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Intimate partner violence urgent implications for women s health

Intimate Partner Violence: Urgent Implications for Women's Health

Nancy Glass, PhD, MPH, RN

Co-Director, Center for Health Disparities Research

Oregon Health & Science

Objectives Health

  • Define intimate partner violence (IPV).

  • Describe the overlap of forms of IPV.

  • Describe the prevalence of this public health problem.

  • Describe physical, psychosocial and pregnancy related effects of IPV.

Objectives Health

  • Discuss use of assessment tools in clinical practice.

  • Identify local and national resources for women in abusive relationships.

Definition intimate partner violence
Definition: Intimate Partner Violence Health

  • Centers for Disease Control and Prevention (CDC)

    • Physical and/or sexual violence (use of physical force) or threat of such violence; or psychological/ emotional abuse and/or coercive tactics when there has been prior physical and/or sexual violence; between persons who are spouses or non marital partners (dating, boyfriend-girfriend, same-sex) or former spouses or non marital partners (Saltzman ‘99)

Definition intimate partner violence1
Definition: Intimate Partner Violence Health

  • Conceptualized as a risk factor for many health problems rather than a disease or syndrome or diagnosis.

Intimate partner violence

Intimate Partner Violence Health

Population-based telephone survey (N=8000 women) (Tjaden & Thoennes, 1998)

25% of women reported lifetime physical and/or sexual assault by an intimate or ex-intimate partner

Estimated 4.8 million women report physical/sexual violence from an intimate in the past year.

40% of assaults result in injuries

20% seek health care services related to the assault

10% of Oregon women report physical/sexual violence from an intimate in the past year (Oregon DHHS).

Overlap between physical sexual and emotional abuse n 889 campbell et al 02
Overlap between physical, sexual and emotional abuse (N = 889) (Campbell et. al. ’02)

Sexual (N = 243)

32 (3.6)

31 (3.5)

14 (1.6)

166 (18.7)

177 (19.9)

166 (18.7)

303 (34.0)

Emotional (N = 677)

Physical (N = 649)

General health outcomes
General Health Outcomes 889)

  • Serious health outcomes, last long after the violence has ended.

  • Survivors of IPV report poorer overall health status, poorer quality of life, and functional status as compared to women who report never experiencing IPV (Glass 2001, Sullivan et al., 1999; Plichta, 1996).

Health Effects - 5 Major Studies 889) (controlled, pop based or large HMO – Campbell et. al. ’02; Coker’00; Leserman’98; McCauley’95; Plichta ‘96)

Health Effects - 5 Major Studies 889) (controlled, pop based or large HMO – Campbell et. al. 02; Coker’00; Leserman’98; McCauley’95; Plichta ‘96)

Mental health outcomes
Mental Health Outcomes 889)

  • Depression and Post Traumatic Stress Disorder (PTSD) most commonly reported mental health outcome of IPV (Campbell, 2001; Glass, 2001; Campbell et al., 1997; Campbell et al., 1995)

  • 59.2% of injured women from a Level 1 Trauma Center reported symptoms of PTSD (up to 5 years after the injury) (Glass, 2001)

  • Relationship between IPV and suicidiality (McCauley et al., 1995)

Mental health outcomes1
Mental Health Outcomes 889)

  • Substance Use (ETOH, illegal drugs, prescription drugs). (Sharps et al., 2001)

  • Women with depression and/or PTSD may use substances to calm, cope with all three PTSD specific symptoms clusters (intrusion, avoidance, and hyperarousal)

  • Dangerous reciprocal relationship between violence re-victimization and substance use (Dansky et al., 1997)

Health care utilization
Health Care Utilization 889)

  • Examined relationship of IPV and health care utilization in population and clinical studies has revealed; poorer overall physical and mental health, higher incidence of injuries, increase consumption of health care resources (hospitalization, health visits, prescriptions) (McCauley et al., 1995; Campbell et al., 2001).

  • Although there is an increased use of health care by abused women, only 20% are correctly identified (Campbell et al., 2002)

Prevalence pregnancy related violence
Prevalence: Pregnancy-Related Violence 889)

  • IPV during pregnancy range from 0.9% to 20.1% (Gazmararian et al., 1996)

  • The majority of studies, the prevalence estimate has ranged from 4%-8%

  • Wide range of prevalence estimates likely the results of a variety of measures, populations sampled and methodology

Oregon prevalence pregnancy related violence
Oregon Prevalence: Pregnancy Related Violence 889)

  • Findings are based on the results of the 2000 Oregon DHS Pregnancy Risk Assessment Monitoring System (PRAMS)

    • Ongoing survey of women who have recently given birth.

    • 2,100 new mothers participated in the representative sample

Oregon prevalence pregnancy related violence1
Oregon Prevalence: Pregnancy-Related Violence 889)

  • “During your recent pregnancy did your husband or partner push, hit, slap, kick, choke or physically hurt you in any other way"

    • 2.6% of respondents answered YES

    • Additionally, 0.8% of respondents, reported that someone else had physically hurt them while they were pregnant (ex-partner, ex-boyfriend)

    • 1,472 new mothers reported being physically hurt while pregnant in 2000

Oregon prevalence pregnancy related violence2
Oregon Prevalence: Pregnancy Related Violence 889)

  • In addition to violence during the pregnancy:

    • 3.8% of respondents reported being physically hurt by their husband or partner in the 12 months before they became pregnant

    • Another, 1.6% of respondents, reporting being physically hurt by someone else in the 12 months before they became pregnant

    • 2,339 new mothers reporting being physically hurt in the year prior to the pregnancy

Pregnancy and violence
Pregnancy and Violence 889)

  • Public health perspective, an important question is risk patterns to develop prevention programs to reduce IPV during pregnancy

  • “Are pregnant women at a greater risk of physical/sexual violence by their male partners or ex-partners compared to women who are not pregnant?”

    • Studies using national probability samples (e.g. National Family Violence Survey, 1985; 1992 National Alcohol and Family Violence Survey; National Survey of Families and Households, 1988) have indicated that pregnant women were no more likely to be victims of IPV than women who were not pregnant

    • In one survey, National Survey of Families and Households, 1988, persistent violence was more likely to occur among couples in which the male partner perceived that the pregnancy of his female partner occurred sooner than intended

Risk factors for pregnancy related violence
Risk Factors for Pregnancy-Related Violence 889)

  • Cumulative effect of multiple contextual and relationship factors and stressors, can impact parental perception of newborns, family environment, attitudes toward parenting, and levels of relationship discord (Fisher et al., 1998)

Consequences of pregnancy related violence
Consequences of Pregnancy-Related Violence 889)

  • Consequences for both the unborn child and pregnant mother:

    • Late entry into prenatal care

    • Low birth weight babies

    • Premature labor

    • Unhealthy maternal behaviors

    • Fetal trauma

    • Health issues for the mother

Consequences of pregnancy related violence1
Consequences of Pregnancy-Related Violence 889)

  • Late entry into prenatal care

    • Healthy People 2010, 90% of pregnant women will begin prenatal care in first trimester

    • Abused women are twice as likely to delay prenatal care until the 3rd trimester compared to women who were not abused (Goodwin et al., 2000)

    • Late entry to prenatal care is a risk factor for pregnancy complications including low birth weight babies and premature labor

Consequences of pregnancy related violence2
Consequences of Pregnancy-Related Violence 889)

  • Low birth weight and Premature Labor

    • Studies have been inconsistent in findings related to the association between IPV, premature labor and low birth weight infants (Curry & Harvey, 1998; Cokkinides et al., 1999).

    • In addition to IPV, low birth weight and premature labor may be associated with late entry into prenatal care, as well as unhealthy behaviors by the mother (e.g. smoking, poor nutrition)

Consequences of pregnancy related violence3
Consequences of Pregnancy-Related Violence 889)

  • Fetal Trauma (e.g miscarriage, spontaneous abortion)

  • Experiencing IPV puts the unborn baby at risk

    • Increased risk of miscarriage (Jacoby et al., 1999)

    • Association between current IPV and at least one spontaneous abortion in the woman’s obstetric history (Jacoby et al., 1999)

    • Increased risk of placental abruptions (Connolly et al., 1997)

Consequences of pregnancy related violence4
Consequences of Pregnancy-Related Violence 889)

  • Unhealthy Maternal Behaviors

    • IPV indirect contribution to negative consequences for both unborn child and mother by increasing the risk for unhealthy maternal behaviors

      • Abused women are more likely to smoke during pregnancy than women who are not abused (Cokkinides & Coker, 1998)

      • Prenatal patients (n=2000), victims of IPV were more likely to smoke, drink and use drugs than women who were not abused (Martin et al., 1996)

      • IPV victims were more likely to be in the most severe substance abuse category during pregnancy than nonabused women (Martin et al., 1996)

Consequences of pregnancy related violence5
Consequences of Pregnancy-Related Violence 889)

  • Health Issues for Mothers

    • Unhealthy diet, severe postpartum depression, lower self-esteem, breastfeeding difficulties, anemia and poor weight gain have all been associated with IPV and pregnancy (Bohn & Holz, 1996)

Femicide 889)

  • Femicide, murder of women

  • 7th leading cause of premature death for women in US

  • #2 cause of death - African-American women aged 15-34

  • 40-50% of US femicides by an intimate partner or ex-intimate partner (SHR analyses misclassifies many – Langford, ’98)

  • 67%-80% of intimate partner femicides were previously battered by their murderer

Pregnancy and femicide
Pregnancy and Femicide 889)

  • Femicide

    • Femicide accounted for 25% of the injury deaths of pregnant women in NY City (Dannenberg et al., 1995)

    • 13% of pregnancy related deaths were femicides in NC (Parsons & Harper, 1999)

    • 11 city study on intimate partner femicide, victims of femicide or attempted femicide were more likely to have been abused during pregnancy by the perpetrator than the comparison group of abuse women (McFarlane et al., 1999).

    • Study found a 3 fold increased risk of femicide, if the woman was abused during pregnancy

Pregnancy and femicide1
Pregnancy and Femicide 889)

  • Femicide

    • Pregnancy in and of itself – is NOT a risk factor for femicide

    • Abuse during pregnancy is one of several risk factors for femicide/attempted femicide

Femicide 889)

  • Femicide

    • Important to note other significant risk factors:

      • Previous threats to kill her

      • Partner/ex-partner unemployed and not looking for work

      • Partner/ex-partner is not the biological parent of a child living in the home

      • Woman is leaving the relationship and partner/ex-partner is controlling

      • Partner/ex-partner owns a gun

Kerry repp act oregon
Kerry Repp Act-Oregon 889)

  • Focus on women as victim of violence during pregnancy

  • Raise awareness of pregnancy as a dangerous time for some abused women

  • Training for health care professionals, coroners, law enforcement, judges related to lethality and pregnancy

Kerry repp act oregon1
Kerry Repp Act-Oregon 889)

  • We need to know if femicide is the leading cause of maternal mortality in Oregon

  • Multidisciplinary Fatality Review System

    • State and County levels

    • Surveillance system of femicides in Oregon

    • Develop prevention and intervention strategies

Effects of ipv on children
Effects of IPV on Children 889)

  • Anxiety reactions and post-traumatic stress symptoms, e.g., irritability, agitation, trouble concentrating, exaggerated startle response, intrusive, unwanted memories

  • School problems, e.g., declining grades, behavioral problems, truancy, suspensions, expulsions

  • More physical health problem than general population.

  • Worries about their mothers actual (e.g., battering) and potential (e.g., smoking, pregnancy) health hazards

  • Later, higher levels of violent behavior and arrests in children who have themselves been abused or neglected

Missed opportunities
Missed Opportunities 889)

  • Few women report being asked about IPV at their health care visit (Glass et al., 2001)

  • 41% of women murdered by intimate or ex-intimate partner were seen at a health care agency for an injury or mental health issue in the year prior to murder (Sharps et al., 2001)

  • 20% of perpetrators of partner homicide were seen by a physician or mental health provider in year prior to murder (Sharps et al., 2001)

Public Health Problem 889)

Health Policy: Screening

Screening literature evidence insufficient
Screening literature: 889) “evidence insufficient”

  • Ramsey et al., British Medical Journal, 2002

  • MacMillan & Wathen, Canadian Task Force on Preventive Health Care, JAMA 2003

  • Anglin & Sachs., Acad Emerg Med, 2003

  • Nelson et al., US Preventive Service Task Force, Annals Int Med., 2004

889) Sometimes clinical judgement trumps Cochrane. Sometimes humanity trumps evidence. Or perhaps the type of evidence we demand for this kind of healing should be different from what we demand for the efficacy of anticoagulation in atrial fibrillation.”

Lachs, Ann Intern Med 2004 p. 400

Who to screen
Who to screen? 889)

  • EVERYONE! (Routine, Universal Screening)

    • Only 56% of women presenting to the ED because of intimate partner violence had an injury related diagnosis

How to screen for ipv
How to Screen for IPV 889)

  • Display visual information

    • How far does someone have to go in your setting before they know it is OK to talk about IPV?

  • Ask in private

    • Strategies to remove others from room prior to asking

  • Make it a safe process

    • Be nonjudgemental

What to ask
What to ask? 889)

  • Keep it simple!

  • How you ask more important than what you ask!

  • Have you been injured by a partner or ex-partner in the past year?

  • Is there anyone making you feel unsafe?

  • Has anyone made you have sex against your will?

Abuse Assessment Screen 889)

1. Have you ever been emotionally or physically abused by your partner or someone important to you?

2. Within the last year, have you been hit, slapped, kicked, pushed or shoved, or otherwise physically hurt by your partner or ex-partner?

If YES, by whom

Number of times

3. Does your partner ever force you into sex?

4. Are you afraid of your partner or ex-partner?

Heltin & McFarlane, 1986

Mark the area of any injury on body map.

Does screening identify women at risk
Does Screening Identify Women at Risk? 889)

  • Women with a positive partner violence screen are 9 times more likely (28% vs. 2%) to experience physical violence in the next three months (Koziol-McLain, 1999).

Document 889)

  • Use her words

  • Name of perpetrator

  • History of abuse

  • Body Map, Photographs

  • Danger Assessment (Lethality, Suicide, Depression)

  • Interventions (Safety Plan)

  • Referrals (Hotline, Shelter, Legal, Police)

Assess safety
Assess Safety 889)

  • Escalating violence (lethality)

  • Use or threat of weapon (gun, knife)

  • Lack of support and isolation

  • Recent separation from partner

  • Risk to children

  • Depression

  • Risk for suicide

Danger assessment campbell 2004
Danger Assessment 889) (Campbell, 2004)

  • Developed in 1985 to increase battered women’s ability to take care of themselves (Self Care Agency; Orem ‘81, 92)

  • Interactive, uses calendar - aids recall plus women come to own conclusions - more persuasive & in adult learner/ strong woman/ survivor model

  • Intended as lethality risk instrument versus reassault (e.g. SARA, K-SID) - risk factors may overlap but not exactly the same

Danger assessment
Danger Assessment 889)

  • 20 items yes/no plus calendar

    • Shows pattern - frequency & severity of past year

    • Aids recall

  • Summative, no cutoff

  • 10 samples of 2251 battered women

  • Internal consistency = .60-.86; test-retest .89-.94

  • Construct validity: convergent w/CTS & ISA (r = .55-.75); discriminant group

NATIONAL DOMESTIC VIOLENCE HOTLINE 889) 1-800 799-SAFE (7233)Family Violence Prevention