- Email: [email protected]
Predicting physical abuse against pregnant Hispanic women
Predicting Physical Abuse Against Pregnant Hispanic Women Judith McFarlane, DrPH, William Wiist, DHSc, MPH, Mary Watson Context:
Abuse during pregnancy is common and has adverse health effects on maternal and infant health. To prevent abuse to pregnant women, predictors must be identified and incorporated into routine screening and intervention protocols.
Objective:
To investigate whether or not symbolic violence and threats of violence by a male intimate were associated with physical violence against pregnant Hispanic women.
Design:
Cross-sectional interview survey questionnaire.
Setting:
Urban, public health prenatal clinics.
Participants: 329 pregnant, physically abused Hispanic women. Main Outcome Measure:
Physical abuse against pregnant Hispanic women as measured on the Severity of Violence Against Women Scale.
Results:
Regression analysis showed that symbolic violence and threats of violence by the perpetrator were jointly and independently significantly (P , .0005) associated with physical violence.
Conclusions: Because symbolic violence is significantly associated with physical violence against pregnant women, screening and early intervention programs should focus on such behavior. Medical Subject Headings (MeSH): pregnancy, abused women, women, violence, domestic violence, pregnancy complications, Hispanic Americans (Am J Prev Med 1998;15: 134 –138) © 1998 American Journal of Preventive Medicine
Introduction
A
buse during pregnancy may affect as many as 20% of pregnant women.1 Complications of pregnancy, including low weight gain, anemia, infections, and first and second trimester bleeding, are significantly higher for abused women2,3 as are fetal distress4 and lower infant birthweight.3,5 Abuse during pregnancy is also associated with significantly higher maternal rates of depression; suicide attempts; and tobacco, alcohol, and illicit drug use.6 –10 Family violence researchers have sought to identify characteristics of abused women and abusive men that might have practical value in tailoring interventions to end abuse and in the design of primary prevention programs. The work of O’Campo and colleagues11 illustrates the results of much research in this area: Individual and neighborhood socioeconomic and deTexas Woman’s University (McFarlane, Watson), Houston, Texas 77030; and Injury Prevention Center of the Greater Dayton Area (Wiist), Dayton, Ohio 45402. Address correspondence to: Judith McFarlane, Texas Woman’s University, 1130 M.D. Anderson Blvd., Houston, Texas 77030.
134
Am J Prev Med 1998;15(2) © 1998 American Journal of Preventive Medicine
mographic characteristics are significantly associated with abuse but are not immediately or easily modifiable. Other researchers have sought to identify factors that are more malleable and more amenable to primary prevention. One line of research into intimate partner violence proposes that there is a continuum in aggression (e.g., verbal abuse, psychological aggression, threats, minor physical aggression, severe physical aggression) in which the minor forms of abuse are predictive of severe forms.12,13 Most men who report using minor violence against their intimate female partners report using verbal aggression, and those who report severe violence report using both minor violence and verbal aggression.14 Psychological aggression is a predictor of physical aggression15 and threats of violence may occur at the transition from psychological aggression to physical aggression.16 A continuum of violence exists in both dating and marital relationships. Threats and verbal abuse are predictive of courtship violence in college men.17 Psychological aggression, verbal aggression, threats, and
0749-3797/98/$19.00 PII S0749-3797(98)00035–X
passive aggression discriminate the physically abusive from the nonviolent and predict physical aggression at 30 months of marriage.15,18 Self-reports of women also suggest a continuum of abuse, either temporally or in levels of abuse. Women with the highest frequency and severity of abuse feel that they can use emotional abuse to predict physical abuse.19 Abused women report more fear that their husbands will become verbally threatening, and they are more likely to be in psychological aggressive relationships, than nonabused women.20 The purpose of this study was to assess whether or not symbolic violent behaviors, defined as violence toward inanimate objects, and threats of violence are associated with actual physical violence to pregnant Hispanic women. Hispanic women were targeted. The Report of the Panel of NIH Research on Antisocial, Aggressive, and Violence-Related Behaviors and their Consequences21 stated that “An area of prime concern is the paucity of information on Hispanic, Native American, AfricanAmerican, and Asian involvement in aggressive and violent behavior, either as victims or as agents.”
Methods The research reported here is from the baseline data of a randomized intervention study of the differential effectiveness of three levels of abuse prevention services offered during the prenatal period at public health clinics in a large metropolitan city. The clinics selected were the most closely matched on the annual number of new prenatal clients and the ethnicity of the women. The three clinics each served between 2,000 and 3,000 maternity patients per year at 12,000 to 17,000 patient visits per clinic. At least 97% of the maternity patients at each of the three clinics were Hispanic. During their first visit to the maternity clinic, all pregnant women were screened by a registered nurse, without the male partner present, for abuse during the past year and since the pregnancy began. If the woman answered yes to abuse and the perpetrator was her current or former male partner (i.e., husband, exhusband, boyfriend, ex-boyfriend), she was referred to an on-site counselor. No further information was collected about women who were not abused or who were abused by someone other than a male intimate partner. The bilingual counselor administered a consent form and verbally administered the Severity of Violence Against Women Scale (SVAWS),22 either in English or Spanish. The SVAWS is a 46-item questionnaire22 designed to measure Symbolic Violence (4 items) (e.g., “Threw, smashed, or broke an object”), Threats of Physical Violence (15 items) (e.g., “Threatened to hurt you”), and Physical Violence (27 items) (e.g., “Choked you”). Women indicated on a 4-point scale how often the behavior occurred during the past 12 months
(never, once, a few times, many times) and received a score on each of the three dimensions. Previous research found that internal consistency reliability estimates range from .92 to .96 for a sample of 707 college female students and from .89 to .96 for a sample of 208 community women. The alpha coefficient for the internal reliability of the instrument with the study sample reported here ranged from .89 to .91 for the three dimensions.
Results The study sample consisted of 342 pregnant women who had been physically or sexually assaulted by their male partners in the year prior to or during their present pregnancy. Data was collected over a 12-month period. Ninety-six percent (n 5 329) of the women were Hispanic (primarily Mexican and Mexican American), and about 70% indicated that they were monolingual Spanish speaking. Therefore, this report will include only data about the 329 self-identified Hispanic group (defined as not Anglo, African American, or Asian, and of Spanish-speaking decent). The mean age of the abused women was 23.86 years (SD 5 5.38). The median age was 23 years and the women’s ages varied from 15 to 42 years. Seventy-six percent of the women were at least 20 years of age. Their mean number of years of education was 8.38 years (SD 5 3.21). Sixty-six percent of the women had an annual family income of less than $10,000; 6%, $20,000 or more. Twenty percent of the women were working full- or part-time. Thirty percent were legally married and living with their spouse; 56% lived with a male partner. The mean gestational age at the first prenatal visit was 17.65 weeks (SD 5 7.49). Forty percent of the women were in their first trimester of pregnancy and 46% in their second trimester. The mean number of children living with the women was two and the mean age of the youngest child was 3 years. Diagnostic screening of the study sample revealed five outliers that represented women with extremely high levels of physical violence but low levels of threats and symbolic abuse. Studentized residual analysis for these subjects was significant and further confirmed that these women represented outliers. These five women were removed from the data set on the premise that they represented a sample of a different population. Regression assumptions having been met, a multiple regression least squares equation was calculated for the remaining 324 women to test the association of threats and symbolic violence entered jointly and independently with actual physical violence. For this sample of 324 pregnant abused Hispanic women, symbolic violence and threats of violence by the perpetrator were significantly associated with physical violence against the woman (R2 5 .64; F 5 284.305;
Am J Prev Med 1998;15(2)
135
df 5 2,321; P , .0005). A partial F test determined that symbolic violence is significantly associated with physical violence after controlling for threats (F CHANGE 5 17.919; df 5 1,321; P , .0005). Threats are also significantly associated with physical violence after adjusting for symbolic violence (F CHANGE 5 227.565; df 5 1,321; P , .0005). Although threats explained appreciably more variance (R2 5 .62) than symbolic violence (R2 5 .38); symbolic violence was significantly and singularly associated with physical violence against women in this sample. Inclusion of the five outliers did not change the conclusions of the research. Specifically, for the total sample of 329 pregnant abused Hispanic women (inclusive of five outliers), symbolic violence and threats of violence by the perpetrator were significantly associated with physical violence against the woman (R2 5 .62; F 5 260.449; df 5 2,326; P , .0005). A partial F test determined that symbolic violence is significantly associated with physical violence after controlling for threats (F CHANGE 5 18.599; df 5 1,326; P , .0005). Threats are also significantly associated with physical violence after adjusting for symbolic violence (F CHANGE 5 208.631; df 5 1,326; P , .0005). Although threats explained appreciably more variance (R2 5 .59) than symbolic violence (R2 5 .37), symbolic violence was significantly and singularly associated with physical violence against women in this sample.
Discussion Symbolic violence and threats of violence by the perpetrator were jointly and independently associated significantly with physical violence against pregnant women in this study. These findings suggest that symbolic violence is part of a progressive continuum of violence. Since symbolic violence behaviors can be assessed quickly and easily, “pre-abuse” screening and intervention tools for personal and clinical use can be developed. If points along the continuum are associated with modifiable characteristics, then the continuum could be used to plan targeted intervention programs. For example, information about the importance of symbolic violence behaviors could be added to primary prevention programs such as parenting classes and included in health professions training curriculum. Such information might also be used by adolescent and adult women to make decisions about relationships that might result in physical violence. Males also need information about the predictive significance of their symbolic violent behaviors. Since men who engage in low levels of psychological aggression are more likely to cease or interrupt their violence,12,13 counselors, teachers, educators, and other professionals could target early intervention programs
136
toward men who exhibit symbolic violence and, hopefully, prevent later physical violence. The consideration of “pre-abuse” screening for men and women in primary care settings is important. Demographic measures may not predict abuse. Previous research on this sample of pregnant abused Hispanic women found no differences in severity of intimate partner abuse by levels of income, education, employment status, or self-perception of ability to support oneself.23 Overall the family income level of the women in this study was low. Economic status combined with cultural factors such as concerns about one’s documentation status, language, availability of services for violence intervention in the neighborhood of one’s residence, and access to transportation may work to limit women’s ability to obtain services to address violence. McFarlane et al.24 reported that, in a study of 199 Hispanic, Anglo, and African-American abused women, the Hispanic women were the least likely to use community resources to deal with the abuse. Sorenson and Telles25 found that while MexicanAmerican and non-Hispanic whites reported nearly equal rates of hitting or throwing things at their spouse, Mexican Americans born in the United States reported higher rates than those born in Mexico. The authors suggested that those findings may be explained by the exposure of subsequent generations of immigrant families to conflict between the familial culture of origin and the dominant culture in which they reside. To avoid raising concerns about documentation status, information about country of birth was not obtained in the study reported here about abused pregnant Hispanic women and thus intergenerational comparisons could not be made. The research reported here had several limitations. Because the data is cross-sectional rather than longitudinal, it is not known if the symbolic violence preceded or followed the physical violence. Because the Symbolic Violence Scale of SVAWS consists of only four items, it may be less sensitive to detecting variability in symbolic violence than it is to threats or actual physical violence. Therefore, while the results reported here are consistent with violence continuum research, the findings could have been due to measurement error. An additional limitation of the study is that severity of violence was measured only in women who had been physically or sexually abused in the past year. It is not known whether women who were not physically or sexually abused had experienced symbolic violence. If a large proportion of the male partners of nonabused women exhibit symbolic violence, the value of screening for symbolic violence could be less than indicated by the results reported here. Inclusion of both abused and nonabused women in a study of the severity of violence would provide a stronger predictive measure
American Journal of Preventive Medicine, Volume 15, Number 2
of the risk of abuse associated with symbolic violence than the correlations reported here. While additional clinical studies could provide some indication of the risk associated with symbolic violence, a population-based longitudinal study that assesses for severity of violence over time would address both the limitations of the cross-sectional nature of the results reported here and the selection bias due to including only abused women in the measurement of severity. Studies of severity of violence also need to be conducted on other ethnic groups, in non-urban settings, and among women who are not pregnant. A model of physical violence in the absence of threats or symbolic violence also requires additional research.
Conclusions Healthy People 2000: National Health Promotion and Disease Prevention Objectives26 denotes prevention of violence as one of the 21 priority objectives for the Nation. Healthy People 2000: Midcourse Review and 1995 Revisions calls for the training of health care professionals to address the needs of victims of violence.27 Public health officials recommend that standard protocols be implemented in health care settings in the belief that “early identification, supportive education, effective referral, and ongoing support and follow-up for abused women at primary care sites could eventually reduce the prevalence of abusive injury by up to 75%.28 If the association reported here between symbolic violence and actual physical violence is substantiated by additional research, the ability of public health professionals to identify pregnant women at risk of abuse and to intervene early would be strengthened. This research was supported in part by Cooperative Agreement U50/CCU611305 from the National Center for Injury Prevention & Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. Its contents are solely the responsibility of the authors and do not necessarily reflect the official views of the CDC.
References 1. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. J Am Med Assoc 1996;275:1915–20. 2. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and infant birthweight in adult and teen women. Obstet Gynecol 1994;84:323– 8. 3. McFarlane J, Parker B, Soeken K. Abuse during pregnancy: associations with maternal health and infant birthweight. Nurs Res 1996;45:37– 42. 4. Dye TD, Tollivert NJ, Lee RV, Kenney DJ. Violence, pregnancy and birth outcomes in Appalachia. Paediatr Perinat Epidemiol 1995;9:35– 47.
5. Bullock LF, McFarlane J. The birth-weight-battering connection. Am J Nurs 1989;89:1153–5. 6. McFarlane J, Parker B, Soeken K. Physical abuse, smoking, and substance use during pregnancy: prevalence, interrelationships and effects on birthweight. J Obstet Gynecol Neonat Nurs 1996;25:313–20. 7. Amaro H, Fried L, Cabral H, Zuckeeman B. Violence during pregnancy and substance use. Am J Pub Health 1990;80:575– 89. 8. Berenson A, Striglich N, Wilkinson G, Anderson G. Drug abuse and other risk factors for physical abuse in pregnancy among white non-Hispanic, Black and Hispanic women. Am J Obstet Gynecol 1991;164:491–9. 9. Martin SL, English KT, Clark KA, Cilenti D, Kupper LL. Violence and substance use among North Carolina pregnant women. Am J Pub Health 1996;86:991– 8. 10. Campbell JC, Polland M, Waller JB, Ager J. Correlates of battering during pregnancy. Res Nurs Health 1992;15: 219 –26. 11. O’Campo P, Gielen AC, Faden R, Xue X, Kass N, Want M. Violence by male partners against women during the childbearing year: a contextual analysis. Am J Pub Health 1995;85:1092–7. 12. Aldarondo E. Cessation and persistence of wife assault: a longitudinal analysis. Am J Orthopsychiatry 1996;66:141– 51. 13. Aldarondo E, Sugarman DB. Risk marker analysis of the cessation and persistence of wife assault. J Consult Clin Psych 1996;64:1010 –19. 14. Sugarman DB, Aldarondo E, Boney-McCoy S. Risk marker analysis of husband-to-wife violence: a continuum of aggression. J Appl Soc Psychol 1996;26:313–37. 15. Murphy CM, O’Leary KD. Psychological aggression predicts physical aggression in early marriage. J Consult Clin Psychol 1989;57:579 – 82. 16. Hornung CA, McCullough BC, Sugimoto T. Status relationships in marriage: risk factors in spouse abuse. J Marriage Fam 1981;43:675–92. 17. Ryan M. Do courtship violent men have characteristics associated with a “battering personality”? J Fam Violence 1995;10:99 –120. 18. O’Leary KD, Malone J, Tyree A. Physical aggression in early marriage: prerelationship and relationship effects. J Consult Conical Psychol 1994;62:594 – 602. 19. Follingstad DR, Laughlin JE, Polek DS, Rutledge LL, Hause ES. Identification of patterns of wife assault. J Interpers Violence 1991;6:187–204. 20. Cascardi M, O’Leary KD, Lawrence EE, Schlee KA. Characteristics of women physically abused by their spouses and who seek treatment regarding marital conflict. J Consult Clin Psych 1995;63:616 –23. 21. National Institutes of Health. Report of the panel of NIH research on antisocial, aggressive, and violence-related behaviors and their consequences. Washington, DC: National Institutes of Health; 1994. 22. Marshall L. Development of the severity of violence against women scales. J Fam Violence 1992;7:103–21. 23. Wiist W, McFarlane J. Severity of spousal and intimate partner abuse to pregnant Hispanic women. J Health Care Poor Underserved (in press). 24. McFarlane J, Soeken K, Reel S, Parker B, Silva C. Re-
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source use by abused women following an intervention program: associated severity of abuse and reports of abuse ending. Pub Health Nurs 1997;14(4):244 –50. 25. Sorenson SB, Telles CA. Self-reports of spousal violence in a Mexican-American and non-Hispanic White population. Violence Victims 1991;6:3–16. 26. U.S. Department of Health and Human Services. Healthy people: national health promotion and disease preven-
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tion objectives. DHHS publication no. (PHS) 91-50212. Washington, DC: Public Health Service; 1990. 27. U.S. Department of Health and Human Services. Healthy people 2000: midcourse review and 1995 revisions. Washington, DC: Public Health Service; 1995. 28. Rosenberg M, Fenley MA. Violence in America. A public health approach. New York: Oxford University Press, 1991:150.
American Journal of Preventive Medicine, Volume 15, Number 2
Abuse during pregnancy is common and has adverse health effects on maternal and infant health. To prevent abuse to pregnant women, predictors must be identified and incorporated into routine screening and intervention protocols.
Objective:
To investigate whether or not symbolic violence and threats of violence by a male intimate were associated with physical violence against pregnant Hispanic women.
Design:
Cross-sectional interview survey questionnaire.
Setting:
Urban, public health prenatal clinics.
Participants: 329 pregnant, physically abused Hispanic women. Main Outcome Measure:
Physical abuse against pregnant Hispanic women as measured on the Severity of Violence Against Women Scale.
Results:
Regression analysis showed that symbolic violence and threats of violence by the perpetrator were jointly and independently significantly (P , .0005) associated with physical violence.
Conclusions: Because symbolic violence is significantly associated with physical violence against pregnant women, screening and early intervention programs should focus on such behavior. Medical Subject Headings (MeSH): pregnancy, abused women, women, violence, domestic violence, pregnancy complications, Hispanic Americans (Am J Prev Med 1998;15: 134 –138) © 1998 American Journal of Preventive Medicine
Introduction
A
buse during pregnancy may affect as many as 20% of pregnant women.1 Complications of pregnancy, including low weight gain, anemia, infections, and first and second trimester bleeding, are significantly higher for abused women2,3 as are fetal distress4 and lower infant birthweight.3,5 Abuse during pregnancy is also associated with significantly higher maternal rates of depression; suicide attempts; and tobacco, alcohol, and illicit drug use.6 –10 Family violence researchers have sought to identify characteristics of abused women and abusive men that might have practical value in tailoring interventions to end abuse and in the design of primary prevention programs. The work of O’Campo and colleagues11 illustrates the results of much research in this area: Individual and neighborhood socioeconomic and deTexas Woman’s University (McFarlane, Watson), Houston, Texas 77030; and Injury Prevention Center of the Greater Dayton Area (Wiist), Dayton, Ohio 45402. Address correspondence to: Judith McFarlane, Texas Woman’s University, 1130 M.D. Anderson Blvd., Houston, Texas 77030.
134
Am J Prev Med 1998;15(2) © 1998 American Journal of Preventive Medicine
mographic characteristics are significantly associated with abuse but are not immediately or easily modifiable. Other researchers have sought to identify factors that are more malleable and more amenable to primary prevention. One line of research into intimate partner violence proposes that there is a continuum in aggression (e.g., verbal abuse, psychological aggression, threats, minor physical aggression, severe physical aggression) in which the minor forms of abuse are predictive of severe forms.12,13 Most men who report using minor violence against their intimate female partners report using verbal aggression, and those who report severe violence report using both minor violence and verbal aggression.14 Psychological aggression is a predictor of physical aggression15 and threats of violence may occur at the transition from psychological aggression to physical aggression.16 A continuum of violence exists in both dating and marital relationships. Threats and verbal abuse are predictive of courtship violence in college men.17 Psychological aggression, verbal aggression, threats, and
0749-3797/98/$19.00 PII S0749-3797(98)00035–X
passive aggression discriminate the physically abusive from the nonviolent and predict physical aggression at 30 months of marriage.15,18 Self-reports of women also suggest a continuum of abuse, either temporally or in levels of abuse. Women with the highest frequency and severity of abuse feel that they can use emotional abuse to predict physical abuse.19 Abused women report more fear that their husbands will become verbally threatening, and they are more likely to be in psychological aggressive relationships, than nonabused women.20 The purpose of this study was to assess whether or not symbolic violent behaviors, defined as violence toward inanimate objects, and threats of violence are associated with actual physical violence to pregnant Hispanic women. Hispanic women were targeted. The Report of the Panel of NIH Research on Antisocial, Aggressive, and Violence-Related Behaviors and their Consequences21 stated that “An area of prime concern is the paucity of information on Hispanic, Native American, AfricanAmerican, and Asian involvement in aggressive and violent behavior, either as victims or as agents.”
Methods The research reported here is from the baseline data of a randomized intervention study of the differential effectiveness of three levels of abuse prevention services offered during the prenatal period at public health clinics in a large metropolitan city. The clinics selected were the most closely matched on the annual number of new prenatal clients and the ethnicity of the women. The three clinics each served between 2,000 and 3,000 maternity patients per year at 12,000 to 17,000 patient visits per clinic. At least 97% of the maternity patients at each of the three clinics were Hispanic. During their first visit to the maternity clinic, all pregnant women were screened by a registered nurse, without the male partner present, for abuse during the past year and since the pregnancy began. If the woman answered yes to abuse and the perpetrator was her current or former male partner (i.e., husband, exhusband, boyfriend, ex-boyfriend), she was referred to an on-site counselor. No further information was collected about women who were not abused or who were abused by someone other than a male intimate partner. The bilingual counselor administered a consent form and verbally administered the Severity of Violence Against Women Scale (SVAWS),22 either in English or Spanish. The SVAWS is a 46-item questionnaire22 designed to measure Symbolic Violence (4 items) (e.g., “Threw, smashed, or broke an object”), Threats of Physical Violence (15 items) (e.g., “Threatened to hurt you”), and Physical Violence (27 items) (e.g., “Choked you”). Women indicated on a 4-point scale how often the behavior occurred during the past 12 months
(never, once, a few times, many times) and received a score on each of the three dimensions. Previous research found that internal consistency reliability estimates range from .92 to .96 for a sample of 707 college female students and from .89 to .96 for a sample of 208 community women. The alpha coefficient for the internal reliability of the instrument with the study sample reported here ranged from .89 to .91 for the three dimensions.
Results The study sample consisted of 342 pregnant women who had been physically or sexually assaulted by their male partners in the year prior to or during their present pregnancy. Data was collected over a 12-month period. Ninety-six percent (n 5 329) of the women were Hispanic (primarily Mexican and Mexican American), and about 70% indicated that they were monolingual Spanish speaking. Therefore, this report will include only data about the 329 self-identified Hispanic group (defined as not Anglo, African American, or Asian, and of Spanish-speaking decent). The mean age of the abused women was 23.86 years (SD 5 5.38). The median age was 23 years and the women’s ages varied from 15 to 42 years. Seventy-six percent of the women were at least 20 years of age. Their mean number of years of education was 8.38 years (SD 5 3.21). Sixty-six percent of the women had an annual family income of less than $10,000; 6%, $20,000 or more. Twenty percent of the women were working full- or part-time. Thirty percent were legally married and living with their spouse; 56% lived with a male partner. The mean gestational age at the first prenatal visit was 17.65 weeks (SD 5 7.49). Forty percent of the women were in their first trimester of pregnancy and 46% in their second trimester. The mean number of children living with the women was two and the mean age of the youngest child was 3 years. Diagnostic screening of the study sample revealed five outliers that represented women with extremely high levels of physical violence but low levels of threats and symbolic abuse. Studentized residual analysis for these subjects was significant and further confirmed that these women represented outliers. These five women were removed from the data set on the premise that they represented a sample of a different population. Regression assumptions having been met, a multiple regression least squares equation was calculated for the remaining 324 women to test the association of threats and symbolic violence entered jointly and independently with actual physical violence. For this sample of 324 pregnant abused Hispanic women, symbolic violence and threats of violence by the perpetrator were significantly associated with physical violence against the woman (R2 5 .64; F 5 284.305;
Am J Prev Med 1998;15(2)
135
df 5 2,321; P , .0005). A partial F test determined that symbolic violence is significantly associated with physical violence after controlling for threats (F CHANGE 5 17.919; df 5 1,321; P , .0005). Threats are also significantly associated with physical violence after adjusting for symbolic violence (F CHANGE 5 227.565; df 5 1,321; P , .0005). Although threats explained appreciably more variance (R2 5 .62) than symbolic violence (R2 5 .38); symbolic violence was significantly and singularly associated with physical violence against women in this sample. Inclusion of the five outliers did not change the conclusions of the research. Specifically, for the total sample of 329 pregnant abused Hispanic women (inclusive of five outliers), symbolic violence and threats of violence by the perpetrator were significantly associated with physical violence against the woman (R2 5 .62; F 5 260.449; df 5 2,326; P , .0005). A partial F test determined that symbolic violence is significantly associated with physical violence after controlling for threats (F CHANGE 5 18.599; df 5 1,326; P , .0005). Threats are also significantly associated with physical violence after adjusting for symbolic violence (F CHANGE 5 208.631; df 5 1,326; P , .0005). Although threats explained appreciably more variance (R2 5 .59) than symbolic violence (R2 5 .37), symbolic violence was significantly and singularly associated with physical violence against women in this sample.
Discussion Symbolic violence and threats of violence by the perpetrator were jointly and independently associated significantly with physical violence against pregnant women in this study. These findings suggest that symbolic violence is part of a progressive continuum of violence. Since symbolic violence behaviors can be assessed quickly and easily, “pre-abuse” screening and intervention tools for personal and clinical use can be developed. If points along the continuum are associated with modifiable characteristics, then the continuum could be used to plan targeted intervention programs. For example, information about the importance of symbolic violence behaviors could be added to primary prevention programs such as parenting classes and included in health professions training curriculum. Such information might also be used by adolescent and adult women to make decisions about relationships that might result in physical violence. Males also need information about the predictive significance of their symbolic violent behaviors. Since men who engage in low levels of psychological aggression are more likely to cease or interrupt their violence,12,13 counselors, teachers, educators, and other professionals could target early intervention programs
136
toward men who exhibit symbolic violence and, hopefully, prevent later physical violence. The consideration of “pre-abuse” screening for men and women in primary care settings is important. Demographic measures may not predict abuse. Previous research on this sample of pregnant abused Hispanic women found no differences in severity of intimate partner abuse by levels of income, education, employment status, or self-perception of ability to support oneself.23 Overall the family income level of the women in this study was low. Economic status combined with cultural factors such as concerns about one’s documentation status, language, availability of services for violence intervention in the neighborhood of one’s residence, and access to transportation may work to limit women’s ability to obtain services to address violence. McFarlane et al.24 reported that, in a study of 199 Hispanic, Anglo, and African-American abused women, the Hispanic women were the least likely to use community resources to deal with the abuse. Sorenson and Telles25 found that while MexicanAmerican and non-Hispanic whites reported nearly equal rates of hitting or throwing things at their spouse, Mexican Americans born in the United States reported higher rates than those born in Mexico. The authors suggested that those findings may be explained by the exposure of subsequent generations of immigrant families to conflict between the familial culture of origin and the dominant culture in which they reside. To avoid raising concerns about documentation status, information about country of birth was not obtained in the study reported here about abused pregnant Hispanic women and thus intergenerational comparisons could not be made. The research reported here had several limitations. Because the data is cross-sectional rather than longitudinal, it is not known if the symbolic violence preceded or followed the physical violence. Because the Symbolic Violence Scale of SVAWS consists of only four items, it may be less sensitive to detecting variability in symbolic violence than it is to threats or actual physical violence. Therefore, while the results reported here are consistent with violence continuum research, the findings could have been due to measurement error. An additional limitation of the study is that severity of violence was measured only in women who had been physically or sexually abused in the past year. It is not known whether women who were not physically or sexually abused had experienced symbolic violence. If a large proportion of the male partners of nonabused women exhibit symbolic violence, the value of screening for symbolic violence could be less than indicated by the results reported here. Inclusion of both abused and nonabused women in a study of the severity of violence would provide a stronger predictive measure
American Journal of Preventive Medicine, Volume 15, Number 2
of the risk of abuse associated with symbolic violence than the correlations reported here. While additional clinical studies could provide some indication of the risk associated with symbolic violence, a population-based longitudinal study that assesses for severity of violence over time would address both the limitations of the cross-sectional nature of the results reported here and the selection bias due to including only abused women in the measurement of severity. Studies of severity of violence also need to be conducted on other ethnic groups, in non-urban settings, and among women who are not pregnant. A model of physical violence in the absence of threats or symbolic violence also requires additional research.
Conclusions Healthy People 2000: National Health Promotion and Disease Prevention Objectives26 denotes prevention of violence as one of the 21 priority objectives for the Nation. Healthy People 2000: Midcourse Review and 1995 Revisions calls for the training of health care professionals to address the needs of victims of violence.27 Public health officials recommend that standard protocols be implemented in health care settings in the belief that “early identification, supportive education, effective referral, and ongoing support and follow-up for abused women at primary care sites could eventually reduce the prevalence of abusive injury by up to 75%.28 If the association reported here between symbolic violence and actual physical violence is substantiated by additional research, the ability of public health professionals to identify pregnant women at risk of abuse and to intervene early would be strengthened. This research was supported in part by Cooperative Agreement U50/CCU611305 from the National Center for Injury Prevention & Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. Its contents are solely the responsibility of the authors and do not necessarily reflect the official views of the CDC.
References 1. Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. J Am Med Assoc 1996;275:1915–20. 2. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and infant birthweight in adult and teen women. Obstet Gynecol 1994;84:323– 8. 3. McFarlane J, Parker B, Soeken K. Abuse during pregnancy: associations with maternal health and infant birthweight. Nurs Res 1996;45:37– 42. 4. Dye TD, Tollivert NJ, Lee RV, Kenney DJ. Violence, pregnancy and birth outcomes in Appalachia. Paediatr Perinat Epidemiol 1995;9:35– 47.
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