more likely to experience higher levels of depressive symptoms when compared with women who did not. Statistically significant differences were found for being forced to have sexual intercourse (all p’s <0.0001) and ever being hit, slap or physically hurt by a boyfriend, girlfriend, or spouse in the past 12 months (p’s range from 0.012 to 0.0003) with regard to each depressive symptom item. Conclusion. Behavioral women-focused interventions need to address mental health issues associated with risky sexual behaviors in order to be more efficacious.

Introduction

S

exually transmitted diseases (STDs) continue to have a major impact on public health in the United States. Estimates by the Centers for Disease Control and Prevention (CDC) show that 19 million STD infections occur annually, with almost half of those infections among young Americans aged 15–24 (Weinstock, Berman & Cates, 2004). STDs can be difficult to track, owing to nonreporting of infections; some infections are asymptomatic (CDC, 2001). To address the high rates of STDs and create effective interventions and initiatives to reach Healthy People 2010 (United States Department of Health and

Supported by NIH Grant (#: U 19AI35814-06, NIAID). * Correspondence to: Makeda J. Williams, PhD, MPH, CHES, National Cancer Institute, National Institutes of Health, 6130 Executive Blvd, Suite 100, Bethesda, MD 20892; Phone 301-451-1445; Fax: 301-496-3954. E-mail: [email protected]. Copyright © 2008 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Human Services [USDHHS], 2000) goals and objectives, many studies have focused on the reduction of STDs and risky sexual behaviors (Bachanas et al., 2002; Champion, Shain, Piper, & Perdue, 2002; DiClemente et al., 2001; Erbelding, Hummel, Hogan, & Zenilman, 2001; Orr, Celentano, Santelli, & Burwell, 1994; Shrier, Harris, & Beardslee, 2002; Shrier, Harris, Strenberg, & Beardslee, 2001). However, psychological factors, such as depression, have been shown to influence the engagement in risky sexual behaviors (USDHHS, 2000). STD clinic patients have high rates of human immunodeficiency virus (HIV)/STD risk behaviors and a high degree of mental distress at the time of clinic presentation (Erbelding et al., 2001). The mental distress of these patients could influence their ability to acquire knowledge, perceive risk, process intervention messages, and enact behavior change (Erbelding et al., 2001). Sexual coercion is also an important factor associated with high-risk sexual behaviors among women. In 1995, 16% of females aged ⱕ15 years reported their 1049-3867/08 $-See front matter. doi:10.1016/j.whi.2008.06.004

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first sexual intercourse as involuntary (Abma et al., 1997). Sexual violence against women contributes both directly and indirectly to STD transmission. Women experiencing sexual violence are less able to protect themselves against STDs or pregnancy (USDHHS, 2000). In a study on intimate partner violence against minority women, McFarlane et al. (2005) found that sexually assaulted women reported significantly more posttraumatic stress disorder symptoms compared with non–sexually assaulted women. Therefore, mental distress and sexual violence experiences among STD clinic patients could potentially limit the success of interventions designed to change risky sexual behaviors. African-American women are disproportionately affected by sexually transmitted infections. They experience higher morbidity and mortality rates than any other subpopulation (CDC, 2006). Past clinical research on depression in African-American women has been scarce. There are many factors contributing to fewer African Americans being diagnosed with clinical depression. These factors include mistrust of medical health professionals, cultural barriers, reliance on family support and the religious community rather than mental health professionals, a “masking” of depressive symptoms by other medical conditions, and socioeconomic factors, such as limited access to medical care (National Mental Health Association, n.d.). Sexual abuse and other types of victimization can lead to depressive symptomatology and high-risk behaviors, including substance abuse, risky sexual behaviors (e.g., unprotected sex, multiple partners, casual sex with known or unknown STD/HIV-infected persons), self-injuries (e.g., self-mutilation or suicide attempts), and delinquency (e.g., aggravated assault, theft, aggressive behavior, or sexual assault; Danielson et al., 2006; Wingood & DiClemente, 1998; Carey et al., 2004). According to Livingston, Testa, and VanZile-Tamsen (2007), theories regarding the effect of sexual abuse and other types of victimization have proposed that situations from which a person cannot escape or avoid can lead to feelings of powerlessness, learned helplessness, and low self-esteem. Such psychological and social vulnerabilities within the victim can result in sexual behaviors that place her at risk for STDs (Livingston et al., 2007). To our knowledge, this is the first study that has examined all 4 domains (sexual abuse, interpersonal victimization, depression, and high-risk sexual behaviors) that can lead to HIV infection and STDs among STD clinic patients. The intent of this study was to examine cross-sectionally whether women with a history of interpersonal victimization are more likely to have higher depressive symptom levels than women who do not have a history of interpersonal victimization. Our first hypothesis was that women forced to have sexual intercourse will be more likely to have higher levels of depressive symptoms than women who report not

being forced. The second hypothesis was that women who have been hit, slapped, or physically hurt by their boyfriend or spouse in the past year will be more likely to have higher levels of depressive symptoms than women who did not experience physical violence. Methods Study Design The research design for this study was cross-sectional. Data were collected at the time of the baseline assessment of a larger study within an STD clinic in Birmingham, Alabama (Annang, Grimley & Hook, 2006; Grimley, Annang, Houser & Chen, 2005). Study participant data were collected via audio, computerized, selfinterviewing (ACASI) technology. Using the mouse to click on a labeled icon, each participant was guided through the assessment. The Institutional Review Board of the University of Alabama at Birmingham approved the study protocol before implementation. Study Participants Patients were eligible to participate in the study if 1) they presented to the clinic for STD evaluation; 2) were between the ages of 18 and 40 years; and 3) provided informed consent to participate in the study after being provided with a brief description of the study purpose and requirements. All women in the study were seeking a clinical evaluation (no followups were recruited) and were “walk-ins” either selfreferred or contacted by a previous partner, current partner, Disease Intervention Specialist, or other general health services about possible infections. Over a 2-year period, 960 STD clinic patients were recruited. Of these, 455 were African-American women and served as the sample for the current study. Women of other racial/ethnic groups (10%) were excluded because this study focused on African-American women. Study Variables Several sociodemographic variables were used to describe the characteristics of the sample, including age, employment status, education level, and marital status. Other background information such as having any type of health insurance, if they had any general health care visits within the last 12 months, and reason for STD clinic visit were used. The assessment items used for depressive symptoms were a modified version of the CES-D scale (Radloff, 1977). Depressive symptoms were measured based on the assessment: “Please tell me how often you felt this way during the past week . . .” “You felt depressed,” “You felt lonely,” “You cried,” and “You felt sad.” Response options were the following: ⬍1 day; 1–2 days; 3– 4 days; or 5–7 days. The scale for each depressive symptom (“depressed,” “lonely,” “cried,” and “sad”) ranged from 0 (⬍1 day) to 3 (5–7

Williams and Grimley / Women’s Health Issues 18 (2008) 375–380

days). Women who reported depressive symptoms ⬍1 day were considered to be not experiencing depressive symptoms. Women who reported depressive symptoms ⱖ2 days in the past week were considered as experiencing depressive symptoms. Interpersonal victimization was measured by 2 questions. The first question was “During the past 12 months, did your boyfriend, girlfriend, or spouse ever hit, slap or physically hurt you?” This was a dichotomous variable with 2 levels, “yes” or “no.” The second question was “Have you ever been forced to have sexual intercourse when you did not want to?” This was also a dichotomous variable with 2 levels, “yes” or “no.” Other variables assessed included perceived STD risk, STD history, repeat clinic visits, condom use with main and/or casual partners, and substance use (e.g., cigarette smoking, alcohol use, illegal drug use). Data Analysis Records were written to a file identified by participant ID number, and later aggregated into a Microsoft Access database file. A composite score of the depression items was created and a factor analysis was conducted to determine whether or not the 4 items used to assess depression (feeling depressed, lonely, crying, or sad) represented a single factor of the concept which was followed by a reliability analysis using Cronbach’s alpha (␣). The 2 hypotheses of the study were related to interpersonal victimization and higher depressive symptom levels. The dependent variables were depressive symptoms, and the independent variable was interpersonal victimization. Statistical analysis conducted for the hypotheses was the proportional odds model (ordinal logistic regression; McCullagh, 1980), which is appropriate for ordered categorical data. In this model, the odds ratio for each predictor is constant across all possibilities of the collapsed response variable; when a testable assumption occurs, the odds ratios are translated as the odds of being lower or higher on the outcome variable (Gameroff, 2005). The assumption is that the log of the odds ratio is proportional to the distance between the values of the explanatory variable, with each threshold maintaining proportionality (Spyrides-Cunha, Demetrio & Carmago, 2000). This assumption must be tested for the proportional odds model to be true. The score test for the proportional odds assumption was determined using chi-square with p ⱕ .05 indicating statistical significance. If the assumption is true (p ⱖ .05), assumptions about the levels of depressive symptoms are avoided (i.e., 2 days may be different than 7 days). If the assumption is not true (p ⱕ .05), the depressive symptoms may be nominal (i.e., 2 days may not be different than 7 days), meaning the logit surfaces are parallel and that the odds ratios are constant across all possible cut points of the ordinal

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Table 1. Demographic Variables For Study Population Variables Age (yrs) ⱕ19 20–25 26–30 31–35 36–40 41–45 Employment Employed Unemployed Student Other Education ⱕ8th High school (9th–11th) High school diploma/equivalency examination College degree Marital status Married Not married Health care plan Yes No Health care plan: pay schedule Your employer Your parent’s employer You or someone else Medicaid, medical assistance, other state-funded plan Other General health care visit in last 12 months Yes No Reason for STD clinic visit Symptoms Told that sexual partner was infected Wanted to get checked out

Frequency

%

83 216 80 47 26 3

18.2 47.5 17.6 10.3 5.7 0.7

225 168 58 4

49.5 36.9 12.7 0.9

5 357 29

1.1 78.5 6.4

40

8.8

33 422

7.3 92.7

238 217

52.3 47.7

37 28 23 121

8.1 6.2 5.1 26.6

8

1.8

129 326

28.4 71.6

145 86 224

31.9 18.9 49.2

outcome (Gameroff, 2005). All analyses were performed using SAS, version 9.0. Results Descriptive Statistics The data indicated that African-American women participating in the study (N ⫽ 455) had a mean age 24.68 years (Table 1). Approximately 50% of the sample was employed and had a high school diploma; the majority (93%) was unmarried. Of the total sample, 150 (33%) reported having been forced to have sexual intercourse and 100 (22%) had been physically abused in the past year. Results from the factor analysis of the 4-item assessment of depression resulted in a 1-factor solution with excellent internal consistency (Cronbach’s ␣ ⫽ 0.85; Table 2). Mean composite scores for depressive symptoms were high for women who were 36 – 40 years old (mean, 8.42; standard deviation [SD], 0.637), unem-

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Table 2. Depressive Symptoms: Factor Analysis

Item-total Statistics Depressed Lonely Cried Sad Reliability coefficients N of cases ⫽ 959.0 Alpha ⫽ 84.81

Scale Mean if Item Deleted

Scale Variance if Item Deleted

Corrected Item-Total Correlation

Alpha if Item Deleted

5.438 5.5495 5.8916 5.6288

6.5366 6.5463 7.5916 6.5468

0.7189 0.6614 0.5973 0.7793

0.7928 0.8203 0.8428 0.7675

N of items ⫽ 4

ployed (mean, 8.23; SD, 0.236), completed 9th–11th high-school grades (mean, 8.88; SD, 0.320), did not have a general health care visit in the last 12 months (mean, 8.20; SD, 0.196), and told that sexual partner was infected (mean, 8.30; SD, 0.323; Table 3). Depressive Symptoms and Being Forced to Have Sexual Intercourse Our first hypothesis stated that women who have been forced to have sexual intercourse would be more likely to have a higher level of depressive symptom than women who reported no forced sexual intercourse. Being forced to have sexual intercourse was highly related to each of the depressive symptoms, supporting this hypothesis (Table 4). Women who were forced to have sexual intercourse were 1.75 times more likely to have a higher level of depression (p ⬍ .0001), 2.18 times more likely to have a higher level of loneliness (p ⬍ .0001), 1.82 times more likely to have a higher level of crying (p ⬍ .0001), and Table 3. Composite Score of Depressive Symptoms For Selected Demographic Variables Variable Age (yrs) ⱕ19 20–25 26–30 31–35 36–40 41–45 Education ⱕ8th High school (9th–11th) High school diploma/equivalency examination College degree Marital status Married Not married General health care visit in last 12 months Yes No Reason for STD clinic visit Symptoms Told that sexual partner was infected Wanted to get checked out

Mean (SD) 7.69 (0.389) 8.12 (0.259) 7.75 (0.372) 8.00 (0.466) 8.42 (0.637) 6.50 (1.773) 8.60 (1.574) 8.88 (0.320) 7.76 (0.216) 7.30 (0.557) 7.58 (0.618) 8.09 (0.172) 7.70 (0.312) 8.20 (0.196) 7.86 (0.295) 8.30 (0.323) 8.09 (0.237)

2.10 times more likely to have a higher level of sadness (p ⬍ .0001) in the past week than women who were not forced to have sexual intercourse. The score test for the proportional odds assumption was ␹2 ⫽ 4.07 (p ⫽ 0.13; df ⫽ 2) for level of depression, ␹2 ⫽ 5.25 (p ⫽ 0.07; df ⫽ 2) for level of loneliness, ␹2 ⫽ 4.21 (p ⫽ 0.12; df ⫽ 2) for level of crying, and ␹2 ⫽ 5.999 (p ⫽ 0.05; df ⫽ 2) for level of sadness. Ordinality was important for levels of depression, loneliness, or crying, but there was no difference in the levels of sadness indicating that sadness may be nominal. Therefore, the proportional odds assumption was true for all depressive symptoms except level of sadness. Depressive Symptoms and Being Hit, Slapped, or Physically Hurt by Boyfriend or Spouse The second hypothesis stated that women who have been hit, slapped, or physically hurt by their boyfriend or spouse in the past 12 months would be more likely to have higher depressive symptom levels than women who had not experienced such abuse. The results indicated that being hit, slapped, or physically hurt by a boyfriend or spouse in the past 12 months was significantly associated with all 4 depressive symptoms (p values range, .012–.0003; Table 5). Women who were hit, slapped, or physically hurt by their boyfriend or spouse in the past 12 months were 1.40 times more likely to have a higher level of depression (p ⫽ .01), 1.63 times more likely to have a higher level of loneliness (p ⫽ .0003), 1.63 times more likely to have a higher level of crying (p ⫽ .0008), and 1.50 times more likely to have a higher level of sadness (p ⫽ .003) in the past week than women who were not

Table 4. Relationships Between Forced Sexual Intercourse and Depressive Symptom Variables*: Cumulative Logit Results Psychological Distress Variables Higher Higher Higher Higher

level level level level

of of of of

depression loneliness crying sadness

OR

95% Wald Confidence Intervals

P

1.75 2.18 1.82 2.10

1.38–2.22 1.72–2.78 1.41–2.36 1.64–2.68

⬍.0001 ⬍.0001 ⬍.0001 ⬍.0001

*Each row represents a separate model.

Williams and Grimley / Women’s Health Issues 18 (2008) 375–380 Table 5. Relationship Between Being Hit, Slapped Or Physically Hurt By Their Boyfriend or Spouse and Psychological Distress Variables*: Cumulative Logit Results Psychological Distress Variables Higher Higher Higher Higher

levels levels levels levels

of of of of

depression loneliness crying sadness

OR

95% Wald Confidence Intervals

P

1.40 1.63 1.63 1.50

1.08–1.83 1.25–2.14 1.23–2.17 1.15–1.98

.012 .0003 .0008 .0032

*Each row represents a separate model.

hit, slapped, or physically hurt by their boyfriend or spouse in the past 12 months (Table 5). The score test for the proportional odds assumption was ␹2 ⫽ 6.48 (p ⫽ .04; df ⫽ 2) for level of depression, ␹2 ⫽ 1.56 (p ⫽ .46; df ⫽ 2) for level of loneliness, ␹2 ⫽ 1.13 (p ⫽ .57; df ⫽ 2) for level of crying, and ␹2 ⫽ 5.607 (p ⫽ .06; df ⫽ 2) for level of sadness. Ordinality was important for levels of loneliness, crying, and sadness, but there was no difference in the levels of depression, indicating that depression may be nominal. Therefore, the proportional odds assumption was true for all depressive symptoms except for the general question “I felt depressed.”

Discussion Of the 455 African-American women in our clinic sample, one third reported the experience of being forced to have sexual intercourse. In the past 12 months, nearly one quarter of these women had been victims of interpersonal violence. Statistically significant differences were found for being forced to have sexual intercourse and for being hit, slapped, or physically hurt by a boyfriend or spouse in the past 12 months with regard to each depressive symptom studied when compared with women who did not experience any interpersonal victimization. The proportional odds model accounted for the ordinality of the data by not collapsing the depressive symptom variables, thus allowing for stronger statistical power and avoiding assumptions about the level of depressive symptoms. The importance of ordinality was found for higher levels of depression, loneliness, and crying in women who were forced to have sexual intercourse. The results also indicated that higher levels of loneliness, crying, and sadness were for women who were forced to have sexual intercourse. Overall, women in the study sample who had experience interpersonal victimization with the past year were more likely to experience a higher level of depressive symptoms in the past week. Results from this study have some similarities with previous studies with African American women. For example, the Orr et al. (1994) study showed that high levels of depressive symptoms were associated with risk factors for possible HIV infection among predom-

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inately young, African-American women attending urban health centers. Also, women with high levels of depression are more likely to participate in risky sexual behaviors. For example, Champion et al. (2002) found that women who had an STD and sexual abuse history were more likely to report symptoms of psychological distress than nonabused women. Salazar et al.’s (2005) study of sexually active African-American adolescents showed that low self-esteem can play a critical role in the context of sexual risk reduction programs for this population. Yet, Erbelding et al. (2001) report that depressive mood syndromes may actually decrease the effectiveness of risk reduction counseling in clinical STD clinics, suggesting that the underlying issues of victimization and depression need to be addressed, worked through, and resolved before sexual risk reduction programs are implemented. The present study is the first to examine reciprocal relationship between interpersonal victimization, depressive symptoms, and STD/HIV infection among African-American women. The results indicate that interpersonal victimization and depression play an important role in the risk reduction and physical and psychosocial well-being for this population. Limitations Findings from this study may be useful to clinicians and public health researchers interested in reducing risky sexual behaviors and STD infections among this African-American female population. Several limitations to this study should be noted. First, a longitudinal research design could provide a better understanding of the influences of depressive symptoms. Repeated measures would allow for observing patterns of depressive symptoms over time, as opposed to over a short period of time. Second, this study was conducted using secondary data, which did not allow for any manipulation of existing items on the assessment. A third limitation was the use of a modified CES-D scale. Focusing on only 4 responses (depressed, lonely, cried, and sad) for how women felt in the past week and collapsing the continuous variables into dichotomous variables may have resulted in the loss of variability for the original CES-D scale. Moreover, converting continuous scores into “yes” and “no” forced choice responses may have increase power, but important information is lost when using this approach. Fourth, results from this study with African-American women seeking care at an STD clinic may not be generalizable to other female populations or other African-American subpopulations. A final limitation of the study was the use of self-report data. Participants may not have responded accurately to some of the questions on the assessment owing to social desirability or recall problems, thus underestimating or overestimating answers introduces bias in the findings. However, a number of studies support

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ACASI as a method of collecting data on more sensitive issues such as sexual practices and other high-risk activities (Paperny, 1997; Turner et al., 1998). Conclusion African-American women continue to be disproportionately affected by STD/HIV infections. Public health researchers and clinicians interested in STD prevention and control need to be more aware of the context of these women’s lives. Such factors as depression, culture, social, and environmental factors must be taken into account in a woman’s ability to adopt and maintain behavior change. Women would be better served if STD clinics, mental health organizations, shelters for abused women, and substance abuse rehabilitation centers worked together to improve women’s health. References Abma, J. C., Chandra, A., Mosher, W. D., Peterson, L. S., & Piccinino, L. J. (1997). Fertility family planning and women’s health: New data from the 1995 National Survey of Family Growth. Vital and Health Statistics, 23, 1–114. Annang, L., Grimley, D. M., & Hook, E. W., III. (2006). Vaginal douching practices among African American women at risk: Exploring douching prevalence, reasons for douching, and STD infection. Sexually Transmitted Diseases, 33, 215–219. Bachanas, P. J., Morris, M. K., Lewis-Gess, J. K., Sarett-Cuasay, E. J., Sirl, K., Ries, J. K., et al. (2002). Predictors of risky sexual behavior in African American adolescent girls: Implications for prevention interventions. Journal of Pediatric Psychology, 27, 519 –530. Carey, M. P., Carey, K. B., Maisto, S. A., Schroder, K. E., Vanable, P. A., & Gordon, C. M. (2004). HIV risk behavior among psychiatric outpatients: Association with psychiatric disorder, substance use disorder, and gender. Journal of Nervous and Mental Disease, 192, 289 –296. Centers for Disease Control and Prevention (CDC). (2001). Tracking the hidden epidemics: Trends in STD’s in the United States 2000. Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). (2006). Sexually transmitted disease surveillance, 2005. Atlanta, GA: U.S. Department of Health and Human Services. Champion, J. D., Shain, R. N., Piper, J., & Perdue, S. T. (2002). Psychological distress among abused minority women with sexually transmitted diseases. Journal of the American Academy Nurse Practitioners, 14, 316 –324. Danielson, C. K., De Arellano, M. A., Ehrenreich, J. T., Suarez, L. M., Bennett, S. M., Cheron, D. M., et al. (2006). Identification of high-risk behaviors among victimized adolescents and implications for empirically supported psychosocial treatment. Journal of Psychiatric Practice, 12, 364 –383. DiClemente, R. J., Wingood, G. M., Crosby, R. A., Sionean, C., Brown, L. K., Rothbaum B., et al. (2001). A prospective study of psychological distress and sexual risk behavior among black adolescent females. Pediatrics, 108, E85. Erbelding, E. J., Hummel, B., Hogan, T., & Zenilman, J. (2001). High rates of depressive symptoms in STD clinic patients. Sexually Transmitted Diseases, 28, 281–284. Gameroff, M. J. (2005). Using the proportional odds model for healthrelated outcomes: Why, when, and how with various SAS® procedures. SAS SUGI Proceedings: Statistics, Data Analysis and Data Mining. Available: http://www2.sas.com/proceedings/sugi30/ 205-30.pdf. Accessed August 30, 2007.

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Author Descriptions Makeda J. Williams, PhD, MPH, CHES is Program Analyst at the National Institute of Health’s National Cancer Institute. Diane Grimley, PhD, MA is a professor in the Department of Health Behavior at The University of Alabama at Birmingham School of Public Health.