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INVESTIGATING THE EFFECTS OF INTIMATE PARTNER VIOLENCE ON
WOMEN'S HEALTH
By

Cheryl Ann Sutherland

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
.for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

1 999

ABSTRACT

INVESTIGATIN G THE EFFECTS OF INTIMATE PARTNER VIOLENCE ON
WOMEN’S HEALTH

By

Cheryl Ann Sutherland

Prior research consistently demonstrates that intimate partner violence places
women at risk for various physical and psychological health problems, yet few
researchers have examined the. process by which abuse impacts women’s health. Several
researchers have noted that injuries are the most logical link between abuse and physical
health problems. Others have suggested that the stress of surviving an intimate partner’s
violence can significantly jeopardize women’s health. Furthermore, researcher’s reliance
on samples of low—income women has limited our ability to differentiate the effects of
poverty from those due to abuse. Clarifying the complex relationships among abuse,
injuries, stress, income, and health is essential to fully understanding the impact of
intimate partner violence on women’s livelihood. It is also an important step toward
developing interventions that effectively address survivor’s needs.

The present study investigated the effects of injuries, stress, and income on the
relationship between abuse and women’s physical and psychological health. As part of a
larger research project, 397 women - half had been assaulted by an intimate partner -
completed face-to-face interviews after being recruited through newspaper
advertisements to participate in a cross-sectional study on women’s health. Structural

equation modeling techniques (AMOS’s version 3.6) and hierarchical multiple regression

analyses were used to test the path model of direct and indirect relationships among
abuse, injuries, stress, physical health, psychological health, income, and social support.

The results of this study clarified the process by which abuse impacts women’s
health; both injuries and the joint effects of stress and psychological health problems
(depression, suicide ideation, and dissatisfaction with quality of life) significantly
compromised women’s physical health. The findings provide strong support for a stress-
response theory about the effects of abuse on women’s health. The stress associated with
surviving an intimate partner’s violence had a greater impact on women’s physical health
problems than did their injuries, and concomitant rates of depression, suicide ideation,
and dissatisfaction with their quality of life significantly moderated the relationship
between abuse-related stress and women’s physical health problems.

Intimate partner violence had a stronger impact on women’s health than did
income level. Income level did not have a significant direct effect on rates of physical
health problems, and the direct effect of abuse was five times greater than the direct
effect of income on women’s stress levels. However, having a higher income did
significantly reduce the impact of stress on women’s rates of depression and
dissatisfaction with their quality of life. It did not significantly moderate the impact of
stress on women’s rates of suicide ideation. Conversely, women’s satisfaction with the
amount and quality of their social support did not appear to buffer the effects of stress on
their psychological health.

The results of this study underscore the need for comprehensive screening
protocol and coordinated community-response initiatives. Further investigation of

specific abuse-related stressors and longitudinal research are also recommended.

This is dedicated to the women whose strength and courage made this work possible.

They are an inspiration.

iv

ACKNOWLEDGEMENTS

I would like to thank Bill Davidson, my committee chair, for his time, patience,
and sense of humor during my completion of this work. I would also like to express my
gratitude to Cris Sullivan for her unyielding support, guidance, and wisdom. She has
been an incredible mentor throughout this entire project, and I greatly appreciate the time
and energy she gave to ensure its successful completion. Completion of this work would
not have been possible without the contributions of my other committee members: Deb
Bybee, for her encouragement and statistical expertise, and for taking time to provide
valuable feedback on earlier drafts, Linda Beth Tiedje and Tom Reischl for their support
and thought-provoking suggestions. I would also like to thank Kim Eby for initiating this
project, and the National Institute of Mental Health for funding it.

I deeply appreciate the uncompromising dedication of the Women’s Health study
team. The interviewers, especially Tina Peterson, Sarah Hicks-Bentsen, and Kimberly
Lewis, spent many evenings and weekends gathering information. Heidi Vaughn-Hosler
and Alison Ward helped to recruit women, train and supervise interviewers, and keep the
project on an even keel. Sean Hankins and Renee Jamison worked diligently to ensure
that the data was entered and verified. I also appreciate the generosity and flexibility of
the staff members at the Mid-Michigan Chapter of the American Red Cross, especially
Peggy Pertner - for providing a safe and comfortable space to conduct the interviews.

This accomplishment would not have been possible without nourishment from my
family and fiiends. My family’s unconditional support gave me the strength and

confidence to complete this work. I am grateful to my fiiends for their wisdom, support,

and comic relief. I would especially like to thank Jennifer Juras and Ruth Fluery for
always being available to listen and provide reassurance, Becki Campbell for proving
invaluable assistance with the research design, Lynn Breer and Melissa Huber-Yoder, for

helping to keep me on track. Finally, I’d like to thank Becky DeGroodt and Alastair

Stewart for their encouragement and balance.

vi

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................................ viii
LIST OF FIGURES ........................................................................................................ ix
CHAPTER 1 ,
INTRODUCTION ............................................................................................................ 1
Physical and Psychological Consequences of Intimate Partner Violence ............ 8
Physical Health Consequences of Abuse .................................................. 9
Abuse and Psychological Health ............................................................ 14
Relationship Between Physical and Psychological Health ..................... 20
Effects of Injuries and Stress on Women’s Health ............................................. 22
Injuries .................................................................................................... 22
Effects of Stress on Physical Health ....................................................... 24
Effects of Stress on Psychological Health .............................................. 26
Abuse, Stress, and Health Outcomes ...................................................... 27
- Moderating Role of Social Support ........................................................ 30
Effects of Income on Stress and Physical Health ............................................... 33
The Effect of Income on Stress ............................................................... 34
The Effect of Income on Physical Health ............................................... 34
Moderating Effect of Income .................................................................. 35
Rationale for the Current Study .......................................................................... 36
CHAPTER 2
METHOD * ..... ................................................................................................... 44
Research Design .................................................................................................. 44
Research Participants .............................................................................. 44
Interviews. ............................................................................................... 50
Measures .................. i ..................... - ...................................................................... 53
Abuse“ .................................................................................... 54
Injuries .................................................................................................... 58
Stress ....................................................................................................... 59
Physical Health Outcomes .............................................................. 60
Psychological Health Problems .............................................................. 62
Social Support ......................................................................................... 64
Income ..................................................................................................... 65
Analyses .............................................................................................................. 66
CHAPTER 3
RESULTS ................................................................................................................. 68 ~
Descriptive Statistics ........................................................................................... 68
Abuse Experiences .................................................................................. 68
' Injuries .................................................................................................... 73
vii

Stress ....................................................................................................... 74

Psychological Health Problems .............................................................. 78
Physical Health Outcomes ...................................................................... 79
Income ..................................................................................................... 81
Social Support ......................................................................................... 84
Correlations Among Observed Variables ........................................................... 84
Path Model of Hypothesized Relationships ........................................................ 86
Modeling Strategy ................................................................................... 86
. Measurement Model ............................................................................... 86
Testing Hypothesized Relationships ................................................................... 93
Testing of Mediating Effects .................................................................. 95
Testing of Moderating Effects ................................................................ 96
Assessment of the Structural Model ................................................................... 97
To What Extent Does Intimate Partner Violence Affect Women’s
Physical Health? .................................................................................... 100
To What Extent Does Women’s Income Impact the Relationship
Between Abuse and Their Physical Health? ......................................... 106

To What Extent Does Women’s Satisfaction with Their Social
Support Impact the Effects of Abuse on Their Psychological

Health? .................................................................................................. 1 17
CHAPTER 4
DISCUSSION ............................................................................................................... 125
Summary of Results .......................................................................................... 125
Major Descriptive Findings .............................................................................. 126
Interpretation of the Path Model ....................................................................... 132
Methodological Limitations .............................................................................. 137
Implication for Future Research, Intervention, and Policy ............................... 140
APPENDICES ............................................................................................................. 145
APPENDIX A- Newspaper Adverisements .................................................... 146
APPENDIX B— Recruitment Script and Screening Forms .............................. 151
APPENDIX C - Interviewer Training Syllabus ............................................... 158
APPENDIX D— Participant Agreement Form ................................................. 168
APPEN DD( E — Women’s Health Study Interview ......................................... 170
APPENDIX F - Guide to Community Resources ............................................ 210
APPENDIX G — Standardized Residual Covariance Matrices for
Measurement Models ............................................................................ 215
REFERENCES ............................................................................................................. 230
viii

Table 1.
Table 2.
Table 3.
Table 4.

Table 5.

Table 6.
Table 7.
Table 8.
Table 9.
Table 10.
Table 11.
Table 12.
Table 13.
Table 14.

Table 15.

Table 16.

Table 17.

Table 18.

Table 19.

Table 20.

LIST OF TABLES

Recruitment Method (N = 397) ....................................................................... 46
Demographic Characteristics (N = 397) .......................................................... 48
Psychometric Properties of Instruments .......................................................... 55
Summary of Scale Scores (N = 397) ............................................................... 69
Types of Physical and Sexual Abuse Experience in Past Six

Months (N = 207) ............................................................................................. 70

Types of Psychological Abuse Experienced in Past Six Months (N = 344)....72

Types of Injuries Sustained in the Past Six Months (N = 397) ........................ 73

Occurrence Rates for Difficult Life Circumstances (N = 397) ........................ 75

Stressful Life Event: Rates of Occurrence (N = 397) ..................................... 76
Rates of Depression and Suicide Ideation ..................................................... 79
Occurrence Rates of Chronic Health Problems (N = 397) ............................ 80
Occurrence Rate of Physical Health Symptoms (N = 397) ........................... 82
Frequency Distribution of Percent Poverty Rates .......................................... 83
Uncorrected Correlation Matrix of Observed Variables (Indicators) ............ 85
Maximum-Likelihood (ML) Estimates for Measurement

Models 1, 2, 3, and 4 ...................................................................................... 91
Final Measurement Model: Indicators and Their Factor
Loadings (N = 397) ........................................................................................ 94
Standardized Estimates for Structural Model ................................................ 99
Mediating Effect of Injuries on Abuse and Physical Health ....................... 102
Mediating Effect of Stress on Abuse and Psychological Health ................. 104
Mediating Effect of Psychological Health on Stress and Physical Health .. 105

ix

 

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Table 21.
Table 22.
Table 23.
Table 24.
Table 25.
Table 26.

Table 27.

Table 28.

Table 29.

Table 30.

Moderating Effect of Income on Stress and Depression ............................. 109

Moderating Effect of Income on Stress and Suicide Ideation ..................... 112
Moderating Effect of Income on Stress and Quality of Life ....................... 113
Moderating Effect of Social Support on Stress and Depression .................. 1 19
Moderating Effect of Social Support on Stress and Suicide Ideation .......... 120
Moderating Effect of Social Support on Stress and Quality of Life ............ 121

Standardized Residual Covariance Matrix of Observed
Variables-(Indicators) (N = 397): Model 1 ................................................... 200

Standardized Residual Covariance Matrix of Observed
Variables (Indicators) (N = 397): Model 2 ................................................... 200

Standardized Residual Covariance Matrix of Observed
Variables (Indicators) (N = 397): Model 3 ................................................... 200

Standardized Residual Covariance Matrix of Observed
Variables (Indicators) (N = 397): Model 4 ................................................... 200

LIST OF FIGURES

Figure 1. Conceptual Model of Hypothesized Relationships ........................................ 39

Figure 2. Initial Measurement Model of Hypothesized Relationships
Among Observed Variables (Indicators) and Latent Constructs ..................... 88

Figure 3. Structural Model of Hypothesized Relationships with Standardized
Coefficient Estimates ..................................................................................... 98

Figure 4. Regression Lines Indicating Moderating Effect of Income on
Stressful Life Events and Depression ........................................................... 110

Figure 5. Regression Lines Indicating Moderating Effect of Income on ‘
Difficult Life Circumstances and Quality of Life (note: higher score
equals greater dissatisfaction) ...................................................................... 1 14

Figure 6. Regression Lines Indicating Moderating Effect of Income on
Stressful Life Events and Quality of Life (note: higher score equals
greater dissatisfaction) .................................................................................. 1 15

Figure 7. Regression Lines Indicating Moderating Effect of Social Support

on Difficult Life Circumstances and Quality of Life (note: higher
score equals greater dissatisfaction) ............................................................. 123

xi

CHAPTER 1

INTRODUCTION

Intimate partner violence is a pervasive social problem that compromises the
personal health and safety of millions of women (National Coalition Against Domestic
Assault, 1995; Stark & Flitcraft, 1982; Straus & Gelles, 1986). For the past two decades
researchers have documented staggering rates of intimate partner violence against women
of all ages, racial and ethnic groups, and socioeconomic levels. A recent national random
survey of women’s health estimates that 4.4 million adult women are physically or
sexually abused by‘an intimate partner each year (Plichta, 1996). Other researchers
estimate that between 12% and 35% of medical patients (Abbott, Johnson, Koziol-
McLain, & Lowenstein, 1995; Council on Scientific Affairs, American Medical
Association (AMA), 1992; Domino & Haber, 1987; Haber & Roos, 1985; McCauley,
Kern &, 1997; Warshaw, 1989) and 22% to 50% of mental health clients (Carmen,
Rieker, & Mills, 1984; Post, Willett, Franks, House, Back & Weissberg, 1980; Swett &
Halpert, 1993;Waldinger, Swett, Frank, & Miller, 1994) have been physically, sexually,
or emotionally abused by an intimate partner at some point in their adult lives.

Battered women suffer countless injuries, acute and chronic health problems, and
symptoms of depression and anxiety. Cross-sectional and longitudinal investigations of
women from domestic violence shelter programs, emergency rooms, and mental health
settings consistently demonstrate a strong positive relationship between intimate partner
violence and health problems. As a result of prior research, we’ve learned that a lover’s

pounding fists damage more than flesh and bone, that the scars of seemingly endless beat-

 

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downs last long after the bruises fade and the scabs heal. Both the immediate and long-
term health consequences of the assaults are often severe and debilitating.

The social ramifications of intimate partner violence extend beyond individual
pain and suffering. Health problems may impede daily functioning thereby reducing
productivity as well as increasing health care costs. If visible, the injuries alone may
prevent a woman from going to work or attending classes because they might attract
attention and humiliation. Even if they’re not visible, they may interfere with her ability
to perform job-related tasks or to concentrate on her work. Other health problems
associated with abuse - such as chronic illnesses, various health symptoms, and
depression —- can also strain a woman’s relationship with her employer, coworkers,
family members, fiiends, and service providers. In effect, a partner’s violence places her
in double jeopardy: once because of the health problems she suffers and again because of
the impact her health problems have on her livelihood.

Eliminating the violence from women’s lives is one way to reduce prevailing
health problems. Researchers have demonstrated that a survivor’s anxiety, depression,
and physical health problems intensify as her partner’s violence continues, but gradually
decrease with subsequent reductions in violence (Sutherland, Bybee & Sullivan, 1998;
Campbell, Sullivan & Davidson, 1995; Follingstad, Brennan, Hause, Polek, and
Rutledge, 1991). Unfortunately, it is highly unlikely that intimate partner violence will
cease being a social problem any time soon. We need to develop alternative strategies for
reducing the harmful effects of abuse on women’s physical and psychological health
now. A key first step in developing these strategies is to examine the relationship

between abuse and women’s physical and psychological health: to explain how intimate

l

partner violence affects women’s psychological and physical health. While researchers
consistently demonstrate a strong link between abuse and women’s health issues, few
have examined the process by which intimate partner violence affects health problems
(Eby, 1996; Campbell and Lewandowski, 1997; Sutherland, Bybee & Sullivan, 1998).
Clarification of this process is necessary for effective intervention.

Researchers have demonstrated that stress is a key contributing factor in the
relationship between abuse and health outcomes (Eby, 1996; Campbell, Kub, Belknap, &
Templin, 1997; Jaffe, Wolfe, Wilson & Zak, 1986). Campbell and associates (1997)
found that rates of daily hassles significantly. predicted levels of depression among 164
battered women. In a comparative study of low-income women, Eby (1996) confirmed
that “abused” women reported higher levels of stress (i.e., stressful life events and daily
life circumstances), physical health symptoms and depression than did “non-abused”
women. Furthermore, using structural equation modeling techniques, Eby demonstrated
that the efiect of abuse on low-income women’s physical and psychological health was
mediated by the stress they experienced. These findings support previous assumptions
that battered women suffer numerous physical and psychological health problems in
response to stressors associated with intimate partner violence.

However, researchers have noted similar effects associated with living in poverty.

Women living in poverty experience a greater number of financial stressors (e. g., job
losses, unpaid bills, inadequate housing) and have insufficient financial resources to
address those and other undesirable events (e.g., frequent illness, legal problems) than do
middle or high-income women (Mcleod & Kessler, 1990). As a result, low-income

women are more likely to suffer higher levels of depression and anxiety (Hirschfeld &

Cross, 1982; Lynch, Kaplan & Shema, 1997; Murphy, Olivier, Monson, Sobol, Federrnan
& Leighton, 1991) and. chronic physical health problems (Kingston & Smith, 1997;
Lynch, Kaplan & Shema, 1997; Luepker, Rosamond, Murphy, Sprafka, Folsom,
McGovern & Blackburn, 1993; Stronks, Van Den Bos & Mackenbach, 1997) than
women with higher incomes.

Eby’s (1996) comparative study indicated that the effects of abuse remain strong
even when controlling for women’s low-income status. Low-income “abused” women
reported higher stress levels and poorer health outcomes than did the group of low-
income “non-abused” women. While these findings validate previous assumptions about
the effects of intimate partner violence, the extent to which living in poverty impacts
women’s stress and health remains unclear. This is an important issue to consider.
Clarifying the relationship between poverty and stress is crucial to understanding the full
impact of abuse on women’s physical and psychological health. Failing to do so could
result in an underestimate of the true association between intimate partner violence and
women’s health.

Explicating the relationship between poverty and stress also enhances our ability
to develop effective intervention strategies for women of various income levels. Eby
(1996) noted that financial issues were the most frequently reported stressors for
“abused” and “non-abused” women. The most likely explanation for this finding is that
all of the women were living in poverty, so financial issues were a primary concern for
them. However, another possible explanation for the finding may relate to the dynamics

of intimate partner violence.

Violent intimate partners use a variety of tactics to establish power and control in
the relationship. The shoving, pushing, kicking, choking, raping and various emotional
assaults are calculated attempts to assert that dominance. Abusive partners often
maintain control by restricting women’s access to financial resources (e. g., controlling
their money and activities, restricting employment options, or ruining their credit rating).

Concern about financial issues may be a salient issue for many battered women
regardless of their socioeconomic status. If concerns about financial issues are primary
stress factors for survivors regardless of income level, then providing access to specific
community resources may be key to alleviating the harmful effects of intimate partner
violence. Interventions that do not address these concerns may be less effective in
preventing poor health outcomes. Therefore, in addition to improving estimates of the
effect of intimate partner violence on women’s health, clarifying the effects of poverty on
stress may lead to more effective interventions for battered women.

The social support women receive from their friends and family also may have an
impact on the relationship between abuse-related stress and health outcomes. Past
research indicates that social support may buffer the extent to which stress compromises
women’s psychological health. Friends and family members may provide various
resources ranging from emotional support to financial assistance when crises occur. If
those resources address women’s needs, they may reduce the impact of crises.
Investigating the extent to which social support “protects” women from the deleterious
effects of intimate partner violence is important. Survivors of intimate partner violence
actively seek support from their fiiends and family; they may need safe shelter for

themselves and their children, information about community resources, money, or

UI

someone to talk with. Having the social support available to them when they need it may
enhance their ability to alleviate the effects of abuse-related stress.

To summarize, intimate partner violence is associated with numerous immediate
and long-term physical and psychological health problems. Several researchers have
suggested that it is the stress of surviving an intimate partner’s assaults that compromise
women’s health, yet few investigators have actually examined the process by which
abuse predisposes women to chronic illness, complex physical health symptoms, and
compromised psychological health (i.e., depression, suicide ideation, and dissatisfaction
with quality of life). Understanding this process is crucial to developing effective
interventions to reduce the onset of long-term health problems. Findings from a cross-
sectional comparative study of low-income women have demonstrated that women’ 5
stress levels mediate the relationship between abuse and health outcomes. However, the
extent to which living in poverty effects this process remains unclear. Further research
with women from a range of income levels is needed to estimate the true effect of
intimate partner violence and to develop intervention strategies that effectively meet the
needs of women.

A review of the literature is presented to clarify the complex relationship between
intimate partner violence and women’s health. This review discusses studies that
examined the effect of abuse, stress, and poverty on women’s physical (i.e., injuries,
chronic illness, and physical health symptoms) and psychological (i.e., depression,
suicide ideation, and quality of life) health. It includes cross-sectional and longitudinal
investigations and critically assesses the extent to which existing literature explains the

process by which intimate partner violence affects poor health outcomes. Finally, the

review discusses research about the role of social support in moderating the relationship
between abuse and psychological health.

Two issues about the direction and content of the literature review need to be
addressed at this time. First, although there are three common types of abuse, physical,
sexual, and psychological, the trend of previous research has been to delineate the
consequences of physical and sexual abuse. We know relatively little about the effects of
psychological abuse on women's physical and psychological health. Therefore, the
review will contain research that specifically addresses the effects of physical and sexual
abuse.

Second, much of what we currently know about intimate partner violence and its
effects on women's health has been derived from studies about low-income women or
women in crisis (i.e., living in a battered women’s shelter or seeking medical attention
from emergency rooms or mental health care facilities). There have been very few
studies about abuse where researchers examined community-based samples or samples
with a range of incomes. The literature search for this review did identify a few
comparative studies, but not comparative studies using middle- or high-income women.
Therefore, the information presented in this review is limited with respect to its
generalizability to women who are not living in poverty, and to some extent women who

are not in a state of crisis.

Physical and Pachological Consequences of Intimate Partner ViolencePrior

studies have provided valuable information about the physical and psychological
consequences of intimate partner violence. For decades, health care practitioners and
medical researchers have documented high rates of physical health symptoms, chronic
health problems, depression, anxiety, and suicidal ideation among battered women. They
and other researchers have found that battered women often suffer a complex array of
physical and psychological health problems that appear unrelated to injuries or
predisposing health conditions. Much of previous research has been based on the
experiences of low-income wOmen or women who are in a state of crisis (i.e., seeking
emergency medical or mental health care or safety in a battered women’s shelter). As
such, the extent to which the poor health outcomes are due to intimate partner violence
remains unresolved. Despite this limitation, a review of the existing literature pertaining
to the physical and psychological health consequences of abuse provides meaningful
insight to battered women’s experiences.
Physical Health Consequences of Abuse

Physical health smptoms. Health care practitioners and other researchers have
demonstrated that battered women endure numerous physical health symptoms.
Comparative retrospective studies of emergency room and primary health clinic patients
indicate that battered women seek medical attention for health complaints more often
than do non-battered women (Council on Scientific Affairs, 1992; Domino & Haber,
1987; Drossman, Leserman, Nachman, Li, Gluck, Toomy & Mitchell, 1990; Hamberger,
1994; Koss, Koss, & Woodruff, 1991). They also report a greater range of specific health

symptoms. For example, Eby (1996) found that women in the “abused” group reported a

greater number and frequency of physical health problems than did women in the “non-
abused” group. Frequently reported symptoms include those associated with sleep
problems such as fatigue, insomnia and recurrent nightmares (Eby, 1996; Jaffe, Wolfe,
Wilson, and Zak, 1986; Kerouac et al., 1986; Sutherland et al., 1998); headaches, chest
pain, back and limb problems, and disturbing physical sensations (Domino & Haber,
1987; Drossman, 1994; Drossman, Talley, Leserrnan, Olden & Barrio, 1995; Eby, 1996;
F ollingstad, Brennan, Hause, Polek & Rutledge, 1991; Kerouac et al., 1986; Sutherland et
al., 1998); stomach and gastrointestinal problems (Drossman et al., 1990; Follingstad et
al., 1991; Scarcini, McDonald-Haile, Bradley & Richter, 1994; Sutherland et al., 1998;
Tally, Fett & Zinsmeister, 1995; Talley, F ett, Zinsmeister & Melton, 1994); respiratory
problems such as choking sensations, hyperventilation, and asthma (Abbot, Jonson,
Kozoil-McLain & Lowenstein, 1995; Keroac et al., 1986); and gynecological symptoms
such as pelvic pain, menstrual problems, miscarriages, and hysterectornies (Eby et al.,
1995; Eby, 1996; Rapkin, Kames, Darke, Stampler & Nalibotf, 1990; Rodriguez, 1989;
Schei & Bakketeig, 1989; Sutherland et al., 1998; Toomey, Hernandez, Gittleman &
Hulka, 1993).

Most battered women suffer between three and eleven physical health symptoms
at any given point in time (F ollingstad et al., 1991; Sutherland et al., 1998). In many
cases the symptoms appear unrelated and have an unspecified origin. Health care
providers have characterized the symptoms as manifestations of stress and have found
them difficult to diagnose and treat. As a result, physicians may have provided
inadequate or harmful treatment for women’s health symptoms without ever addressing

the underlying cause of the complaints. Improved identification procedures in emergency

rooms and primary care facilities have revealed that the vague pain complaints when
combined with other physical health symptoms may be strong indicators of intimate
partner violence (Attala, 1994; Drossman et al., 1995; Randall, 1990; Saunders,
Hamberger & Hovey, 1993). When asked, a woman often attributes her physical health
problems to her partner’s physical and psychological abuse (Abbott et al., 1995; Eby,
1996). For example, Eby (1996) found that most women reported that symptoms such as
headaches, sleep problems, muscle tension or soreness, poor appetite, and nightmares
were due to their partner’s abusive behavior.

The extent of women’s physical health symptomatology is directly related to their
experiences of abuse. Researchers have found that the frequency and severity of health
symptoms is strongly associated with the frequency and severity of abuse (Eby, 1996;
Follingstad et al., 1991; Sutherland etal., 1998). As the violence becomes more frequent
and severe, so does a woman’s physical health symptomatology. Furthermore, the extent
to which women experience physical health symptoms is directly linked to their
experiences of violence. Sutherland and colleagues’ (1998) longitudinal investigation
demonstrated that women’s physical health symptoms gradually decreased over time as
their experiences of abuse declined. The concomitant decline in abuse and physical
health symptomatology indicates that intimate partner violence has a significant impact
on women’s physical health. That the effects of abuse persisted even in the absence of
abuse suggests that a partner’s violence has a long-lasting impact on a woman’s health. It
seems likely that women suffer multiple physical health symptoms because of their

partners’ violence against them.

10

Chronic health problems. While there is sufficient evidence to conclude that
intimate partner violence causes multiple physical health symptoms, the relationship
between abuse and chronic health problems is less clear. Health care practitioners and
researchers have noted high prevalence rates of physical and sexual abuse among patients
sufi’ering from conditions such as arthritis (Kerouac et al., 1986), chronic pain (e.g., lower
back, abdominal, headache, and pelvic pain) (Domino & Haber, 1987; Haber & Roos,
1985; Rapkin, Kames, Darke, Stamler & Naliboff, 1990; Toomey, Hernandez, Gittleman
& Hulka, 1993), and gastrointestinal illness (e. g., gastroesophageal, noncardiac chest
pain, and irritable bowel syndrome) (Drossman et al., 1990; Scarinci et al., 1994; Talley
et al., 1995; Talley et al., 1994). While the prevalence rates vary depending on the type
of problem and reporting procedures, researchers have estimated that between 31% and
56% of female gastrointestinal illness sufferers report a history of physical or sexual
abuse (Drossman et a1, 1995). Among chronic pain sufferers between 53% and 66% of
the patients reported a history of abuse. These high prevalence rates suggest a strong link
between history of abuse and chronic health problems. For example, in a study of 997
gastroenterology outpatients, Talley et a1. (1995) noted that patients who reported a
history of physical or sexual abuse were twice as likely to have chronic gastrointestinal
disease than were patients who did not report a history of abuse.

While previous studies imply a direct link between intimate partner violence and,
chronic health problems, few researchers have actually assessed the extent to which abuse
causes chronic health problems. Furthermore, much of what we do know has been based
on retrospective clinical studies that lack a clear distinction between experiences of

childhood sexual trauma and intimate partner violence. Prevalence rates are often based

ll

on history of abuse, which includes childhood sexual and physical abuse in addition to
intimate partner violence (Drossman et al., 1995; Scarinci et al., 1994; Talley et al., 1994;
Talley et al., 1995; Toomey et al., 1993). The lack of differentiation between childhood
experiences of abuse and intimate partner violence may lead to an overestimation of the
effects of intimate partner violence on chronic health problems. The reliance on clinical
samples to determine prevalence rates restricts our ability to generalize existing
information to women who haven’t sought medical attention or who were misdiagnosed.

Consequently, our knowledge about the process by which intimate partner
violence affects chronic health problems is limited. This is an important gap in the
literature. Chronic health problems can severely limit a person’s ability to perform daily
tasks or secure stable employment. They also require consistent medical attention, which
can be extremely expensive. For a battered woman, having a chronic health problem may
be detrimental to her safety as well as her overall health. If her partner feels that she has
not performed her. duties as ordered, he may use this as another excuse to- beat or
humiliate her more. . Clearly this is one consequence of intimate partner violence that
needs further explOration.

In summary, battering takes its toll on women's physical health in at least two
distinct ways. Previous researchers have demonstrated a strong positive relationship
between intimate partner violence and women’s physical health symptomatology. More
frequent and severe violence results in higher rates of physical health symptoms. In
addition, longitudinal analyses indicate a long-lasting impact of abuse on women’s
experiences of physical health symptoms. The relationship between intimate partner

violence and chronic illness is less clear. While researchers have noted high prevalence

12

rates of abuse among chronic pain and gastrointestinal illness sufferers, several
methodological limitations prevent us from fully understanding the effect of intimate
partner violence on chronic health problems.
Abuse and Psychological Health

Intimate partner violence may be the most common single background factor for
female patients in mental health settings (Stark and Flitcraft, 1988). Studies of mental
health clinic populations reveal that 37% to 50% of psychiatric inpatients have a history
of adulthood sexual or physical abuse (Post, Willett, Franks, House, Back & Weissberg,
1980; Swett & Halpert, 1993). Many battered women endure symptoms of psychological
stress such as depression and anxiety (Alpert, 1995; Bergman & Brismar, 1991;
Campbell, Kub, Belknap‘& Templin; Campbell, Sullivan & Davidson, 1995; Carmen et
al., 1984; Cascardi & O’Leary, 1992; Follingstad et al., 1991; Gleason, 1993; Goodman
et al., 1993; Jaffe et al., 1986; Koss, 1990; Mitchell & Hodson, 1983; Mullen, Romans-
Clarkson, Walton & Herbison, 1988; Sato & Heiby, 1992; Stark & F litcraft, 1988; West,
Fernandez, Hillard, Schoof & Parks, 1990) and posttraumatic stress (Astin, Lawrence &
F oy, 1993; Cascardi, O’Leary, Lawrence & Schlee, 1995; Dutton & Goodman, 1994;
Gleason, 1993; Kemp, Green, Hovanitz & Rawlings, 1995; Kemp, Rawlings & Green,
1991; Koss, 1990; Walker, 1991). Stark and Flitcraft (1988) estimated that nearly 37% of
battered women are diagnosed with depression or other situational disorder, and one in
ten suffers some form of a psychotic break.

Comparative studies demonstrate that battered women are more likely to suffer
severe depression, anxiety, and suicide ideation than are non-battered women (Cascardi &

O’Leary, 1992; Eby, 1996; Gelles & Harrop, 1989; Gleason, 1993; Jaffe et al., 1986;

13

Kerouac et al., 1986; Orava, McLeod & Sharpe, 1996; Rhodes, 1992). For example,
Jaffe et a1. (1986) compared depression and anxiety levels between 56 battered and 89
non-battered women using the General Health Questionnaire. T-test comparisons
revealed that depression scores for the group of battered women were significantly higher
than they were for the non-battered group. Eby’s (1996) comparative study of low-
income women yielded similar results. Women in the “abused” group reported poorer
psychological health than did women in the “non-abused” group. These findings suggest
a distinct relationship between intimate partner violence and poor psychological health
outcomes. A more thorough review of research pertaining to the relationship between
abuse and women’s experiences of depression and suicide ideation is presented below.

l_)_egression. Depression may be the most prominent mental health consequence of
battering (Goodman, et al., 1993; McGrath et al., 1990; Walker, 1984). Although actual
prevalence rates of depression among studies of battered women vary depending upon
sample characteristics, there is consistent evidence to suggest that battered women suffer
symptoms of depression at a greater rate than do women in the general population. The
US. Department of Health and Human Services (U SDHHS) Clinical Practice Depression
Guidelines Panel estimated that the point prevalence rates for major depressive disorders
among women is 9.3% (U SDHHS, 1993). Studies of shelter and community samples
consistently demonstrate much higher prevalence rates of depression among battered
women. Within shelter populations, researchers report that 70% to 85% of battered
women eXperience at least mild depression, while between 30% and 55% of battered
women suffer symptoms of severe depression (Campbell et al., 1995; Cascardi &

O’Leary, 1992; Follingstad et al., 1991; Gleason, 1993; Sato & Heiby, 1992; West et al.,

14

1990). The prevalence rate among a community sample of battered women was lower,
but still significantly higher than the general population. Campbell et a1. (1997)
interviewed 164 battered women who were recruited from newspaper advertisements and
bulletin board postings. Using the Beck Depression Inventory, the investigators found
that 28% were moderately to severely depressed and 11% were severely depressed.

As noted earlier, battered women are more likely to suffer symptoms of
depression than are their non-battered counterparts. Other researchers have demonstrated
' a strong positive relationship between the frequency and severity of abuse and rates of
depression and anxiety (CMpbell et a1, 1997; Campbell et al., 1995; Cascardi &
O’Leary, 1992; Eby, I996; Khan, Welch & Zillmer, 1993; Sutherland et al., 1998). This
means that women’s rates of depression are significantly higher for those whose partners’
assault them severely and often. It also implies that a woman’s level of depression may
increase if her partner’s violence escalates in frequency and severity.

Researchers have demonstrated that intimate partner violence has serious
consequences for women’s psychological health. The prevalence rate estimates and
comparative analyses provide strong empirical support for concluding that abuse has an
impact on women’s levels of depression. However, they do little to explain the process
by which abuse affects depression. Some researchers assume a stress-response theory of
abuse (Campbell etal., 1997; Campbell et al., 1995; Carmen, Russo & Miller, 1981; Eby,
1996; Mitchell & Hodson, 1983), which emphasizes the relationship between the stress of
abuse and depression. Other researchers favor a more intra-personal perspective (Gellen
et al., 1984; Gleason, 1993). Most of previous research is based-on cross-sectional data

gathered from clinical settings and battered-women’s shelters. The methodological

15

limitations of these studies have prevented them from being conclusive. However, recent
empirical evidence seems to support the stress-response theory.

Eby’s (1996) comparative study of low-income women provided support for a
stress-response theory of depression. Using structural equation modeling techniques, she
demonstrated that abuse indirectly affects psychological health outcomes (i.e.,
depression, suicide ideation, and quality of life) through women’s experiences of stress.
Approximately 60% of the efiect of abuse on women’s psychological health was
mediated through stress. This means that for low-income women abuse has a strong
impact on levels of depression, but the extent to which battered women experience
symptoms of depression-depends in large part on their concurrent levels of stress.

Campbell’s et al. (1995) longitudinal assessment of depression among 139
battered women provided valuable information about the effects of abuse on depression
over time. First, the results of the study provided further support for a stress-response
theory of psychological health problems; depressive symptoms reduced most within ten
weeks after women left a shelter, and continued to decline as the frequency and severity
of abuse declined. Second, the results demonstrated that experiences of abuse had both
predictive and concurrent effects on women’s experiences of depression. These results
indicated that abuse has a resounding and long-lasting impact on women’s mental health
status, even after the violence has ended.

Although several researchers have established a strong link between abuse and
depression, the process by which abuse affects psychological health problems needs
further exploration. Most of existing research is based on cross-sectional data gathered

fiom clinical settings and battered women's shelters, or from women who are living in

16

poverty. Researchers’ reliance on low-income and in-crisis samples limits our ability to
generalize and interpret these findings. Examining these relationships using comparative
samples of women from a broad range of income levels and who are not necessarily in a
state of crisis would enhance our understanding about the impact of intimate partner
violence on women’s experiences of depression.

Suicide ideation.; While depression and anxiety appear to be the most common
psychological health problems among battered women, researchers have found a
consistent relationship between history of abuse and suicidal ideation or deliberate
attempts at self-harm (Bergman and Brismar, 1991; Eby, 1996; Koss, 1990; Stark, 1984;
Stark and Flitcrafl, 1983 & 1988). Stark and Flitcraft (1988) suggest that battering may
be the single most important context yet identified for female suicide attempts. In their
epidemiological review of relevant research, the authors concluded that between 3 5
percent and 40 percent of abused women attempt suicide. Estimates suggest that battered
women are, in fact, 4.8 times more likely to attempt suicide than non-battered women
(Stark and Flitcrafi, 1988). Nearly 50 percent of those battered women who attempt
suicide will do so more than once (Stark, 1984). Perhaps battered women view suicide as
their last resort to stopping the violence.

Our current understanding of the relationship between abuse and psychological
health is limited by at least two factors. First, most researchers surveyed samples from
clinical settings or battered women’s shelters in order to explicate the relationship
between abuse and mental health. These were women who actively sought psychiatric
services or a safe haven, and probably do not represent the entire population of battered

women. Second, prior studies have generally relied on information about low-income

17

women. The information gleaned from these studies has provided valuable information
about the process by which intimate partner violence impacts women’s psychological
health. However, it does not fully explain the extent to which intimate partner violence
affects women’s level of depression and suicide ideation.These studies demonstrate that
abuse takes a deleterious toll on women's physical and psychological health. Battered
women are at risk for long-term health consequences of continuous sexual and physical
assaults. They endure the pains and scars of countless injuries, and deal with debilitating
physical and psychological health problems. We seem to know much about the effects of
violence on low-income women's health. However, we know very little about the process
by which different forms of abuse impact the physical and psychological health of
women who are not living in poverty. We know even less about the factors that may
exacerbate or prevent the development of health problems.
Relationship Between Physical_ and Psychological Health
Previous research indicates that women who suffer repeated physical, sexual, and
verbal assaults from their intimate partners and who are isolated from fiiends, family, and
other support systems are likely to exhibit symptoms of depression and anxiety.
Empirical evidence also suggests that these symptoms of depression and anxiety may
exacerbate or at least partially explain, their physical health symptoms such as headaches,
back pain, nausea, low energy, and muscle tension.
Few researchers have empirically addressed the relationship between the
psychological and physical effects of intimate partner violence (Sutherland et al., 1998).
However, researchers have established a significant relationship between poor physical

health status and symptoms of depression and anxiety (Betrus, Elmore & Hamilton, 1995;

18

 

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Hays, Wells, Sherbourne, Rogers & Spritzer, 1995; Judd, Paulus, Wells & Rapaport,
1996; Katon, Kleinman & Rosen, 1982a, 1982b; Schulberg, McClelland & Burns, 1987).
Depression and anxiety often impede physical functioning and may even increase
women’s susceptibility to physical illnesses such as cancer (Spiegel, 1996), chronic

fatigue (Mann, Matthews, Lane, Tennen, Hesselbrock, Mendola & Affleck, 1989),
endocrine disorders (Musselman & Nemeroff, 1996), and immunodeficiency disorders
(Maj, 1996). Furthermore, individuals with symptoms of depression are more likely to

report frequent pain and illness, limited physical activity, and general poor health than are

non-depressed individuals (Betrus et al., 1995; Judd et al., 1996; Leino & Magni, 1993;

Lewinsohn, Seeley, Hibbard, Rhode & Sack, 1996; Von Korff, Le Resche & Dworkin,
1993; Von Korff & Simon, 1996) and chronically ill patients (Hays et al., 1995; Wells et
al., 1989).

Despite recent advances in identifying the relationship between depression and ‘

- anxiety and physical health problems, the issue of causal direction (i.e., whether
depression predicts physical health problems or vice versa) remains unclear. Several
prospective studies have demonstrated that depression predicted higher rates of physical
health problems, with no support for the opposite direction (Hays et al., 1995; Leino &
Magni, 1993; Von Korff et al., 1993). Other prospective studies revealed a reciprocal
relationship between depression and physical health problems over time (Aneshensel,

F rerichs & Huba, 1984; Lewinsohn et al., 1996).

Sutherland’s et a1. (1998) longitudinal study of 139 battered women attempted to
clarify the issue of causal direction. The study investigated the relationships between and

among women’s experiences of abuse, injuries, psychological health (i.e., depression and

19

anxiety), and physical health symptoms over time. Changes in women’s physical and
psychological health were examined across three time periods: immediately after exit
from a domestic violence shelter, 8 1/2 months after shelter exit, and again six months
later. The investigators used structural equation modeling techniques to assess the
relationships among abuse, injuries, psychological health and physical health both within
and across time points. Within each time point, abuse explained a modest proportion of
variance in anxiety and depression (R2 = .21) and the joint effects of abuse and anxiety
and depression explained more than half the variance in physical health symptoms (R2 =
.53). Abuse had an indirect effect on physical health symptoms, but no significant direct
effect. Patterns in-the longitudinal model mirrored these relationships. At each time
point, recent abuse had a direct impact on change in anxiety and depression as well as an
indirect impact, through anxiety and depression, on change in physical health symptoms.
Methodological limitations restricted the investigators’ ability to accurately test the
mediating effect of anxiety and depression across time points as well as the reciprocal
relationship between psychological health and physical health. Therefore, the extent to
which depression and anxiety mediates the relationship between abuse at one time point
and physical health symptomatology at later time points remains unclear.

The resultsof Sutherland’s et a1. (1998) longitudinal study did demonstrate that
the effects of abuse on physical health symptoms were mediated through concurrent
levels of anxiety and depression. Evidence of the mediating relationship provides one
explanation of how abuse may lead to physical health problems; the intervening effect of

abuse on depression and anxiety leads to subsequent negative effects on physical health.

20

I)!

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1.:

I

Effects of Injuries and Stress on Women’s Health

I_ni_urie_s

Injuries tend to be the most visible and immediate consequences of abuse.
Batterers inflict injuries that range from black eyes, bruises, and fractured ribs to more
severe problems such as head trauma, detached retinas, gunshot wounds, and
miscarriages (Berrios & Grady, 1991; Drake, 1982; Kerouac, Taggart, Lescop & Fortin,
1986; Sullivan, 1991; Sutherland et al., 1998; Warhaw, 1989). A woman battered when
she is not pregnant is most likely to suffer head and upper-body injuries (Berrios &
Grady, 1991; Drake, 1982; Derouac et al., 1989). If she is pregnant during her partner’s
assault(s), she is most likely to be beaten in the breast, abdominal and genital areas
(W arshaw, 1989). Women rarely suffer only one type of injury from an assault
(Sutherland et al., 1998). The cuts, scrapes, bruises, and broken bones might heal without
a trace of what happened. If not, the permanent scars will forever remind her of her
partner’s brutality. In many cases, the injuries are permanently damaging, life-
threatening, or both.

The extent to which injuries lead to long-term health problems is unclear. Several
researchers have suggested that injuries from repeated assaults may predispose women to
debilitating health problems (Alpert, 1995; Berrios & Grady, 1991; Council on Scientific
Affairs, AMA, 1992; Haber. & Roos, 1985; Randall, 1990). Broken bones, torn
ligaments, lacerations, and head trauma have been linked to health problems such as
chronic pain, hearing and vision loss, epilepsy, and arthritis (Goldberg & Tomlanovich,
1985; McCauley, Kern, Kolodner, Dill, Schroeder, DeChant, Ryden, Bass & Derogatis,

1995). Similarly, women who have received injuries as a result of a sexual assault are

21

 

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likely to report physical health symptoms such as pelvic pain and abnormal vaginal
bleeding or other discharge (Eby, Campbell, Sullivan & Davidson, 1995).

While there is reason to assume a direct relationship between injuries and physical
health problems, the extent to which injuries lead to poor health outcomes is not well
understood. Typically, researchers have documented abuse-related injuries as a way of
generating prevalence rates of abuse, yet few researchers have examined the relationship
between injuries and other less visible health problems. Sutherland and colleagues
(1998) recently addressed this issue while investigating the long-term health effects of
abuse. Using longitudinal structural equation modeling techniques, the investigators
found that while abuse was strongly related to increased levels of injuries, injuries were
not significantly related to the physical health symptoms women reported. These
findings seem to contradict previous assumptions about the effect of injuries.

For years health care providers and medical researchers have documented cases
where abuse-related injuries predisposed women to numerous chronic health problems.
On the other hand, health care practitioners report that battered women often seek
medical attention for symptoms that appear unrelated to a specific injury or chronic
health problem.

Clearly the relationship between abuse and physical health is complex and cannot
be explained by looking at injuries alone. However, abuse-related injuries are significant
consequences of intimate partner violence, and the extent to which they contribute to
women’s physical health problems remains unclear. Further investigation of the impact

of injuries on women’s physical health is needed.

22

Effect of Stress on Physical Health

The adverse effects of battering on women's physical and psychological health
have been well documented in the abuse literature, yet few researchers have investigated
the process by. which abuse affects women's health (Eby, 1996; Campbell et al., 1997;
Sutherland et al., 1998). A leading assumption among researchers has been that women’s

physical and psychological health problems are caused by stress associated with intimate
partner violence (Campbell, 1989; Campbell et al., 1995; Campbell et al., 1997; Dutton
and Goodman, 1994; Eby, 1996; Firm, 1985; Follingstad, et al., 1991; Goodman, Koss &
Russo, 1993; Jaffe, Wolfe, Wilson & Zak, 1986; Mitchell and Hodson, 1983). Over the
past few decades, the relationship between stress and health has been researched
extensively. A brief review of the literature on the health effects of stress is presented to
illustrate the process by which women’s experiences of abuse may impact their physical
and psychological health.

Stress has been linked to various physical health conditions such as frequent
headaches, backaches, respiratory infections, gastrointestinal problems, and fatigue
(Barnett, Davidson, and Marshall, 1991; DeLongis, Folkman, and Lazarus, 1988; Seyle,
1982); coronary heart disease and associated risk factors (e.g. diabetes, high blood
pressure, high cholesterol, obesity) (Elliott, 1995; Pearlin, 1989). For example, Ullrnan
and Siegel (1996) examined the relationship of traumatic events to physical health in a
randomized community survey. Results of their study indicated that individuals who
experienced traumatic events had poorer perceptions of their physical health, more
Chronic limitations in physical functioning, and more chronic medical conditions than did

individuals who did not experience traumatic events.

23

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Barnett et al. (1991) examined the relationship between work and physical health
symptoms with a sample of 403 female health-care professionals. They found that work-
related stress (i.e., concerns regarding discrimination, job overload, hazard exposure,
supervision, and job mobility) was significantly related to physical health
symptomatology. When all five concerns were entered into a regression equation, only
work overload and hazard exposure were significant predictors of physical health
symptoms. I

Elliott (1995) reviewed the current literature on the relationship between
psychosocial stress and women's coronary disease. She found evidence to confirm that
psychosocial stress is linked to coronary heart disease, ischerrric heart disease, myocardial
infarction, and a variety of risk factors for coronary heart disease (e.g., high blood
pressure, cholesterol). Despite the mounting evidence linking stress to physical health
problems, the process by which stressful life events or daily hassles impacts women’s
physical health remains unclear. Furthermore, the extent to which income levels affect
the relationship between stress and physical health needs further exploration.

Effects of Stress on Psychological Health

Stressful life circumstances may jeopardize an individual's psychological health as
well as their physical health. Previous research indicates that high levels of stress are
associated with psychological distress symptoms such as depression (Amatea and F ong,
1991; Avison & Turner, 1988; Bailey, Wolfe, and Wolfe, 1994; Breslau and Davis,

1986; DeLongis, F olkman, and Lazarus, 1988; Eby, 1996; Eckenrode, 1984; Holahan &
Moos, 1991; Kendler, K.S., Kessler, R.C., Walters, E., et al., 1995; Kuyken and Brewin,

1994; Nelson, 1989; Revicki, Whitley, Gallery, and Allison, 1993; Russell and Cutrona,

24

1991; Stephens, Franks, and Townsend, 1994; Thoits, 1982; USDHHS, 1993a, 1993b),
‘ negative affect (Bailey, Wolfe, and Wolfe,l994; Eckenrode, 1984; Stephens, Franks, and
Townsend, 1994), and anxiety (Bailey, Wolfe, and Wolfe,l994; Nelson, 1989; Pugliesi,
1989; Thoits, 1982). For example, Holahan and Moos (1991) compared high- and low-
stressor groups on levels of depressed mood and depressive features. Their results
indicated that individuals with high levels of stress experienced significantly more
symptoms of depression than low-stress individuals. Avison and Turner's (1988)
analyses of different stressors indicated that enduring interpersonal difficulties represent
significant sources of long-term stressfirl experiences. Furthermore, their results
demonstrated a strong positive link between chronic strains and depressive symptoms.

To summarize, previous research has established a strong relationship between
stress and negative health outcomes. The physical and psychological consequences of
stress mirror many of the health problems experienced by battered women.
Conceptualizing abuse as a stressor may help to explain these similarities.Abuse. Stress.
and Health Outcomes

Several researchers have suggested that abuse creates stress in women's lives, and,
as such, may activate a combination of distress responses. If not resolved, the stress
responses may become manifested in the form of physical health symptoms
(somatization) and/or psychological health problems. Previous research indicates that
while most victims of violence experience immediate distress response, battered women
may find it more difficult to resolve distress reactions. Researchers have indicated that
abuse-related stress reactions may develop into physical and psychological health

problems (Eby, 1996; Campbell et al., 1997; Goodman, Koss & Russo, 1993; Follingstad

25

et al., 1991; Koss, 1990; Stark & F litcraft, 1988). Koss (1990) postulated that a woman's
ability to resolve the immediate post-victimization stress response hinges on two factors:
1) the interpersonal nature of the victimization and 2) the extent to which social norms
support women's responsibility for the provocation of sexual and physical assault. Even
when evaluated many years after the assault, victims of sexual violence and assault are
significantly more likely than non-victims to qualify for psychiatric diagnoses such as
major depression, generalized anxiety, obsessive-compulsive disorder, Posttraumatic
Stress Disorder (PTSD), and substance abuse (Koss, 1990; Browne, 1992; Walker, 1984).

Unlike women who experience an isolated incident of sexual or physical assault,
battered women often encounter repeated episodes of violence. They may not have an
opportunity to resolve immediate post-victimization distress responses. Furthermore, our
society still holds women accountable for their life circumstances. While we revere
traditional family values, we criticize women for staying in abusive relationships. It is
not surprising, therefore, to find that battered women experience high levels of stress and
subsequent physical and mental health problems.

The occurrence of stress-related health symptoms, such as chronic pain, fatigue,
gastrointestinal illness, and anxiety, among battered women has been documented well in
the literature. Most people would agree that the physical violence itself is stressful.
Women often report monitoring their own behavior to defuse their partner’s temper or at
least minimize the severity of the violence. They talk about the uncertainty of knowing
when or where the attacks will occur or of being unable to sleep for fear their partners
will kill them or harm their children while they’re sleeping. Clearly, the violence itself

can be stressful for women.

26

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Surviving an intimate partner’s violence can be stressful in other ways as well.
Researchers have demonstrated that battered women experience more negative life events
and daily hassles than do non-battered women (Campbell et al., 1997; Eby, 1996; Jaffe et
al., 1986). These may include tensions with family members, fiiends, neighbors,
employers, and service providers who either insist that she leave the relationship, insist
that she preserve the relationship, or imply that she is somehow responsible for the
violence. They may also include concerns about finances, her children’s emotional and
physical health, or her own health. Combined with the stress directly related to the
assaults, these abuse-related stressors may have a resounding impact on women’s
physical and psychological health. In a comparative study, J affe and associates (1986)
found that battered women had significantly more somatic complaints, a higher level of
anxiety, and more symptoms of depression than did non-battered women. In addition,
battered women’s health was significantly related to other stressors in their life such as
negative life events, marital problems, child behavior problems, and fiequent relocations.

Eby (1996) also found that “abused” women had higher levels of stress (i.e.,
stressful life events and daily hassles) than did “non-abused” women. More importantly,
Eby’s study demonstrated that women’s experiences of stress mediated the relationship
between abuse and both physical health symptoms and psychological health (i.e.,
depression and quality of life). These findings suggest that stress is a key component in
the process by which abuse affects women’s health.

The extent to which battered women experience health problems may depend
upon women’s perceived availability of social support. Dohrenwend (1978) proposed a

conceptual framework for understanding the complex relationships between stress and

27

psychopathology. This same model has been applied to the relationship between stress
and physical health outcomes (DeLongis et al., 1988). The psychosocial stress model
suggests that situational factors (i.e., material and social supports) and psychological
factors (i.e., values and coping abilities) influence the extent to which stressful life events
result in negative health outcomes (Levine and Perkins, 1987). This model will be used
as a conceptual fi‘amework for investigating the moderating effects of social support.
Moderating Role of Social Support

Dohrenwend's (1978) psychosocial stress model suggests that social support
moderates the relationship between stress and health outcomes. That is, social support
may reduce the deleterious effects of stress on health outcomes. For example, Holahan
and Moos (1986) found that positive family support was a significant factor for predicting
reduced depression. DeLongis, Folkman, and Lazarus (1988) examined the effects of
daily stress on 75 married couples' somatic symptoms and moods. The results of their
study indicated that persons with unsupportive relationships and low self-esteem were
more likely to experience physical health problems such as the flu, sore throat, headaches,
and backaches. In addition, they were susceptible to complex mood disturbances
(DeLongis, Folkman, and Lazarus, 1988). The processes by which social support affects
the relationship between stress and health are complex.

Reviews of empirical literature (e.g., Broadhead et al., 1983; Cohen and Wills,
1985; Kessler et al., 1985; Pearlin, 1989) often conclude that high levels of social support
are associated with lower risk for physical and psychological problems. Researchers have
posited two competing models regarding this association. One model, the main-effects

hypothesis, suggests that social support directly influences individuals' physical and

28

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psychological health regardless of stress. That is, high levels of social support are
associated with positive physical and psychological health outcomes irrespective of
whether individuals experience stress (Cohen and Wills, 1985; Wilcox, 1981).

The second model, termed the buffering hypothesis, closely resembles
Dohrenwend's (1978) conceptualization of social support. The buffering hypothesis
suggests that social support protects individuals from the potentially harmful effects of
stressful events (Cohen and Wills; 1.985; Wilcox, 1981). The moderating effect of this
model is demonstrated with a stress x support interaction, such that the relationship
betweenrslress and health diminishes as social support increases. In essence, the
buffering model suggests that social support is related to physical and psychological
outcomes only during periods of elevated stress. Social support may influence the
relationship between stress and health outcomes by reducing or eliminating the
immediate stress reaction, or by directly affecting physiological processes (Cohen and
Wills, 1985).

Although both models have received substantial empirical support across a variety
of situations and circumstances (Cohen and Wills, 1985), the buffering model does not
appear to adequately explain the role of social support in battered women's lives (Eby,

1996; Follingstad, 1991; Mitchell and Hodson, 1983). Eby (1996) tested the moderating
effects of social support using a community sample of low-income abused and non-
abused women. The results of her analyses indicated that social support did not
significantly reduce the relationship between stress and psychological health, even when

stress levels were high. The results did demonstrate a positive direct association between

29

social support and psychological health, which appears to support the main-effect
hypothesis.

Combined, these findings contradict earlier assumptions regarding the moderating
effect of social support. They suggest that a battered woman's perception of social
support is beneficial to her overall psychological health regardless of the stress she may
be experiencing. There are two plausible explanations for these findings. First, Eby
(1996) examined the perceived social support Of women who were living in poverty. The
main effect hypothesis suggests that women who are highly satisfied with the amount and
quality of social support they receive would experience greater psychological health
regardless of the level of stress they experience. It is possible that although women felt
better knowing they had satisfactory social support, these resources were not sufficient to
protect women fiom the long-term effects of their stressful life circumstances. In fact,
Eby (1996) reported that even though many battered women were satisfied with the
amount and quality of social support they received, several noted that their family and
friends did not understand their life circumstances, particularly with regard to the abuse
they experienced.

A second possible explanation for the lack of evidence to support a moderating
relationship may relate to methodological issues. Cohen and Wills (1985) noted that to
test the moderating effects of social support, one needs adequate variability in stress,
social support, and symptomatology. The authors posited that this requirement is often
violated in samples where all participants are under relatively high stress to begin with
0-8., homogenous), such as samples of low-income women. Although the group of

abused women reported significantly higher stress levels than the group of non-abused

30

women, all women were navigating the dire circumstances of poverty. All women were
already dealing with highly stressfirl life circumstances, regardless of the abuse they may
have been experiencing. . It is possible that the sample was too homogenous for
significant detection of moderating effects.
Effects of Income on Stress and Physical Health

Abuse has a resounding impact on women’s psychological and physical health.
Survivors of intimate partner violence suffer a myriad of physical health symptoms and
chronic illnesses as well as symptoms of depression, anxiety, and suicidal ideation. \
While previous research indicates a strong causal relationship between abuse and poor
health outcomes, investigators have noted similar effects associated with living in
poverty. Low-income women are more likely to suffer higher levels of depression and
anxiety (Hirschfeld & Cross, 1982; Lynch, Kaplan & Shema, 1997; Murphy, Olivier,
Monson, Sobol, Federman & Leighton, 1991) and chronic physical health problems
(Kingston & Smith, 1997; Lynch, Kaplan & Shema, 1997; Luepker, Rosamond, Murphy,
Sprafka, Folsom, McGovern & Blackburn, 1993; Stronks, Van Den Bos & Mackenbach,
1997) than are women with higher incomes.
The Effect of Income on Stress

Women from low-income households endure unique stresses associated with
living in poverty (i.e. income instability, frequent moves, lack of transportation, poor
housing conditions) (Belle, 1990; Thoits, 1982). They experience a greater number of
financial stressors (e.g., job losses, unpaid bills, inadequate housing) and have
insufficient financial resources to address those and other undesirable events (e. g.,

fi'equent illness, legal problems) than do middle or high-income women (Mcleod &

31

Kessler, 1990). For example, low-income women are likely to reside in substandard and
overcrowded housing. High levels of dissatisfaction with housing conditions as well as
lack of privacy may lead to elevated stress levels (Fuller, Edwards, Sermsri &
Vorakitphokatorn, 1993). As a result the chronic stress of living in poverty may be a key
underlying cause of several physical and psychological health problems (Belle, 1990).
The Effect of Income on Physical Health

In addition to the chronic stresses associated with living in poverty, several other
factors predispose women to poor health outcomes. Low-income women are more
susceptible to various illnesses and communicable diseases such as Hepititis and
Tuberculosis than are women with higher incomes because of substandard housing and
sanitation conditions. They are more likely to be exposed to toxic environmental
substances (Havenaar & Van Den Brink (1997) and have limited access to quality health
care and preventive services, often receive delayed treatment for illness, and rarely have a
regular source of medical care (Bindman, Grumbach, Osmond et al., 1995; Kington &
Smith, 1997; Weissman, Fielding, Stem & Epstein, 1991). The combined influence of
these factors places low-income women at greater risk for chronic illness and other health
problems. On the other hand, women with higher incomes have greater access to
resources including quality health care and health maintenance programs (e. g., health
club memberships). They have the financial resources to consistently purchase nutritious
foods and maintain healthy eating habits, and are more likely than women with low
. incomes to participate in health promotion activities. It is likely that income level can

have a significant impact on women’s physical health.

U)
N

 

 

..u

Moderating Effect of Income

Access to financial resources may buffer the effects of stress on women’s
psychological health. Women with middle and high incomes may suffer fewer and less
severe health problems because they have the financial resources to effectively deal with
stressful situations. For example, women with higher incomes have access to quality
health care and preventive services. When they or members of their families are
hospitalized for an illness or injury, knowing that they have the financial resources to
cover the cost may reduce the extent to which this stressful event impacts their
psychological well-being.

Since most of prior research examining the effects of intimate partner violence has
been based on the experiences of low-income women, effects of living in poverty may
confound the effects of abuse on women’s health. Few researchers have sought to
differentiate the effects of poverty from those due to abuse. Eby’s (1996) comparative
study indicated that the effects of abuse remain strong even when controlling for
women’s low-income status. Low-income “abused” women reported higher stress levels
and poorer health outcomes than did the group of low-income “non-abused” women.
While these findings validate previous assumptions about the effects of intimate partner
violence, the extent to which living in poverty impacts stress and health remains unclear.

Rationale for the Current Study

The literature review delineated several gaps in our understanding about the
relationship between abuse and women's physical and psychological health. First, we
lack a clear understanding of how experiences of abuse affect the physical and

psychological health of women who are not living in poverty. To date, there have been

33

very few studies about battered women where a range of incomes was included in the
sample. The financial strain of surviving poverty-level conditions may place low-income
women at greater risk for health problems. By virtue of their socioeconomic status,
women with higher incomes may not have to deal with similar stressful life
circumstances. They reside in more permanent housing situations, have access to
transportation, have financial stability, and receive quality health care. Therefore, abuse
may have a different impact on their long-term health than it does for low-income
women. In order for us to develop comprehensive community-based strategies that
effectively address the various needs of all women, we need to know how abuse impacts
the physical and psychological health of women across a range of incomes.

A second limitation of the current literature is that most prior studies contain
samples of women who are in the midst of a severe crisis. Much of our understanding
about the psychological and physical impacts of abuse has been derived from samples of
women presenting in emergency departments or battered women's shelters. Campbell et
a1. (1995) noted that the long-term effects of abuse on women's symptoms of depression
decrease over time. That is, as more time is placed between the abusive situation and the
measure of depression, the symptomatology decreases. Similarly, physical health
problems tend to decline over time, once the crisis is over. Few studies have examined
the relationship between abuse and health outcomes using random samples of women
from the community. A random sample of community women may provide more
variability in measures of abuse, injuries, stress, and health. Hence, the generalizability

of research results will increase.

34

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A third limitation is that the current research regarding abuse and health lacks a
comprehensive approach to health outcomes. Much of previous research examined the
relationship between abuse and psychological health, abuse and physical health
symptoms, or abuse and'psychosomatic symptoms. Few researchers have combined the
various health indices with a measure of chronic health problems. Yet, the abuse
literature suggests that battered women suffer various chronic health problems in addition
to physical health symptomatology. Similarly, the literature regarding stress research
indicates that women may experience chronic health problems as a result of stressful life
experiences. The inclusion of a chronic health problems measure will provide a more
comprehensive view of women's health experiences.

The present study had two primary goals. The first goal was to clarify the
relationship between intimate partner violence and women’s psychological and physical
health. Previous research has indicated that several complex relationships may exist
between women's experiences of abuse and their physical and psychological health.
Several researchers have assumed abuse to be a considerable stressor in women's lives.
Abuse may exacerbate already existing stressful life circumstances or even provoke its
own immediate stress reaction. It is likely that these circumstances of abuse will
adversely affect battered women's health.

The second goal was to explore the extent to which income level impacts the
effects of abuse on women’s physical health and psychological health. For the most part,
previous research about the deleterious effects of abuse on women's health has been
limited to low-income women. Studies of low-income women have increased our

understanding about the health consequences of intimate partner violence, but provide

35

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36

limited evidence that women’s health problems are due to the abuse rather than
conditions of poverty.

A conceptual path model of proposed relationships among abuse, health and
income is presented in Figure 1. According to the proposed model, the relationships
between abuse and women's health as well as the impact of income on these relationships
will be explained by several hypotheses. These hypotheses were generated to address

three general research questions.

1. To what extent does intimate partner violence affect a woman’s physical

 

My Several hypotheses were tested to better understand the
relationship between abuse and physical health outcomes. They asserted
both direct and indirect relationships among the constructs.

' a. Women's experiences of abuse will have a direct positive effect on
women's experiences of injuries. That is, women who experience
higher levels of abuse will report higher levels of injuries than will
women who experience lower "levels of abuse.

b. Women’s experiences of injuries will have a direct positive effect on
women's experiences of health problems. That is, women who
experience higher levels of injuries will report higher levels of physical
health problems than will women who report lower levels of injuries.

c. Women’s experiences of injuries will partially mediate the relationship
between abuse and physical health problems. It is expected that when

the effect of injuries are accounted for, the relationship between abuse

37

and physical health problems will decrease in significance and/or

_ magnitude.
. Women's experiences of abuse will have a direct positive effect on
women's experiences of stress. That is, women who experience higher
levels of abuse will report higher levels of stress than will women who
experience lower levels of abuse.
. Women's experiences of stress will have a direct positive effect on
their psychological health. That is, women who report higher levels of
stress will experience worse psychological health (i.e., high levels of
depression and dissatisfaction with quality of life) than women who
report lower levels of stress.
Women’s psychological health will have a direct positive effect on
their physical health problems. That is, women who report higher
levels of depression and dissatisfaction with their quality of life will
report higher rates of physical health problems than will women with
lower levels of depression and dissatisfaction with quality of life.
. Women’s experiences of stress will partially mediate the relationship
between abuse and psychological health. This means that abuse will
have a direct positive effect on psychological health as well as stress
such that women who report higher levels of abuse will report higher
levels of psychological health. But when the effect of stress is
considered the significance and/or magnitude of that relationship will

decline. In other words, a woman’s stress level may partially explain

38

her level of depression, dissatisfaction with quality of life, and suicide
ideation.

h. Psychological health will partially mediate the relationship between
stress and physical health problems. This means that stress will have a
direct positive effect on physical health problems as well as
psychological health such that women with higher stress levels will
report higher rates of physical health problems than will women with
lower stress levels. But, when the effect of psychological health is
accounted for, the-significance and/or magnitude of the relationship
between stress and physical health problems will decrease. In other
words, women’s levels of depression and dissatisfaction with their
quality of life may partially explain the relationship between stress
levels and physical health problems.

To what extent does a woman’s income impact the regrtionship between

abuse and her physical health? Three hypotheses were tested to examine

the impact of income on the relationship between abuse and physical
health. Two of these hypotheses proposed direct relationships between
income and stress and physical health, while the third asserted a buffering
effect on the relationship between stress and psychological health.

a. Women’s income will have a direct negative effect on their stress
level. That is, women who report higher incomes will report lower

levels of stress than will women who report lower incomes.

39

b. Women’s income will have a direct negative effect on their physical
health outcomes. That is, women who report higher incomes will
report lower levels of physical health problems than will women who
report lower incomes.

c. Women’s income will moderate the relationship between their stress
levels and their psychological health. There will be a significant
interaction effect of income .with levels of stress on women's
psychological health. At lower income levels the relationship between
level of stress and women's psychological health will be strong and
positive. At higher income levels, the relationship between level of
stress and women's psychological health will decline.

3. To whpt extent does p woman’s satisfaction with their social support impact
the effects of abuse on their psychological hegth? The model indicates an
indirect effect of social support. It is hypothesized that social support will
moderate the relationship between stress and women’s psychological health.
There will be a significant interaction effect of social support with levels of
stress on women’s levels of depression and dissatisfaction with quality of life.

When social support scores are low, the relationship between level of stress
and women’s psychological health will be strong and positive. At higher
levels of social support, the relationship between stress and psychological

health will decline.

40

CHAPTER 2

METHOD

Research Design

A cross-sectional multivariate research design was used to understand the
complex relationships between abuse and health outcomes. This design allowed for basic
descriptive and comparative analyses of abused and non-abused women of varying
income levels. In addition, it accommodated a sophisticated approach to testing the
proposed model; structural equation modeling techniques were used to assess the
hypothesized relationships among the variables. A discussion of recruitment and data
collection procedures, measures, and analyses used in this study is presented.
Research Participants

The Women’s Health Study. As part of a larger research project, 397 women
were recruited to participate in the current study. The larger research project, the
Women’s Health Study, was designed to investigate the effects of various life
circumstances (including physical, emotional, and sexual abuse) on women’s physical
health and psychological health. Women for the Women’s Health Study were recruited
primarily through newspaper advertisements, although some women heard about the
research project through a fiiend or relative who had seen the advertisement or had seen a
flyer. Four consecutive advertisements were placed simultaneously in three local
newspapers from August 1996 through June 1997. Each of the four advertisements was

designed to attract women who fit a specific profile (e.g., middle-income women who had

41

been physically banned by an intimate partner during the past six months). The
advertisements are provided in Appendix A.

As noted in the advertisements (see Appendix A), interested women were
instructed to call the Women’s Health Study office to get more information about the
project and to determine their eligibility for participation. Trained Women’s Health
Study team members answered the telephones, recited scripted information about the
project (see Appendix B), screened callers for eligibility, and scheduled the interviews.
Eligibility requirements varied depending on the recruiting profiles (i.e., whether we were
recruiting for a specific income level or “abuse” status), and the screening forms varied
accordingly. An example of the recruitment scripts and corresponding screening forms
(Participant Contact F arm) is provided in Appendix B.

Once eligibility was established, each eligible woman was scheduled for a face-to-
face interview at a time and location that was convenient for her (specific information
about interviewer training and procedures are discussed later). The interviews took place
in several different settings; most were scheduled at the American Red Cross, but some
were also conducted in women’s homes and on—campus (at Michigan State University).
A total of 439 women scheduled interviews with the Women’s Health Study. Out of the
women who scheduled interviews, 399 (91%) completed them.

The Current Study. Three hundred ninety-seven women (90% of all eligible
participants) from the Women’s Health Study met the criteria for the current study: 1)
they were between 18 and 45 at the time of the interview and 2) they were current
residents of the Greater Lansing Area. As noted in Table 1, most of the women in the

current study were recruited through newspaper advertisements.

42

Table 1. Recruitment Method (N = 397)

 

 

Source N %
Newspaper 333 83%
Lansing State Journal (178) (45%)
community newspapers (155) (39%)
Friends/Relatives . 39 10%
Flyers l3 3%
Other 6 2%
Missing 6 2%

 

The demographic characteristics of the women who participated in the study are
presented in Table 2. Seventy percent of the women identified themselves as
white/Caucasian, 20% black/African-American, 6% multiple ethnicity, 5%
Hispanic/Latina, 1% Asian-Pacific, and 1% Native American. Generally, the participants
were in their 305 (mean age = 34, SD = 7.68), employed at least part-time (66%), had
some college experience (74%), and cared for two children (SD = 1.55). Thirty-nine
percent were married or living with an intimate partner, 27% were in a serious
relationship, but not living together, and 34% were not involved in a serious relationship
at the time of the interview. The majority of women (86%) owned or rented housing
accommodations, while the remaining 14% had temporary shelter arrangements with
fiiends, relatives, or some other source. Despite the median household monthly income
of $1,600 (SD = $1,616), 129 women (33%) were surviving on monthly incomes below
the poverty threshold for the number of people supported by that income. In most
households, the monthly income supported at least three people (68%), and in 21 (5%) of
those homes, the income supported between six and nine people. Two hundred thirty two

(59%) women had private medical insurance, 88 (22%) received Medicaid or Medicare,

43

and 77 (19%) were not insured. As expected, 52% of the participants reported that an
intimate partner or ex-partner had physically harmed them within the six months prior to
the interview. ’ ~ I

The demographic characteristics of this sample were somewhat representative of
the Lansing area population. According to the 1990 Census data (U .8. Census Bureau,
1990), the ethnic, educational, and employment distribution of the current sample were
comparable to Lansing Area demographics. Women in this sample were as likely to have
private health insurance or at least Medicaid or Medicare as did people in the Capital area
in 1990 (Health Status Advisory Group Report, 1993). Despite the apparent similarities
between this sample and the Lansing population, there was a key difference. The median
annual income of $18,000 was substantially less than the 1989 estimates of Lansing area
households ($26,398; US. Census Bureau, 1990). This difference is important to note
because it may mean that this particular sample didn’t adequately represent all women
from the Lansing area.
Interviews

Interviewer training. Ten undergraduate students interviewed the project
participants in exchange for independent study course credits (PSY 490). To be eligible
for Independent Study credits in Psychology, students must have had a minimum
cumulative grade point average of 2.5 and at least nine credit hours of Psychology. The
students were selected based on their eligibility, willingness to commit two consecutive

semesters to the research project, and their interest in women's health issues.

44

Table 2. Demographic Characteristics (N = 397)

 

 

Characteristic N %
Race/Ethnicity
White/Caucasian 279 70%
Black/African-American 66 l 7%
Multi-ethnic . 25 6%
Hispanic/Latina 20 5%
Asian/South-Pacific 4 1%
Native-American 3 1%
Age (mean = 34 years)
17-29 years 121 30%
30 - 39 years 154 39%
40 - 50 years 122 31%
Household Monthly Income
(median = $1,600)
$0 - 999 121 31%
$1,000 - 1,999 110 28%
$2,000 - 2,999 64 16%
$3,000 - 3,999 48 13%
$4,000 - 4,999 32 8%
$5,000 - 5,999 11 2%
Over $6,000 ($8,667) 11 2%
Employment Status (p = 277)
Full-time 194 70%
Part-time 69 25%
Temporary/ seasonal l4 5%

 

45

Table 2 (con'd).

 

 

Characteristic N %
Relationship Status

Living together/married 153 38%

Not currently dating 65 16%

Separated/divorced/widowed, 55 14%

not in a new relationship
Girlfriend/boyfriend 54 14%
Separated/divorced/widowed, 54 14%
in a new relationship

Dating, not girl-fboyfiiend l6 4%
Housing Status

Renting apartment or house 172 43%

Own or buying a house 162 41%

Staying with friends/relatives 49 12%

Renting a room 6 2%

Homeless or other shelter ‘ 8 2%
Education Level

Some college 191 48%

Bachelor's degree . 71 18%

High school graduate/GED 37 9%

Less than high school 36 9%

Post-bachelor's degree 32 8%

Vocational/trade school 30 8%
Medical Insrn'ance

Private insurance 232 59%

Medicaid/Medicare 88 22%

None 77 19%
Have Children (mean no. = 2) 295 74%
Harmed by partner or ex-partner

within past 6 months 207 52%

 

46

The students developed interviewing skills through a 10-week intensive training
sequence. The training sequence consisted of weekly reading and discussion assignments
about issues relevant to middle-income women's health, a Cultural Sensitivity Training
seminar, and Interview Practice sessions (See Appendix C for a copy of the Interviewer
Training Syllabus and Training Schedule). Students honed their recruiting and
interviewing skills through role-play exercises and mock interviews. Their progress was
evaluated on a weekly basis through individual and group supervision meetings.
Feedback regarding their skill development was provided to each student via weekly
progress reports.

The second half of the first semester and the entire second semester was devoted
to interviewing project participants. Upon successful completion of the training
sequence, each student was required to interview at least two women each week. The
interviews were arranged at least one week in advance. No student received her
assignment until it was determined that she had mastered the interview (i.e., achieved at
least 95% inter-rater reliability with other students and instructor on a mock interview).

Completed interviews and their tape recordings were submitted each week. The
instructors reviewed and evaluated each completed interview. Interviewers received
weekly feedback reports on their case responsibility and interview technique and coding.

Inter-rater reliability estimates were computed twice during the data collection
sequence; once before the interviewers began conducting interviews, and periodically
(approximately every tenth interview) throughout the second semester of data collection.
The first reliability test was based on the percent agreement of interviewers coding one

taped interview. That is, each interviewer received the same taped interview and coded it

47

according to training procedures. During the second semester, each interviewer coded
another classmate's taped interview. A systematic procedure was employed to ensure that
all possible pairs of interviewers were assessed. Twenty-one inter-rater reliability
estimates were calculated. They ranged from .91 to .97 (some low scores were due to
technical problems rather than “true” discrepancies among interviewers). In addition, a
group inter-rater reliability was computed as the mean of individual percent-agreement
estimates (~.94).

Interview protocol. Interviewers used the following protocol for collecting data:

1. The trained interviewer met the participant at a time and private location
that was convenient for the participant. The interviewer described the
interview process (two-parts - questionnaire and written), reminded the
participant that the interview was strictly confidential and informed her
that she had the right to decline any part of the interview without penalty.
Also, she was reminded that a participant identification number had been
substituted for any identifying information on the interview. This step was
taken to ensure confidentiality.

2. The interviewer asked the participant to sign a consent form (see
Participant Agreement F arm, Appendix D). The signed consent form
demonstrated that the participant understood her rights as a research
participant as well as the subject matter of the interview (both verbal and
written parts).

3. After the interviewer addressed all of the participant's questions or

concerns, she began the verbal section of the interview (see Women 's

48

Health Study Interview, Appendix E). This part of the interview took
anywhere from 60 minutes to 4.5 hours to complete (most were
approximately 90 minutes long).

Upon completion of the verbal section of the interview, the interviewer
reminded the participant about her rights as a research participant. Then,
she asked the participant to complete the written section of the interview
(see Women's Health Study Interview - Written, Appendix E).

When the written section of the interview was completed, the interviewer
separated the consent form and any other identifying information from the
two sections of the interview. Women were thanked for their time,
energy, and cooperation. They were paid a $30.00 remuneration fee for
their efforts, and then asked to sign a receipt of payment. The receipt
remained on file for record-keeping purposes, but kept separate from the
completed interview. Finally, all participants received a Women's Health
Project business card and a complimentary Guide to C ommunity
Resources (see Appendix F).

Unless the participants submitted a written request, no further efforts were
made to contact women who participated in the project. Some women
may request a copy of project results when available. To do so, they must

submit a written request to the Women's Health Study project director.

49

Measures

The purpose of the current study was to clarify the complex relationships between
abuse and women's health. Data was collected through face-to-face interviews using a
structured questionnaire. The interview consisted of two phases. During the first phase,
interviewers administered the oral section of the questionnaire. Upon participants'
completion of the oral section, they were asked to complete the written section of the
questionnaire. Combined, the questionnaire was designed to assess the following
constructs: abuse, injuries, stress, social support, income, physical health, and
psychological health. These constructs were assessed using pre-existing measures as well
as instruments created specifically for this research endeavor. A description of each
construct and associated measures are presented. In addition, established psychometric
properties of preexisting and developed measures are provided. The psychometric
properties of each scale are summarized in Table 3.

m

Three different types of abuse were measured: physical, psychological, and
sexual. Each type of abuse was measured with respect to its occurrence and frequency.
A description of each scale and scoring method is presented below.

Physical abuse. Physical abuse was conceptualized as any incident in which a
person is physically harmed by an intimate partner/ex-partner or spouse/ex-spouse. The
relationship was considered intimate if the participant indicated that the partner was at
least a boyfi'iend or girlfiiend. If a woman had been casually dating, and didn’t consider
the relationship intimate, she wasn’t probed about threats or occurrence of physical harm.

Experience of physical abuse was assessed by a modified version of Straus' (1979)

50

Conflict Tactics Scale (CTS). The modified version of the CTS contained 12 items (see
Appendix E, pg. 215). Women were asked to rate how often, in the past six months, their
assailant engaged in violent behaviors such as pushing and shoving, slapping, choking,
burning, and using a gun or knife against them. Women rated the frequency of their
experiences on a 6-point scale ranging from "Never" to "More than 4 times a week." One
item, “burned,” was dropped from the scale due to a low corrected item-total correlation
value (.28). The internal consistency of the remaining 11 items demonstrated high
reliability (or = .93). The corrected item-total correlations ranged from .55 to .84.
Participants’ scale scores were calculated as the mean frequency rate with which they had
experienced the physical abuse items.

Psychological abuse. Psychological abuse was conceptualized as any act with
which a person was emotionally hurt or harmed by an intimate partner/ex-partner or
spouse/ex-spouse. Again, the relationship was considered intimate if the woman stated
that the partner was at least a boyfiiend or girlfriend. Women's experience of
psychological abuse was measured with a shortened version of the 33-item Index of
Psychological Abuse (IPA) scale (Sullivan, Parisian & Davidson, 1990). The 2l-item
version of the IPA asked wOmen how often, in the past six months, they had been
harassed, controlled, ridiculed, and criticized by an intimate partner (see Appendix E, pg.
213). Using a 4 -point scale that ranged from "Never" to "Often," women rated how
often their partner “tried to humiliate you,” “tried to control your money," and "criticized

Your physical appearance or sexual attractiveness." Each participant’s scale score was

51

Table 3. Psychometric Properties of Instruments

 

 

Corrected
Number of Alpha Item-total

Instrument Items Coefficient Correlations
Abuse

Conflict Tactics Scale (CTS) 11 .93 .55 - .84

Index of Psychological Abuse (IPA) 19 .94 .49 - .82

Index of Sexual Abuse (ISA) ’ 4 .86 .70 - .77
Injuries

Injury Checklist (IC)’ 1 1 NA NA
Stress '

Difficult Life Circumstances (DLC)b 24 NA NA

Stressful Life Events (SLE)b V ‘ 50 NA NA
Physical Health

General Health Question (GHQ) 1 NA NA

Chronic Health Problems (CHP)‘-’ 8 NA . NA

Physical Health Symptoms (PHS) 30 .91 .35 - .69
Psychological Health

Center for Epidemiological Studies - 20 .93 .42 — .80

Depression (CES-D)

Quality of Life Scale (QLS) 9 .88 .41 - .78

Suicide Ideation Scale (SIS)c 2 NA .28
Income

Percent Poverty (INC) 1 NA NA
Social Support‘ '

Companionship (SSC) 2 NA .78

Advice and Information (SSA) 2 NA .76

Practical Assistance (SSP) 2 NA .91

Emotional Support (SSE) 2 NA .88

Financial Support (SSF) 2 NA .73

 

"unlikely that the occurrence of one type of injury would be related to another type of
Injury.

bunlikely that the occurrence of one type of stressful life circumstance/difficult life
situations/chronic health problem will be related to another. These are often unrelated or
isolated issues or life events.

“two items used to construct scale. . .therefore, the alpha coefficient is unstable. Only
uncorrected inter-item correlations are presented.

52

calculated as the mean frequency rate with which they experienced the different forms of
psychological abuse. Two items were dropped from the scale due to low corrected item-
total correlation estimates: “abused or threatened to abuse pets to hurt you” (.38) and
“punished or deprived the children when s/he was angry with you” (.40). The chronbach
alpha coefficient of the remaining 19 items was .94, with corrected item-total correlations
ranging fiom .49 to .82.

Sexual abuse. Sexual abuse was defined as any act or threat of sexual activity by
an intimate partner or ex-partner that was unwanted or forced (Swett, 1993; Winfield,
1990). The relationship was considered intimate if the participant considered the
assailant to be at least a boyfiiend or girlfriend. Four items were used to construct the
Sexual Abuse Scale (SAS). The first item was measured as part of the Index of
Psychological Abuse scale (i.e., shortened version of the IPA). Women were asked to
indicate how many times in the last six months an intimate partner or ex-partner “used
threats to try and have sex with. . .” her. They rated their experiences on a 4-point scale
ranging from “Never” to “Often.” The second item was measured as part of the physical
abuse scale (i.e., modified version of the CTS). Women were asked to rate, on a 6-point
scale, how often in the past six months an intimate partner or ex-partner “forced any
sexual activity (she) didn’t want to happen.” Responses ranged from “Never” to “More
than 4 times a week.” The remaining two items were taken from the written section of
the interview (see Appendix E, pg. 224). For the first question, women were asked,
“How often have any of your partner(s) ever used threats to try and have sex with you in
the past six months?” For the second question, women were asked, “How often have any

of your partner(s) used physical force to have sex with you in the past six months?” Both

53

questions asked women to rate their experiences on a S-point scale ranging from “Never”
to “more than 20 times (in the past six months)” Although the third and fourth items of
this scale repeated the first two questions, women completed these questions without the
verbal prompting of the interviewer. Some women may have felt more comfortable
responding to the written questions than the oral ones.

The four items were measured using different, yet comparable, scales. To
standardize the scoring system, the scales of the two items from the written section and
the one CTS item were converted into a 4-point scale (i.e., the IPA scale). Each
participant’s scale score was calculated as the mean frequency rate with which they
experienced all four items. The internal consistency was .86 with corrected item-total
correlations that ranged from .70 to .77.

b.1939}.

An ll-item Index of Injuries was used to assess the rate at which women
sustained injuries (Sullivan et al., 1992) during the past six months (see Appendix E, pg.
188). All participants were presented with a list'of items that ranged from minor injuries
such as cuts, scrapes, and bruises to more severe injuries such as knife or gunshot
wounds. They were asked to rate the frequency with which they had sustained these
injuries on a 6-point scale ranging from “Never” to “More than four times per week.”
There was little variability in the frequency with which women reported having sustained
injuries; more than half (53%) of the women indicated they had sustained injuries on
average less than once per month. Therefore, responses were dichotomized into “yes”

and “no” (O/l) codes. Individual scale scores were calculated as the total number of

54

injuries reported. Since one wouldn’t expect one type of injury to coincide with another,
estimates of internal consistency were not generated.

Stress

 

Stress was conceptualized as a response to circumstances or events in which the
situational demands exceed perceived resources (personal and environmental). Each
participant’s perceived stress level was measured by assessing their experiences with
various life circumstances and events. Two scales were used to measure participants'
experiences with difficult life circumstances and stressful life events. Descriptions of the
two separate scales are provided.

Difficult Life Circumstances. The Difficult Life Circumstances [DLC] scale
(Barnard, 1988) was used to measure participants' experiences with problematic
situations or circumstances. A 24-item scale, it asked women to indicate whether or not a
particular situation was problematic for them (see Appendix E, pg. 192). The scale
included items such as, "Have you been hospitalized in the past year for any reason,
accident or illness?", "Do you have problems with your credit rating?", and "Do you feel
that you do not have enough privacy?" Women's responses to the scale items were
dichotomously scored 0/], and the scale score was calculated as the sum of all items.

Stressful Life Events. The Life Event Checklist (Reischl, Eby, & Rarnanathan,
1992) was used to assess women's experiences of stressful life events (see Appendix E,
pg. 194). This 49-item checklist of events has several subscales related to intimate
relationships, school, work, family, finances, and legal issues. Participants were asked
whether or not an event took place, then to rate how stressful it was for them. Women

rated their perceived stressfulness of the event on a 5-point scale that ranged from “Not at

55

all stressful" to "Extremely stressful." Each participant's mean stress score was calculated
by summing their stressfulness ratings and dividing by the total number of stressors
endorsed. Internal consistency was not estimated for this scale. As noted by previous
researchers (e.g., Eby, 1996) one should not expect internal consistency among items,
since one stressful life event doesn't necessarily coincide with other stressful life events.
Physic_al Health Outcomes

The Physical Health Outcomes construct was operationalized as a comprehensive
assessment of women's physical health. Three measures were used to examine the
participants’ general health status, physical health symptomatology, and chronic health
problems. A description of the three measures is provided along with their psychometric
properties, where applicable.

General health status. Women's general health status was assessed by one item,
which asked women to rate their general health status on a four-point scale ranging from
“excellent” to “poor.” This item was adopted from the Michigan Lesbian Health Survey
(Bybee, 1990).

Physical health smptomatology. Women's physical health symptomatology was
measured using an adapted version of the Cohen-Hoberman Inventory of Physical
Symptoms (CHIPS, 1983). The modified version of CHIPS contained several symptoms
that fi'equently bother battered women (Campbell, 1989; Eby, 1996; Rodriguez, 1989).
The 35-item scale included symptoms such as sleep problems, muscle tension or
soreness, and pelvic pain (see Appendix E, pg. 186). Participants were asked to indicate

how often they experienced each of the symptoms during the past six months. They rated

56

their experiences on a 6-point scale ranging from “Never” to “More than four times a
week.”

Five items were deleted from the scale due to low corrected item-total correlations
(less than .3 5). The internal consistency of the remaining 30 items was .91 with corrected
item-total correlations ranging fiom .35 to .69. Each participant's score was calculated as
the mean frequency rate with which they experienced the 30 physical health symptoms.

Chronic health problems. An adapted version of a Michigan Lesbian Health
» Survey [MLHS] (Bybee, 1990) subscale was used to measure chronic health problems.
The original subscale of health problems contained a list of 55 items, and asked women
to indicate if they have ever had any of the health problems listed. Participants were
directed to check all the health problems they have ever had, even if they were no longer
experiencing them. The modified version of the subscale titled, Chronic Health Problems
(CI-IP) scale, contained a list of nine most commonly cited health problems (based on
MLHS data and abuse literature), including high blood pressure, arthritis, allergies,
diabetes, and repeated or long-term infections (see Appendix E, pg. 185). Participants
were asked two questions. First, they were asked if they have ever experienced any of the
health problems. Second, they were asked if they were experiencing the problem at the
time of the interview, or had they experienced it in the past only. Participants' responses
were coded on a 3-point scale (1 = Yes, now; 2 = Yes, in past only; 3 = No).

One would not necessarily expect one particular chronic health problem to
coincide with another (e. g.-, Cancer and arthritis), so it is unlikely that a list of chronic
health problems would show high internal consistency. Therefore, no items were

dropped from the scale and individual scores were dichotomously rated 0/] based on their

57

“Yes, Now” responses. Each participant’s scale score was then calculated as the sum of
all items.
Psychological Health

Psychological health was conceptualized as the extent to which women
experienced depression, suicidal thoughts and attempts, and satisfaction with the quality
of their lives. Three measures were used to assess each participant’s psychological
health. A description of each measure and their respective psychometric properties is
provided.

Depression. Depression was measured using the Center for Epidemiological
Studies - Depression Scale (CES-D) (Radloff, 1977). This 20-item scale is a self-report
checklist of psychological distress within the general population (see Appendix E, pg.
223). It assesses the extent to which a person experienced symptoms of depression
within the past week. Participants rated items such as, "I felt hopefirl about the future," "I
thought my life had been a failure," and "I felt that people dislike me" on a four-point
scale ranging from "Rarely or Never" to "Most or All the time". Four of the items were
reverse-scored to coincide with the rating pattern of the other 16 items.

Levels of depression were calculated as the summed rates on all 20 items. Using
the sum-total score, the following criteria were applied to determine each participant’s
depression level: scores 0-15.5 indicated no depression, scores 16.0 - 20.5 indicated mild
depression, scores 21 - 30.5 1 indicated moderate depression, and scores 31 and above
indicated severe depression (Radloff, 1977). Estimates of depression levels were used for
descriptive purposes only. The individual scale scores that were used in further analysis

were computed as the mean rate of all 20 items, and ranged from (1) to (4). The internal

58

consistency was or = .93, with corrected item-total correlations from .42 to .80.

Suicidal ideation. Participants' risk for suicide was assessed by the following two
items: "How often have you thought about ending your life in the past six months?" and
"Have you tried to end your life in the past six months?" Participants rated the frequency
with which they have thought about committing suicide on a 6-point scale (1 = "Never"
to 6 = "More than 4 times a week"). If a woman indicated that she never thought about
committing suicide in the past six months, she was not asked to answer the second
question (see Appendix E, pg. 191). Otherwise, both questions were posed.

Frequency data was collected for the frrst item and also for women who
responded affirmatively to the second question (i.e., “How many times?”). An ordinal
scale was created’to represent women who had not answered either question affirmatively
as well as those who answered the first, but not the second, and those who answered both.

Therefore, women’s responses to both questions were coded as follows: (0) no suicidal
thoughts or attempts, (I) suicidal thoughts, no attempts, (2) suicidal thoughts and at least
one attempt. Reliability estimates were not computed because the scale consisted of only
two items.

Mil! of life. Perceived quality of life was measured with a modified version of
Andrews and Withey's (1976) Quality of Life measure. The adapted version of the
original measure contained nine items. Participants were asked to rate, on a 7-point scale
(1 = "Extremely Pleased" to 7 = "Terrible"), how they currently felt about various aspects
of their lives (see Appendix E, pg. 182). Items included questions such as "How do you

feel about your personal safety?," "How do you feel about what you're accomplishing in

59

your life?," and "How do you feel about your emotional and psychological health"? The
internal consistency of this scale was .88 with corrected item-total correlations ranging
from .41 to .78. Individual scale scores were calculated as each participant’s mean
'feeling' rating.
Social Smrt

Social Support was conceptualized as perceived support from friends and family.
A modified version of Bogat, Chin, Sabbath, and Schwartz’s (1983) Social Support Scale
assessed perceived social support. The original scale contained 9 items, and measured
people's perceived quantity and quality of overall social support, as well as four specific
domains of support: companionship, advice and information, practical assistance, and
emotional support. The revised instrument contained the same basic domains plus one
additional domain, financial assistance (see Appendix E, pg. 183). This ll-item scale
asked participants to rate, on a 7-point scale ranging from "extremely pleased (1)" to
"terrible (7)," their feelings about the quality and quantity of social support they receive.
Internal consistency was calculated as equal to .91, with corrected item-total correlations
ranging from .54 to .77.

Although the reliability estimate and item-total correlations demonstrated that this
scale was internally consistent, moderate inter-dimension correlations (from .29 to .63)
also indicated that the items might represent distinct dimensions. Theoretically, it made
sense to consider that satisfaction with the quality and quantity of one type of support
(e. g., companionship) may be related but also distinct from one’s satisfaction with the
quality and quantity of another type of social support (e.g., financial assistance). The

moderate inter-dimension correlations provided some empirical support for separating the

60

dimensions. The efficacy of this direction was further assessed using confirmatory factor
analysis techniques (discussed in the Measurement Model section of the Results chapter).
Dividing the social support scale into five dimensions resulted in different scale scores;
each scale score was calculated as the mean satisfaction rating of the quality and quantity
of social support.

Income,

Income was operationalized as the extent to which adjusted annual household
incomes were below, at, or above poverty level (i.e., percent of poverty). Annual
household incomes were adjusted to account for the number of people supported by the
average income. Two questions were used to determine participant’s placement with
respect to poverty. First, women were asked to provide an estimate of their average
household monthly income before taxes were taken out. Second, they were asked to
indicate how many people that monthly income supported (see Appendix E, pg. 180).

The percent of poverty rates were calculated using a procedure based on the US.
Census Poverty Threshold Index (1996). First, each woman’s annual income was
computed by multiplying her monthly income by twelve. Then, each woman’s annual
income was divided by the appropriate poverty threshold (i.e., highest allowable income
considered at poverty level for the number of people supported by it) (U .S. Census
Bureau: Poverty Thresholds, 1996). Finally, to generate individual percent poverty rates,
each person’s poverty estimate was multiplied by 100. One hundred percent poverty
would mean that the person’s annual income was at the poverty level. Therefore, any
figure above 100% poverty means that a person’s income is above poverty, and any

figure below 100% poverty indicates that an individual’s annual income is below the

61

poverty line. To be eligible for most government assistance (e. g., Medicaid, Food
Stamps, Financial Aid) a person would need to demonstrate that their annual income was
at or below 125% poverty.
Analyses

Three research questions were investigated in the present study. The first goal
was to better understand the process by which abuse impacted women’s physical health.
Eby’s (1996) model of relationships among abuse, stress, psychological health, and
physical health was modified and tested. The second goal was to examine the extent to
which a woman’s income level (i.e., percent poverty) impacted the relationship between
abuse and physical health problems. The third goal was to examine the buffering effects
of social support on the relationship between women’s stress levels and their
psychological health. Both direct and indirect relationships were hypothesized to address
these goals. Several analytical procedures were employed to describe the sample,
examine the hypothesized relationships among variables, and test the overall fit of the
proposed model. A description of these analyses is provided in the Results section where

applicable.

62

CHAPTER 3

RESULTS

Descriptive Statistics

Descriptive statistics were generated for each of the scales assessing the latent
variables (i.e., abuse, stress, injuries, physical health, psychological health, social support,
and income). Scale means, standard deviations, and response ranges for each construct
are presented in Table 4. Additional descriptive information about the women’s
experiences is summarized below.
Abuse Experiences

Physical Abuse. Two hundred seven (52%) participants met the criteria for
inclusion into the “abuse” group. Typically, women reported between three and eight
different types of abuse (X = 5.52, SD= 2.97). Eighteen women (9%) endorsed one type
of physical abuse, and three (1%) women indicated their partners had used all twelve
forms of violence. Two women did not report being physically abused, but had been
sexually assaulted. As indicated in Table 5, a woman’s partner or ex-partner was most
likely to push, shove, or grab her (96%), throw something at her (61%), slap her with an
Open hand (57%), kick or punch her (56%), hit her or try to hit her with an object (5 5%),
choke her (54%) and/or beat her up (50%). Women were least likely to have been burned

(7%) by a partner or ex-partrrer. On average, the women’s partners or ex-partners

assaulted them two or three times a month.

Table 4. Summary of Scale Scores (N = 397)

 

 

Observed Variable Mean SD
Abuse
Physical Abuse (CTS) 0.45 .713
Range: 0 — 4.55 .
Psychological Abuse (IPA) 0.84 .738
Range: 0 - 2.74
' , Sexual Abuse (ISA) 0.28 .593
Range: 0 - 3.00
Injuries (1C) 2.93 1.66
Range: 0 - 10
Stress
Difl'rcult Life Circumstances (DLC) 6.41 3.46
Range: 0 -— 18 _ .
Stressful Life Events (SLE) 2.48 .775
range: 0 - 4.00
Physical Health
General Health Question8 (GHQ) 2.34 .839
range: 1 — 4.00
, Chronic Health Problems (CI-IF) 1.56 1.42
range: 0 — 6.00 . '
Physical'Health Symptoms (PHS) 1.27 .779
range: 0 - 3.93
Psychological Health
Depression (CES-D) 1.13 .683
range: 1 - 2.95
Quality of Life (QLS)" 4.57 1.03
range: 1.11- 7.00
Suicide Ideation (SIS) 0.52 .601
range: 0 — 2.00
Income (INC) 194 149
range: 0 — 795 (percent poverty)
Social Support
' Companionship (SSC)b 4.86 1.52
range: 1 - 7.00
Advice and Information (SSA)b 5.11 1.22
range: 1 - 7.00
Practical Assistance (SSP)b 5.15 1.59
range: 1 — 7.00
Emotional Support (SSE)b 5.06 1.56
range: 1 - 7.00
Financial Assistance (SSF)b 4.20 1.75
Range: 1 - 7.00

 

IIhigher score indicates less satisfaction
t’higher score indicates greater satisfaction

64

Table 5. Types of Physical and Sexual Abuse Experienced in Past Six Months (N = 207)

 

Type of Abuse N %

 

ths_i_cal Abuse
In the last six months, how often did he/ she:

Push, shove, or grab you 199 96
Throw something at you 242 61
Slap you with an open hand 1 18 57
Kick you or hit you with a fist 1 16 56
Hit you or try to hit you with an object 114 55
Choke you 1 12 54
Beat you up 104 50
Break your glasses or tear your clothing 87 42
Tie you up or physically restrain you in some way 83 40
Threaten you with a gun or knife 48 23
Use a gun or knife against you 25 12
Burn you - 14 7
Sexual Abuse‘;

How often in the past six months has he/she:

Used threats to try and have sex with you (O) ' 75 36
Used threats to try and have sex with you (W) 52 25
Forced any sexual activity you didn’t want to happen (0) 66 32
Used physical force to have sex with you (W) 48 23

 

Note: Frequency estimates are reported for only those women who had been physically
harmed within the six months prior to the interview (N = 207)

IEstimates are reported for women’s responses to questions in the oral (O) and written
(W) sections of the interview

65

Sexual Abuse. Of the 207 women who had been assaulted by a partner or ex-
partner in the six months prior to the interview, 66 (32%) had also been raped. Since few
women (5%) reported only one form or no physical abuse, nearly one in three women
was raped by her partner or ex-partner in addition to being physically assaulted in other
ways.

Psychological Abuse. All women who indicated that they were in an intimate
relationship (i.e., at least girl- or boy-friend type relationship; Q = 261) or who had been
in contact with an abusive ex-partner during the previous six months (13 = 83) were asked
the psychological abuse items. Of the 344 women questioned, only 23 (7%) endorsed
none of the items. On average, women reported at least nine different types of
psychological abuse (X = 9.12, SD = 5.79), and 10% of the women indicated that their
partner or ex-partner had used more than 16 different forms of emotional abuse. One
woman endorsed all 21 items. The most common types of emotional abuse reported are
delineated in Table 6.

As indicated in Table 6, more than half the women said that their partner or ex-
partner had ignored or made light of their anger (81%), criticized their fi'iends or family
(75%), tried to control their activities (69%), lied to them or deliberately misled them .
(69%), called them names (67%), accused them of having or wanting other sexual
relationships (58%), criticized them in public (52%), or discouraged their contact with

fiiends and family (51%) during the six months prior to the interview. An alarming

66

Table 6. Types of Psychological Abuse Experienced in Past Six Months (N = 344)

 

Type of Abuse N %

 

In the last six months, how often has he/she:

Ignored or made light of your anger 278 81
Criticized your friends or family to you 258 75
Tried to control your activities 237 69
Lied to you or deliberately misled you 237 69
Called you names 231 67
Accused you of having or wanting other sexual 186 58
relationships

Tried to control your money 186 54
Ridiculed or criticized you in public 179 52
Discouraged your contact with family or friends 175 51
Threatened to end relationship if you didn’t do what he/ she 145 42

wanted
Broken or destroyed something important to you 141 41
Harassed your family or friends in some way 110 32
Told you about other sexual relationships he/she wanted or 110 32
was having in order to hurt you

Tried to force you to leave your home 103 30
Drove recklessly so that you felt scared or in danger 103 30
Punished or deprived the children when angry with you 86 25
Threatened to take the children away from you 83 24
Left you somewhere with no way to get home 79 23
Threatened to commit suicide when angry with you 76 22
Threatened to hurt your family or friends 65 19
Abused or threatened to abuse pets to hurt you 48 14

 

67

number of women (22%) said that their partner or ex-partner had threatened to commit
suicide when angry with them. Clearly, many women had been emotionally tormented
by a partner or ex-partner even if they had not been physically assaulted.
.Iaju_ri_6§

All 397 women were asked to rate the frequency with which they sustained
injuries during the six months prior to the interview. Their responses are summarized in
Table 7. Overall, women sustained an average of three different types of injuries, ranging
from the more common cuts, scrapes, and bruises (92%) and soreness without bruises
(61%) to the less prevalent broken bones and fractures (11%) and gunshot or knife

wounds (3%). On average, women were injured once a month or less.

Table 7. Types of Injuries Sustained in the Past Six Months (N = 397)

 

 

Injury , N %
Cuts, scrapes, or bruises 365 92
Soreness without bruises 242 61
Strains or sprains 151 38
Burns, including rug burns 143 36
Permanent scarring 143 36
Broken bones or fractures 44 l 1
Dislocated joints 32 8
Loose or broken teeth I 32 8
Pregnancy complications/miscarriage 28 7
Internal injuries 20 5
Knife or gunshot wound 12 3

 

68

Stress

 

Difficult life circumstances. All 397 women were asked to identify daily hassles
(they had experienced during the six months prior to the interview. Their responses are
presented in Table 8. On average, women had experienced three to nine daily hassles
(Mean = 6.4, SD = 3.46), four women (1%) reported no hassles, 23 (6%) endorsed more
than half of the items, and no one said she had experienced all 24. The most commonly
cited daily hassles were long-term debts (73%), problems with credit rating (51%), lack
of privacy (41%), problems with a former spouse or partner (3 8%), and hospitalization
due to accident or illness (3 8%). Those reported least were problems with a landlord
(7%), being without a phone in present home (7%), and having a partner in jail (1%).

SLessful life events. Women had experienced an average of nine (SD = 4.68)
stressful life events during the six months prior to the interview. While no one endorsed
more than half of 50-item scale, 95% reported at least two items, and all but two of the
women said they had experienced at least one of the events. The frequency rates of
response for each stressful life event are presented in Table 9. The most common
stressful life events evolved around financial matters such as having less money than
usual (59%), relationship problems such as increased arguments with a spouse or partner
(49%), and legal issues such as being involved in a law suit or legal action (33%).
Twenty-nine percent of the women reported that they had been a victim of a violent crime
such as rape or assault. The least commonly cited stressful life events were experiencing

the death of a child or that of a partner (both were experienced by less than one percent of

69

Table 8. Occurrence Rates for Difficult Life Circumstances (N = 397)

 

 

Daily Hassle N %
Long-term debts 290 73
Problems with credit rating 203 51
Not enough privacy 163 41
Frequent illnesses 151 38
Problems with former spouse or partner 151 38
Partner away more than half the time b/c of j ob or other 147 37
reason
Work or school interferes w/family life 127 32
Hassled by bill collectors 123 31
Regular arguments with partner 123 31
Hospitalized for accident or illness 1 19 30
Substandard or unaffordable housing 1 11 28
Someone in household has a long-term illness 99 25
Looking for a job and have not been able to find one 95 24
Partner’s work or school interferes with family life 95 24
Children have learning problems or other school problems 95 24
Children have emotional problems 91 23
Problems with neighbors 79 2O
Partner has problem w/ alcohol or drugs 75 19
Have people living with you, you wish weren’t there 56 14
Someone other than partner abusive in some way 56 14
Someone in household other than you or partner have 56 14
problem w/alcohol or drugs

Problems with landlord 28

Without phone at present home 28

Partner in jail 4

 

7O

Table 9. Stressful Life Event: Rates of Occurrence (N = 397)

 

 

Stressful Life Event E %
In the last six months have you:
Less money than usual 234 59
Had increased arguments with your spouse or partner 195 49
Started a new job or had a major change 179 45
in a current job
Had trouble with a family member (not a spouse or partner) 175 44
Separated or ended a long-term committed relationship 139 35
Been involved in a law suit or other legal action 131 33
Been a victim of a violent crime such as rape or assault 115 29
Partner or spouse started a new job or had a big change in 1 l 1 28
current job
Had a serious illness or injuries happen to a family member 107 27
(not partner or child)
Had a serious argument with a friend or neighbor 107 27
Had trouble with partner’s family members 107 27
Taken on a major purchase 99 25
Had new troubles with boss or other people at work 99 25
Move to a new town or neighborhood 99 25
Had a serious illness or injury 95 24
Started classes at school 83 21
Been a victim of property damage or theft 83 21
Quit your job 79 20
Learned that your partner was unfaithful 72 18
Married or started a long-term committed relationship 72 18
Reconciled a marital or romantic relationship 72 18
Your partner been fired, laid off, or quit his/her job 68 17
Experienced the death of a close family member (not 64 16
partner or child)
Had any sexual difficulties 6O 15

 

71

Table 9 (cont’d).

 

 

Stressful Life Event _N_ %
In the last six months have you:

Been without a phone 60 15
Started a steady dating relationship 56 14
Ended a steady dating relationship 52 13
Had a new person move into your home 52 13
Stopped attending classes 52 13
Experienced the death of a close friend 48 12
Experienced the death of a pet 48 12
Had an affair 48 12
Had a serious illness or injury happen to a child 44 11
Had a serious illness or injury happen to a spouse or 44 11
3135956 receiving public assistance 44 1 1
Had your children taken away from you or been threatened 40 10

with having your children removed from your home

Been fired or laid off from your job 32 8
Had your utilities shut off 24 6
Had or adopted a child 20 5
Been released fiom jail 20 5
Been arrested or convicted of a serious crime 20 5
Started menopause 16 4
Had your driver’s license taken away by the police or court 16 4
Had a miscarriage or stillbirth 12 3
Received a jail sentence or probation 8 2
Retired ‘ 4 1
Experienced the death of a child 4 1
Had your spouse or partner retired 4 1
Learned you were unable to have children 4 1
Experienced the death of a spouse or partner 0 O

 

72

the sample). On average, women perceived the stressful life events as somewhat stressful
(Mean = 2.48, SD = .775).
Psychological Health

Three different dimensions of women’s psychological health were assessed:
depression, suicide ideation, and quality of life. All 397 women were asked to respond to
the questions posed by the interviewer in the oral section (e. g., quality of life and suicide
ideation items) and in the written section (e.g., depression items - CES-D).

Depression. Table 10 summarizes the number and percentage of women whose
scores indicated that they were either severely, moderately, mildly, or not depressed.
Sixty-three percent of the women were at least mildly depressed: 37% experienced no
depression, 14% mild depression, 19% moderate depression, and 30% severe depression.

Suicide ideation. Table 10 displays the frequency and percentage of women who
said they had thought about suicide as well as those who attempted suicide within the six
months prior to the interview. Less than half of the participants had ever thought about
committing suicide. Of those who had thought about it, 22 (6%) attempted to end their
lives at least once during the six months prior to the interview. Two women said that
they had attempted suicide more than 10 times. Their partners had assaulted both of
those women within the past six months.

Quality of life. Despite the high rate of depression and suicide ideation, women
were generally pleased with their quality of life. The mean score was 4.60 (SD = 1.08),
with nearly 60% of the sample rating their quality of life as better than “equally satisfied

and dissatisfied.”

73

Table 10. Rates of Depression and Suicide Ideation

 

 

Total
(N = 396)
n %

Depression Level

No depression . 147 37%

Mild 55 14%

Moderate 77 19%

Severe 117 30%
Suicide Ideation

No thoughts, No attempts 213 54%

Thoughts, No attempts 162 41%

Thoughts, Attempts 22 6%

 

Note: one participant did not complete the Depression Scale (CES-D).

Physical Health Outcomes

General Health status. One general health question was used to assess each
woman’s perception of her current health status. With respOnses ranging from poor
(10%) to excellent (14%), most women rated their current health status as either fair
(29%) or good (47%).

Chronic health problems. A summary of women’s responses to questions about
chronic health problems is presented in Table 11. Most women (72%) indicated that they
had at least one type of chronic health problem. Three women said they were dealing
with six problems, and no one reported more than six. The most common types of
chronic health problems endorsed were allergies (45%), extreme weight gain or loss (i.e.

more than 2-3lbs./week for 3 months) (25%), arthritis (20%), and long-term or recurring

74

infections (18%). The chronic health problems reported least were diabetes (p = 20; 5%)

and cancer (p = 4; 1%).

Table 11. Occurrence Rates of Chronic Health Problems (N = 397)

 

 

Chronic Health Problem E %
Allergies 179 45
Excessive Weight Gain or Loss 99 25
(2-3 lbs/week for 3 months)

Arthritis 79 20
Repeated or Long-term Infections 72 18
Eating Disorder 68 17
Heart or Circulation Problems 52 13
High Blood Pressure 44 1 1
Diabetes 20 5

Cancer 4 1

 

Physical health svmptoms. A summary of the types of symptoms women
reported is presented in Table 12. On average, women endorsed 16 different health
symptoms (X = 16, SD = 6.35) at least once a month or less (X = 1.27; SD = .78). One in
four women said that they were bothered by at least 2 1 of the symptoms on the checklist.

Most women reported symptoms indicative of pain and fatigue: feeling low in
energy (93%), sleep problems (88%), headaches (84%), muscle tension or soreness
(81%), back pain (80%), and fatigue (75%). Ulcers (11%) and rectal bleeding (13%)

were the symptoms cited least.

75

Table 12. Occurrence Rate of Physical Health Symptoms (N = 397)

 

 

Physical Health Symptom _N %
Feeling low in energy 369 93
Sleep problems 349 88
Headaches 334 84
Muscle tension or soreness 330 83
Back pain 322 81
Constant fatigue 298 75
Nightmares 266 67
Acid stomach or indigestion 262 66
Heart pounding or, racing 242 61
Diarrhea 234 59
Muscle cramps 230 58
Feeling weak all over 226 57
Stomach pain 222 56
Dizziness 214 54
Severe aches and pains 206 52
Migraine headaches 206 52
Poor appetite 203 51
' Nausea and/or vomiting 194 49
Numbness or tingling in parts of body 194 49
Hot or cold spells 187 47
Pelvic pain 175 44
Shortness of breath 171 43
Pains in your heart or chest 167 42
Ringing in your ears 159 40
Faintness 151 38
Blurred vision 143 36
Hands trembling 135 34

 

76

Table 12 (cont’d).

 

 

 

Physical Health Symptom E %
Painful intercourse 99 25
Choking sensations 64 16
Ulcers 44 11
Smptoms not in final scale:

*Constipation 203 5 1
*Vaginal bleeding or discharge 95 24

(other than your period)
*Bladder infections 75 19
*Painful urination . 72 18
*Rectal bleeding 52 13
Income

The median, standard deviation, and range of household incomes are presented in
Table 2 (Demographic Characteristics). The actual household monthly incomes ranged
from $0 to over $6,000. However, when accounting for family size, most w0men’s
incomes fell within the low and middle-income ranges. On average, women reported
household monthly incomes that were 194% (SD = 149) poverty level (See Table 12).
That is, women’s incomes were nearly twice the poverty line (94% above poverty).

Forty-three percent were within the low-income range (125% poverty level or
less), 19% were between low-income and middle income (up to 200% poverty level), and
37% were within the middle-income range (between 200 and 600%). The remaining two
percent were above the middle-income range (i.e., had incomes that were higher than five

times the poverty line).

77

Table 13. Frequency Distribution of Percent Poverty Rates (N = 397)

 

 

 

Percent Poverty (median = 194%) N %
0 — 125% 167 42%
126 - 200% 75 19%
201 - 600% 147 37%
> 600% 8 2%
Social Supmrt

Overall, women appeared mostly satisfied with the amount and quality of the
support they received from friends and family. Mean satisfaction scores ranged from
4.20 “equally satisfied and dissatisfied” to 5.15 “mostly satisfied.”

Correlations Among Observed Variables

As a preliminary assessment of the hypothesized relationships among the
observed variables (indicators), the direction, strength, and pattern of the uncorrected
correlation coefficients were examined. The uncorrected correlation matrix is presented
in Table 14. It should be noted that logarithmic transformations were performed on the
following variables to correct skewed distributions: physical abuse [CTS — (skew = 2.30;
kirtosis = 6.20)] and sexual abuse [ISA — (skew = 2.65; kirtosis = 7.16)]. The formula for
computing the transformations [LN(14; variable mean)] was based on the
recommendations of Wilkinson, Blank, and Gruber (1996), and substantially improved
the normal distribution of the scale scores; physical abuse [CTS — (skew = 1.32; kirtosis =
1.01] and sexual abuse [ISA — (skew = 1.93; kirtosis = 2.83]. For the most part, the
correlation coefficients indicated that the relationships among the observed variables

were in the expected direction and are of reasonable size.

78

 

 

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79

The pattern of relationships demonstrates convergent validity among the indicators for
abuse, physical health problems, psychological health, and social support, but was less
convincing for stress. For example, the correlation coefficient for difficult life situations
(DLS) and stressful life events (SLE) was lower than the coefficients for difficult life
situations and depression (CBS-D).
Bath Model of Hypothesized Relationships

Modeling Strategy

The path model of hypothesized relationships was tested using the two-step
modeling approach recommended by Shumacker and Lomax (1996). The first step
involved testing the proposed measurement model. Using structural equation modeling
techniques, a confirmatory factor analysis was conducted to assess the extent to which the
‘ observed variables (indicators) measured their respective constructs. This step allowed
for assessing both convergent and discriminant validity of the model. The second step
involved testing the structural model. After recommended modifications were applied to
the measurement model, structural equation modeling techniques were used to test the
hypothesized relationships among the latent constructs. Additional analyses were
conducted to assess the mediating effects of injuries, stress, and psychological health as
well as the moderating effects of income and social support.

The assessment of the measurement model will be described first to provide a
framework for presenting the structural model and additional analyses. The procedures
for testing the structural model, the mediating effects, and the moderating effects will be

presented along with their results for each research question.

80

 

Figure 2. Measurement Model

Measurement model

Using the AMOS version 3.6 (Arbuckle, 1997) Structural Fxruation Modeling
program, a confirmatory factor analysis of the latent constructs was performed to test the
measurement model of hypothesized relationships among the observed variables. The
relationships between the observed variables and their respective latent constructs are
presented in Figure 2. Note that all of the latent constructs were allowed to cova (i.e.,
double-headed arrows leading from each construct to all other constructs in the model).
This restriction was placed on the model so that the relationships among the observed
variables as well as the relationships between observed variables and the latent constructs
were estimated. The primary ellipses represent the latent constructs, the rectangles
represent the observed variables, and the small circular shapes represent error terms (i.e.,
unique variance) associated with each observed variable. To help ensure model
identification (see Amos User ’5 Guide, Version 3. 6), one of the observed variables for
each latent construct was constrained (i.e, set to unity; “1”). The most empirically
reliable observed variable for each construct was selected.

Three criteria were used to evaluate the results of the CFA: 1) overall fit of each
measurement model using Goodness of Fit Statistics [chi-square (x2 ), goodness of fit
index (GFI), adjusted goodness of fit (AGFI), normed fit index (NF 1), comparative fit
index (CF I), Tuck—Lewis Index (TF1) and the root mean-square error of approximation
(RMSEA)], 2) degree to which the sample covariances (observed relationships among
indicators) differed from the implied covariances (standardized residual covariance

estimates greater than _+_ 1.96 indicated that the differences were significant), and 3)

82

statistically significant factor loadings for each indicator on its respective latent construct
(critical ratio values less than 11.96 indicated that the factor loadings were not
significant).

Although the xz was not expected to be significant, the large sample size and
model complexity (degrees of freedom) may have increased the likelihood of detecting
significant differences between the implied variance/covariance matrix and the observed
matrix. Therefore, determination of model fit was based on a comprehensive assessment
of the other fit indices. Good model fit was achieved when the values of these fit indices
exceeded .90(GFI), .80(AGFI), .90(NFI), .90(CFI), .90 (TLI) and when the value for
RMSEA was less than .05. Modifications to the measurement model were guided by the
standardized residual covariances. Values greater than i 1.96 indicated that there was a
significant relationship between the unique variance of two indicators representing
different constructs. Hence, the indicator lacked discriminate validity when compared
with indicators of a different construct. Indicators that consistently shared unique
variance with dissimilar indicators were considered problematic and dropped from the
model.

Assessment of measurement model. At first glance, the proposed measurement
model did appear to provide an adequate fit to the data. While the chi-square statistic
suggested poor fit ()8 = 260, df (116), p <.05), the other goodness of fit indices yielded
more favorable results; the GF I (.93), AGFI (.90), CFI (.95), and TLI (.94) were at or

above the accepted value .90, and the RMSEA (.06) was slightly above the acceptable

83

range .05. Despite these findings, the modification indices and standardized residual
coefficients provided support for some modifications to the measurement model. .
Several observed variables had standardized residual covariance estimates greater
than +1.96. This meant that the unique variance (i.e., the variance not shared by the other
observed variables of the same construct) associated with the observed variables could be
shared by indicators of a different construct. Hence, these observed variables’
discriminate validity could not be assumed. The variables with standardized residual
covariance estimates greater than + 1.96 included: (1) the relationship between financial
support (SSF) and physical health symptoms (PHS), stressful life events (SLE), and
psychological abuse (IPA) (significant difference values were -2.148, 2.776, and -2.l85,
respectively); (2) the relationship between chronic health symptoms (CHP) and emotional
support (SSE), practical assistance (SSA), and sexual abuse (ISA) (significant difference
values of 3.039, 2.582, and -2.428, respectively); and (3) the relationship between quality
of life (QLS) and companionship (SSC) revealed a significant difference value of -2.644.
Based on the concerns noted above and the lack of a strong theoretical argument
.for creating additional latent constructs, three key modifications were performed: (1) the
scale for financial social support (SSF) was dropped from the model, (2) the measure for
chronic health problems (CHP) was dropped, and (3) the scale for companion social
support (SSC) was dropped. Each modification was conducted independently, and after
each modification, the model was again assessed for fit. The results of these
modifications are presented in Table 15. Corresponding standardized residual covariance

matrices are provided in Appendix G.

84

Table 15. Maximum-Likelihood (ML) Estimates for Measurement Models 1, 2, 3 and 4

 

 

Estimates Model 1 Model 2 Model 3 Model 4
Abuse
CTS loading .87 .87 .87 .87
IPA loading .91 .91 .91 .91
ISA loading .67 .67 .67 .67
CTS error .035 .035 .035 ' .035
IPA error .103 .103 .103 .103
ISA error .062 .062 .062 .062
Stress
DLC loading .74 .74 .74 .74
SLE loading .52 .52 .52 .52
DLC error 5.43 5.41 5.42 5.44
SLE error .455 .456 .455 .455
Injuries NA NA NA NA
Psychological Health
CESD loading .84 .84 .84 .85
SIS loading .52 .52 .52 .52
QLS loading .83 .83 .83 .82
CESD error .133 .134 .135 .132
SIS error .264 .264 .264 .263
QLS error .370 .367 .367 .375
Physical Health
GHQ loading .69 .69 .70 .70
CHP loading .58 .58 NA NA
PHS loading .90 .90 .87 .87
GHQ error .369 .369 .362 .362
CHP error 1.34 1.34 NA NA
PHS error .113 .113 .144 .143
Social Support
SSC loading .63 .66 .66 NA
SSA loading .65 .65 .65 .65
SSP loading .78 .74 .74 .75
SSE loading .80 .83 .83 .84
SSF loading .62 NA NA NA

 

85

Table 15(cont’d).

 

 

Estimates Model 1 Model 2 Model 3 Model 4
SSC error 1.38 1.31 1.31 NA
SSA error .856 .857 .856 .858
SSP error 1.01 1.14 1.13 1.11
SSE error .863 .763 .764 .714
SSF error 1.89 NA NA NA

Income NA NA NA NA

Goodness of fit indices

x2 = 259.88 196.88 167.50 139.71
d f = 116 100 85 71
p = 0 O O 0
GFI = .93 .95 .95 .96
AGFI = .90 .92 .92 .93
NFI = .92 .94 .94 .95
CFI = .95 .97 .97 .97
TLI = .94 .96 .96 .96
RMSEA =' .06 .05 .05 .05

 

 

86

Table 16. Final Measurement Model: Indicators and Their Factor Loadings (N = 397)

 

 

Standardized
Measurement
Latent Construct Observed Variables (Indicators) Coefficient
(Factor Loading)
Abuse
Physical Abuse (CTS)‘ .87
Psychological Abuse (IPA) .91
Sexual Abuse (ISA)’ .67
Injuries
Injury Checklist (IC) NA
Stress
Difficult Life Circumstances (DLC) .74
Stressful Life Events (SLE) .52
Psychological Health
Depression (CES-D) .85
- Quality of Life (QLS)b .82
Suicide Ideation (SIS) .52
Physical Health ' ’ ‘
General Health Question (GHQ) .70
. Physical Health Symptoms (PHS) _ .87
Social Support
Advice and Information (SSA) ' .65
Practical Assistance (SSP) .75
Emotional Support (SSE) .84
Income
Percent Poverty (INC) NA

 

‘ To correct positive skew, a log transformation was applied to the physical and sexual
abuse measures.

bItems were reverse-scored so that a high scale score indicated high dissatisfaction with
quality of life. -

87

As noted in Table 15, the first modification — to drop the scale for financial
support (SSF) — improved model fit: )8 = 197, df (100), p= .000; GFI = .95, AGFI = .92,
CFI = .97, TLI = .96, RMSEA = .05. However, significant differences still remained
with respect to the standardized residual covariance estimates for the covariance estimates
of chronic health problems and companion social support. The second and third
modifications - to drop the measure for chronic health problems (CHP) and to drop the
scale for companionship social support (SSC), respectively — yielded similar results; both
modifications improved model fit and produced significant chi-square change effects. As
indicated in Table 15, the final modified measurement model demonstrated good fit to the
data [x2 = 140, df (71), p= .000; GFI = .96, AGFI = .93, CFI = .97, TLI = .96, RMSEA =
.05]. Table 16 presents the latent constructs, the indicators, and their corresponding
factor loadings for the final measurement model.

Testing Hymthesized Relationships

After appropriate modifications were made to the measurement model, the
proposed path model was tested using AMOS’s (Arbuckle, 1997) Structural Equation
Modeling techniques. Testing the structural model assessed the extent to which the
hypothesized relationships among latent constructs 'fit' the data (i.e. the
variance/covariance matrix implied by the model compared to the observed
variance/covariance matrix).

Two criteria were used to evaluate the proposed model and its hypothesized
relationships. First, several Goodness of Fit Statistics [chi-square (x2 ), goodness of fit

index (GFI), adjusted goodness of fit (AGFI), normed fit index (NFI), Tucker-Lewisindex

88

 

(TF1), and RMSEA] were examined to determine how well the proposed model 'fit' the
data. The x2 was expected to be nonsignificant, and the values of the other fit indices
were expected to exceed .90, .80, .90, .90 and not to exceed .05, respectively. Second,
statistically significant factor loadings for each indicator on its respective latent construct
were examined to identify potential modifications to the model (critical ratio values less
than 11.96 indicated that the factor loadings were not significant). Standardized residual
covariance values were examined as well. Values that exceeded :196 indicated potential
modifications to the relationships among indicators of different constructs.

Testing of Mediating Effects

The proposed path model hypothesized several mediating relationships among the
latent constructs. First, number of injuries reported was hypothesized to partially mediate
the relationship between abuse and physical health problems. Second, level of stress was
hypothesized to partially mediate the relationship between abuse and pSychological
health. Finally, psychological health was hypothesized to partially mediate the
relationship between stress and physical health problems.

The mediating effects were tested using structural equation modeling techniques
recommended by Browne (1997). While mediation is typically assessed by employing a
sequence of independent regression equations, Browne (1997) noted two advantages to
using SEM. First, SEM allows investigators to account for measurement error in the
mediating variable. Second, SEM allows for the modeling of nonrecursive structures

(i.e., the possibility that the endogenous variable causes the mediator). A third advantage

89

to using SEM is that it simplifies the process of testing mediators when the model
contains multiple indicators.

The process for testing mediating effects using SEM is the same as that used to
construct a series of regression models. Baron and Kenny (1986) suggest that the process
involve four major steps: I) verify the significant relationship between the independent
variables and the dependent variables, excluding the proposed mediator, 2) verify the
significant relationship between the independent variables and respective mediators,

3) verify the significant relationship between the mediators and the dependent variables,
and 4) verify a significant reduction in the direct relationship between the independent
variable and the dependent variable in the presence of the mediating variable.

Each of the mediating effects was tested separately. The first three conditions
were verified by setting all path parameters, except the paths linking the individual
constructs of interest, to zero. The fourth condition was verified by comparing the size of
the standardized path coefficient estimated in the first step with the size of the path
coefficient after including the mediating variable. A significant reduction in the direct
relationship between the exogenous and endogenous variables indicated a mediating
effect.

Testing of Moderating Effects

The proposed path model hypothesized two moderating as well as direct
relationships among the latent constructs. The moderating effects were tested using two
separate hierarchical multiple-regression analyses. First, the moderating effect of income
on the relationship between stress and psychological health was tested. In this analysis

psychological health was regressed onto stress (i.e., dfficult life circumstances and

90

stressful life events) and income (i.e., percent poverty) as well as two product terms:
difficult life circumstances x income, stressful life events x income. The first block of the
hierarchical multiple regression equation contained each of the main effect variables, and
the product terms comprised the third block.

In the second analysis, the moderating effect of social support on the relationship
between stress and psychological health was tested. In this analysis psychological health
was regressed onto stress and social support as well as two product terms: difficult life
circumstances x social support and stressful life events x social support. The first block
of the hierarchical multiple regression equation contained each of the main effect
variables and the product terms comprised the third block.

Prior to computing the product terms, the scores of the main effect variables were
centered (i.e., the mean score of each measure was subtracted from individual scale
scores). This step was taken to reduce multicollinearity problems among the independent
variables and their product terms and to improve the interpretability of the coefficients.
Assessment of the Structural Model

The structural model of the hypothesized relationships with corresponding path
coefficients is presented in Figure 3 (note that the moderator effects were assessed
separately, using hierarchical multiple regression techniques). The model tested was
based on the modified version of the measurement model, and estimated using AMOS’s
(Arbuckle, 1997) Structural Equation Modeling program. When tested, the structural
model demonstrated acceptable fit to the observed data (variance/covariance matrix), and

accounted for a large portion of the variance in physical health problems (R2 = .71) (see

91

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Table 17. Standardized Estimates for Structural Model

 

 

 

Model Estimates

Parameter (hypothesis) R2 [3
Physical Health .71

Injuries — physical health (1b) .25*

Psychological health — physical health (1 f) .71*

Income - physical health (2b) -.04
Psychological Health ' I .83

Stress — psychological health (1e) .91*
Stress ' i I .52

Abuse — stress (1d) .66*

Income — stfess (2a) -.13*

Injuries ‘ . .25
Abuse - injuries (1 a)

.50*

 

Goodness of fit indices:
)6 = 116.04
(1 f = 48
p = . 0.00
GF I = .96
AGF I = .93
NFI = .95
CFI = .97
TLI = .96
RMSEA = .06
Potential Modification:
Add parameter (Income - abuse), r = -.39*
*p<.05

93

Table 17). The significant chi-square value [x2 = 116, df (48), p= .000] suggested poor fit,
but this finding was contradicted by other goodness of fit indices that are less influenced
by sample size and model complexity. For example, RMSEA (.06), GFI (.96), AGFI
(.93), CFI (.97), and TLI(.96) were well within acceptable range. Furthermore, almost all
of the standardized residual covariance coefficients were less than 1: 1.96. The standard
residual covariance estimate for the relationship between injuries and suicide ideation
(2.47) was significant, which indicated that these two variables shared a common element
not accounted for by the other indicators of their respective constructs. The theoretical
implication of this association and potential for model modification is presented in the
Discussion Chapter.
To Whpt Extent Does Intimate P4artner’s Violence Affect Women’s Physical Hepl_t_h__?

Abuse and injuries. As indicated in Table 17, abuse constituted a small portion of
the variance in injuries (R2 = .25). The moderate size of the path coefficient ([3 = .50) was
positive and significant. This indicates that although injuries may be predicted by other
factors, high levels of abuse do have a positive and significant impact on the number of
injuries women sustain; women with higher levels of abuse reported more injuries than
did women with lower levels of abuse.

Injuries and physical health problems. The hypothesized relationship between
injuries and physical health problems was significant ([3 = .45). The positive sign
indicated that women who reported more injuries had higher rates of physical health

problems than did women who reported fewer injuries.

94

Mediating effect of injuries. Four sequential steps were completed to test the
mediating effect of injuries on the relationship between abuse and physical health
problems (as recommended by Baron & Kenny, 1986 and Browne, 1997). Structural
equation modeling techniques were used to conduct the analyses. Throughout the first
three steps, all other path parameters in the model were set to zero except for those of
interest (i.e., the direct path linking abuse to physical health, the path between abuse and
injuries, the path between injuries and physical health, respectively). The mediating
relationship was tested in the fourth step by setting all other path parameters in the model
to zero except for the following: 1) the direct path between abuse and physical health, 2)
the direct path between abuse and injuries, and 3) the path linking injuries and health.

The results of the four steps are summarized in Table 18. The three preliminary
conditions for a mediating relationship were confirmed. Significant direct relationships
between abuse and physical health (B = .57, p<.05), abuse and physical injuries (B = .49,
p<.05), and injuries and physical health (B = .49, p<.05) were verified. When the direct
relationship between abuse and physical health was tested in the presence of Injuries, the
magnitude of the relationship between abuse and physical health problems decreased (B =
.38, p<.05). While the direct relationship between abuse and physical health remained
significant even when accounting for the effect of injuries, the reduction indicates that
injuries partially mediate the relationship. This finding suggests that the injmies explain
only part of the connection between intimate partner violence and poor physical health.

Injuries, alone, cannot account for battered women’s high rate of physical health

95

 

Table 18. Mediating Effect of Injuries on Abuse and Physical Health

 

 

Significance
Relationships B SE. B T of t
Direct Effects:
Abuse - Physical Health .57 .1 16 4.94 p<.05
Abuse - Injuries .49 .244 2.00 p<.05
Injuries — Physical Health .49 .021 23.14 p<.05
Indirect Effect of Injuries: '
Abuse — Physical Health .38 .121 3.12 p<.05

 

 

problems. Since the model contained alternate explanations for the effects of abuse on
women’s physical health, this finding was not surprising.

Abuse and stress. A moderate portion of variance in stress (R2 = .521) was
explained by the proposed model. The path coefficient from abuse to stress was
significant and positive (B = .66), indicating that as abuse increases, experiences of stress
increase as well. Therefore, abuse has a significant impact on women’s experiences of
difficult life situations and stressful life experiences.

Stress and psychological health. Slightly more than 80% of the variance in
psychological health (R2 ‘= .83) was explained by the proposed model. The path between
stress and psychological health was large and significant (B = .91). The strong positive
relationship indicated that women who reported high stress levels were more likely to
report high levels of depression, dissatisfaction with quality of life, and suicide ideation

than were women who reported low stress levels.

96

Mediating effect of stress. Similar procedures were used to test the mediating
effect of stress as those used to test the mediating effect of injuries. Throughout the first
three steps, all other path parameters in the model were set to zero except for those of
interest (i.e., the direct path linking abuse to psychological health, the path between abuse
and stress, the path between stress and psychological health, and the mediating
relationship linking abuse and stress and psychological health, respectively). The
mediating relationship was tested in the fourth step by setting all other path parameters in
the model to zero except for the following: I) the direct path between abuse and
psychological health, 2) the direct path between abuse and stress, and 3) the direct path
linking stress and psychological health.

The three preliminary conditions for a mediating relationship were confirmed.
Significant direct relationships between abuse and psychological health (B = .64, p<.05),
abuse and stress (B = .72, p<.05), and stress and psychological health (B = .90, p<.05)
were verified. When the direct relationship between abuse and psychological health was
tested in the presence of stress, the magnitude of the relationship between abuse and
psychological health decreased (B = .10, p>.05). This finding demonstrates that stress has
a strong mediating effect on the relationship between abuse and psychological health.
Although the direct relationship between abuse and psychological health did not reduce to
zero in the presence of stress, it was no longer significant. These findings suggest that
women’s stress levels account for most of the effects of abuse on women’s psychological

health.

97

Table 19. Mediating Effect of Stress on Abuse and Psychological Health

 

 

Significance
Relationships B SE. B t of t
Direct Effects:
Abuse — Psychological Health .64 .097 6.62 p<.05
Abuse - Stress .72 .106 6.78 p<.05
Stress — Psychological Health .90 .1 14 6.24 p<.05
Indirect Effect of Stress:
k Abuse — Psychological Health .10 .214 .444 p>.05

 

Psychological health and physical health problems. The relationship between

psychological health (i.e., depression and suicide ideation) and physical health problems
was large and significant (B = .71). As women’s levels of depression and suicide ideation
increased and quality of life decreased, their reports of physical health problems
increased.

WM. Structural equation modeling
techniques were used to test the hypothesis that psychological health mediates the
relationship between stress and physical health. Similar procedures were used to test the
medifiting effect of psychological health as those used to test the mediating effect of
injuries and stress. As noted in Table 20, significant direct relationships between stress

and Physical health (B = .86, p<.05), stress and psychological health (B = .92, p<.05), and
psychological health and physical health (B = .85, p<.05) were verified. When the direct
relationship between stress and physical health was tested in the presence of

psychological health, the magnitude of the relationship between stress and physical health

98

Table 20. Mediating Effect of Psychological Health on Stress and Physical Health

 

 

Significance
Relationships B SE. B t of t
Direct Effects:
Stress - Physical Health .86 .173 4.96 p<.05
Stress - Psychological Health .92 .154 5.99 p<.05
Psychological — Physical .85 .065 13.05 p<.05
Health
Indirect Effect of Psychological
Health:
Stress — Physical Health .64 .473 1.35 p<.05

 

decreased (B = .64, p<.05), but remained significant. While the direct relationship
between stress and physical health remained significant even when accounting for the
effect of psychological health, the reduction indicates that psychological health partially
mediates the relationship. This finding suggests that a battered woman’s level of

depression, suicide ideation, and dissatisfaction with her quality of life explain only some

of what she experiences physically.

To What Extent Does Women’s Income lm act the Relationship Between Abuse and
Ph sical Health?

w. The path coefficient from income to stress was significant and

 

negative (B = -.13). The small negative effect indicates that there is a weak association
bet""3811 income and stress, indicating that women with higher incomes report less stress

than do women with lower incomes. The small beta weight suggests that even though

income has a significant impact on women’s stress levels, the effect on stress is not as

large as what can be explained by other factors, especially levels of abuse.

99

 

Income and physical health problems. The hypothesized path between income

and physical health problems (B = -.04) was not significant. Therefore, it does not appear

as though income was a significant predictor of physical health problems.

Moderating effect of income on the relationship between stress alndgrsvchologipfl

health. The moderating effect of income was tested using a series of hierarchical multiple

 

regression analyses. Psychological health (depression, suicide ideation, and quality of
life) was regressedonto three independent variables (difficult life circumstances, stressful
life events, and income) and two product terms (difficult life circumstances x income and
stressful life events x income) in six separate analyses. The first block of each regression
equation contained one of the main effect variables: (a) stressful life events, (b) difficult
life circumstances, and (c) income (percent poverty). The product terms comprised the
second block of each equation: stressful life events x income and difficult life
circutnstances x income. 1' Prior to computing the product terms, the scores of the main
effect variables were centered (i.e., the mean score of each measure was subtracted from
individual scale scores).

To plot the moderating effects, simple regression lines were calculated based on

recommendations by Aiken and West (1991) and Cohen and Cohen (1983). Only

Significant moderating effects were plotted. First, because income was a continuous

variable, three levels (high, medium, and low) of the centered income score were

prodlmed by setting the cut-off points as one standard deviation above the mean (high;
148.86), the mean (medium; 0), and one standard deviation below the mean (low; -

Mr886). Second, three separate equations were generated to represent the regression of

100

 

the dependent variable (i.e., depression, suicide ideation, and dissatisfaction with quality
of life) on the independent variable (i.e., difficult life circumstances and stressful life
events) at each income level. Finally, the restructured regression equations were used to
compute the predicted dependent variable scores for each level of income. Three separate
regression lines were then generated and plotted.

Stress and depression. Two separate analyses were conducted to test the
moderating effect of income on the relationship between stress and depression. As
indicated in Table 21, the hierarchical multiple regression analyses yielded conflicting
results. While significant interaction effects of income were found for the relationship

between stressfirl life events and depression, the interaction of income and difficult life
circumstances was not significant.

The income x stressful life events product term resulted in a small yet significant

R2 Change when entered into the second block of the equation (R2 = .20) [AF (3, 393) =
6.80, p <.05; Achhange = .014]. Figure 4 depicts the interaction effect of income on the
relationship between stressful life events and depression. As demonstrated in Figure 4,
the PIOtted regression lines indicate that at higher levels of stress the relationship between
Stressful life events and depression is stronger for women with lower incomes than for
Women with higher incomes. These findings suggest while income may have little
impaCt on the relationship between the number of daily hassles women experience and

their level of depression, it does appear to buffer the effect of stressful life events on

depression.

101

Table 21. Moderating Effect of Income on Stress and Depression

 

Depression Scores
Sign.

Variables r B t of t

Difficult Life Circumstances

Block 1: Centered Variables

F = 89.56, p < .0001

R2 = .313

Income (centered) -.29*** -.1 34 -3.04 <.05
Difficult life circumstances (centered) .54*** .503 11.45 <.05
Intercept (constant) 39.87 <.05

Block 2: Interaction Term

F = 59.57, p < .0001

R2 = .313

R2 change = .000, p = .875

Income x Difficult life circumstances -.002 -.007 -. 157 .87 5

Stressful Life Events

BIOCk 1 : Centered Variables
F = 46.24, p < .0001
R2 = . 1 91
Income (centered) -.29*** -.219 -4.73 <.05
StreSSful life events(centered) .38*** .334 7.21 <.05
Intercept (constant) 36.75 <.05

Block 2: Interaction Term
F f 33.67, p < .0001
R2 = -204
R change = .014, p = .009
me x Stressful life events -.01 -.121 -2.61 <.05
. StaIldardized regression coefficients are reported for the step in which they were entered
““0 the model.
** p < .001.

102

 

 

 

 

 

2.0 A
A
A
A
1.8-
1.61
2
o
:2
A 1.4-1
C?
a)
LL]
8 1.21
c:
.2
a3}
a 1.0-
D
E Income Levels
g .8I o
o A low (-148.86)
'6'0 ° medium-O
.4 0 high-(148.86)
-2 -1 0 1 2

Stressful Life Events (centered)

Figure 4. Regression Lines Indicating Moderating Effect of Income on Stressful Life
Events and Depression

103

Table 22. Moderating Effect of Income on Stress and Suicide Ideation

 

Variables

Difficult Life Circumstances

Block 1: Centered Variables
F = 25.31, p < .0001
R2 = .114
Income (centered)
Difficult life circumstances (centered)
Intercept (constant)

Block 2: Interaction Term
F = 17.63, p < .0001
R2 = .119
R2 change = .005, p = .147
Income x Difficult life circumstances

Stressful Life Events

Block 1: Centered Variables
F = 18.66, p < .0001
R2 = .087
Income (centered)
Stressful life events(centered)
Intercept (constant)

Block 2: Interaction Term
F = 12.47, p < .0001
2 = .087
R2 change = .000, p = .673

Suicide Ideation Scores

 

_.22***

.31***

-.O44

a22***
.24***

.055

[3

-.l31
.273

-.074

-.173
.205

-.021

t

-2.62
5.47
18.22

-1 .46

-3.50

' 4.16

17.95

-.422

Sign.
of t

<.05
<.05
<.05

.147

<.05
<.05
<.05

.673

£come x Stressful life events
3. Standardized regression coefficients are reported for the step in which they were entered
1“to the model.

** * p < .001.

104

Table 23. Moderating Effect of Income on Stress and Quality of Life

 

Variables

Difficult Life Circumstances

Block 1: Centered Variables
F = 92.57, p < .0001
R2 = .320
Income (centered)
Difficult life circumstances (centered)
Intercept (constant)

Block 2: Interaction Term
F = 63.52, p < .0001
R2 = .327
R2 change = .007, p = .045
Income x Difflcult life circumstances

Stressful Life Events

Block 1: Centered Variables
F = 46.79, p < .0001
R2 = .192
Income (centered)
Stressful life events(centered)
Intercept (constant)

Block 2: Interaction Term
F = 40.60, p < .0001
R2 = .237
R2 change = .045, p < .0001
$1come x Stressful life events

a Standardized regression coefficients are reported for the step in which they were entered

into the model.
*"' * p < .001.

Quality of Life Scores

 

a27***
.56***

-.085

‘27***

.40***

-.10

105

-.102
.525

-.O89

-.l91
.356

-.219

T

-2.34
12.01
76.12

-2.01

-4.11
7.70
70.39

-4.80

Sign.
of t

<.05
<.05
<.05

<.05

<.05
<.05
<.05

<.05

 

 

 

 

 

5.0
6
4.5- £
9
A 0
8 6 °
15 4.01 A 0
a A. /
t2
:1
E. 3.5. 00
r: 0
6
O
2 o :o’
2.5- °
0
2.0 . . '
-2 -1 0 1

‘ Stressful Life Events (centered)

2

Income Levels
A low (-l48.86)
0 medium - 0

0 high - (148.86)

Figure 5. Regression Lines Indicating Moderating Effect of Income on Stressfill Life
Events and Quality of Life (Note: higher score equals greater dissatisfaction)

106

 

 

 

 

5.‘
A
A o
5.0-1 A o
A o
’45- A °° o
o ' 0°
5 A00
:53 00
552 4.0' A00
5 90°
2. ..
:3 3.5‘ AGO
6 5000
a A°°°
g 30 .oo°
00°
300
000
2.5' 860
2.0 I I I t I
-15 -10 -5 0 5 10

Difficult Life Circumstances (centered)

15

Income Levels
A low (-148.86)
0 medium - O

9 high - (148.86)

Figure 6. Regression Lines Indicating Moderating Effect of Income on Difficult Life
Circumstances and Quality of Life (Note: higher score equals greater
dissatisfaction)

107

Stress pnd suicide ideation. Two separate analyses were conducted to test the
moderating effect of income on the relationship between stress and suicide ideation. As
indicated in Table 22, the hierarchical multiple regression analyses indicated that
women’s income levels did not moderate the relationships between their stress levels and
their levels of suicide ideation. Neither the product term of stressful life events and
income nor the product term of difficult life circumstances and income resulted in
significant R2 change.

Stress and gualig of life. Two separate analyses were conducted to test the

moderating effect of income on the relationship between stress and quality of life. The
results of the hierarchical multiple regression analyses are presented in Table 23 and
indicate that while income may moderate the relationship between stressful life events
and quality of life (R2: .24) [AF (1, 393) = 23.00, p<.05; Achhange = .045], the
moderating effect of income on the relationship between difficult life circumstances and
quality of life is less clear (R2 = .33) [Ali (1, 393) = 4.05, p <.05; Achhange = .007]. The
interaction effect of income on stressful life events and quality of life is displayed in
Figure 5. The pattern of regression lines indicates that at higher levels of stress, the
relationship between stressful life events and dissatisfaction with quality of life was
Stronger for women with lower-incomes than it was for women with higher incomes. The
distinction between the low-income and the higher income groups was more pronounced

When women reported high levels of stressful life events than when low levels of stressful

life events were reported.

108

A similar, but less distinct, pattern emerged when the regression lines were

plotted to present the moderating effect of income on the relationship between difficult
life circumstances and dissatisfaction with quality of life (see Figure 6). Figure 6
demonstrates that the effect of difficult life circumstances on women’s dissatisfaction
with their quality of life was stronger for women within the low-income range than for
women in the medium- or high-income ranges. Overall, these findings suggest that
income buffered the extent to which stress affects women’s dissatisfaction with their
quality of life. In addition, they indicate that income may have a greater buffering impact
on the relationship between women’s experiences of stressfill life events and their
dissatisfaction with the quality of life than it did on the effect of daily hassles.

To summarize, the extent to which income level impacted the effect of abuse on
PhYSical and psychological health is complex. While women with lower incomes were
Significantly more likely to experience higher levels of stress than were women with
higher incomes, they were not significantly more likely to report higher rates of physical
health problems. The extent to which income moderated the relationship between stress
and women’s psychological health varied depending upon the kind of stress and indicator
0f Psychological well-being. It appears that a higher level of income moderated the
effects of stressful life events on women’s level of depression, and dissatisfaction with
the quality of their life, but not their rate of suicide ideation. Similarly, a higher level of

i“collie appeared to buffer. the effects of difficult life circumstances on women’s

dissatisfaction with the quality of their life, but not their level of depression or rate of

sulciide ideation.

109

 

To what extent do women’s saLsfpction with their social support impact the effects of
abuse on their psychological health? The moderating effect of social support was tested
using a series of hierarchical multiple regression analyses. Psychological health
(depression, suicide ideation, and quality of life) was regressed onto three independent
variables (difflcult life circumstances, stressful life events, and income) and two product
terms (difficult life circumstances x social support and stressful life events x social
support) in six separate analyses. The first block of each regression equation contained
one of the main effect variables: (a) stressful life events, (b) difficult life circumstances,
and (c) social support. The product terms comprised the second block of each equation:
stressful life events x social support and difficult life circumstances x social support.
Prior to computing the product terms, the scores of the main effect variables were
centered (i.e., the mean score of each measure was subtracted from individual scale
scores).

To plot the moderating effects of social support, simple regression lines were
Calculated using the same methods previously described for income. Only significant
moderating effects were plotted. Because social support was a continuous variable, three
1eVels (high, medium, and low) of the centered social support score were produced by
setting the cut-off points as one standard deviation above the mean (high; 1.22), the mean
(medium; 0), and one standard deviation below the mean (low; -1 .22). Three restructured

1'egl‘ession equations were used to compute the predicted dependent variable scores for
each level of social support. The regression lines were then generated and plotted.
No significant interaction effects were detected using hierarchical multiple

regression techniques in five of the six analyses. The results of these analyses are

110

Table 24. Moderating Effect of Social Support on Stress and Depression

 

Depression Scores

 

Sign.
Variables r B t of t

 

Difficult Life Circumstances

Block 1: Centered Variables
F = 105.25, p < .0001
R2 = .348
Social support (centered) -.41*** -.244 -5.60 <.05
Difficult life circumstances (centered) .54*** .457 10.49 <.05
Intercept (constant) 40.95 <.05

Block 2: Interaction Term
F = 70.12, p < .0001
R2 = .349
R2 change = .001, p = .611
Social support x Difficult life circum. -.071 .021 .509 .611

Stressful Life Events

Block 1: Centered Variables
F = 68.26, p < .0001
R2 = .257
* Income (centered) -.41*** -.343 -7.73 <.05
Stressful life events(centered) .38*** .308 6.95 <.05
Intercept (constant) 38.36 <.05

Block 2: Interaction Term
F = 45.69, p < .0001
R2 = .259
R2 change = .001,~p = .411
_Social support x Stressful life events -.069 -.037 -.823 .411

 

’ Standardized regression coefficients are reported for the step in which they were entered
into the model.
*** p < .001.

111

Table 25. Moderating Effect of Social Support on Stress and Suicide Ideation

 

Depression Scores

 

Sign.
Variables r B t of t

 

Difficult Life Circumstances

Block 1: Centered Variables
F = 28.24, p < .0001
R2 = .125
Social support (centered) -.27*** -.l76 -3.49 <.05
Difficult life circumstances (centered) .31 *** .250 4.96 <.05
Intercept (constant) 18.34 <.05

Block 2: Interaction Term
F = 18.91, p < .0001
R2 = .126
R2 change = .001, p = .560
Social support x Difficult life circum. -.029 .028 .583 .560

Stressful Life Events

Block 1: Centered Variables
F = 23.51,,p < .0001
R2 = .107
Social support (centered) ‘ -.27*** -.225 -4.63 <.05
Stressful life events(centered) 24*" .194 3.98 <.05
Intercept (constant) 18.15 <.05

Block 2: Interaction Term
F = 15.95, p < .0001
R2 = .109
R2 change = .002, p = .354
_Social support x Stressful life events -.36 .046 .927 .3 54

 

' Standardized regression coefficients are reported for the step in which they were entered
into the model.
*** p < .001.

112

Table 26. Moderating Effect of Social Support on Stress and Dissatisfaction with Quality

of Life

 

Variables

Dificult Life Circumstances

Block 1: Centered Variables
F = 140.21, p < .0001
R2 = .416
Social support (centered)
Difficult life circumstances (centered)
Intercept (constant)

Block 2: Interaction Term
F = 95.73, p < .0001
R2 = .422
R2 change = .006, p < .05
Social support x Difficult life circum.

Stressful Life Events

Block 1: Centered Variables
F = 102.35, p < .0001
R2 = .342 '
Social support (centered)
Stressfill life events(centered)
Intercept (constant)

Block 2: Interaction Term
F = 68.51 < .0001
R2 = .343
R2 change = .002, p = .343
_Social support x Stressful life events

Quality of Life

 

450***
.56***

-.024

_.50***
.40***

-.02

B

-.348
.432

.081

-.439
.304

.040

T

4r44
1tr47

82.78

2.09

-10.52

7.28

78.00

.949

Sign.
of t

<.05
<.05
<.05

<.05

<.05
<.05
<.05

.343

 

’ Standardized regression coefficients are reported for the step in which they were entered

into the model.
*** p < .001.

113

Mean Quality of Life Scores

 

5.01

4.5

4.01

3.0

2.5

 

2.01
-15

Social Support Level

A low - (-1.22)

o 0 medium - 0

 

o 0 high - (1.22)

T

10 15

is
o

I

01
o It
01

Difficult Life Circumstances (centered)

Figure 7. Regression Lines Indicating Moderating Effect of Social Support on Difficult
Life Circmnstances and Quality of Life (Note: higher score equals greater
dissatisfaction)

114

presented in Tables 24-26. As indicated in the Table 26, social support did have a
significant moderating effect on the relationship between difficult life circumstances and
dissatisfaction with quality of life (R2: .42) [AF (1, 393) = 4.36, p < .05; Achhange =
.006]. This interaction effect is presented in Figure 7. Although the results of the
multiple regression analyses suggest that the moderating effect was relatively small, the
plot of regression lines in Figure 7 yielded an interesting interaction pattern.

The pattern of the regression lines indicates that the relationship between difficult
life circumstances and dissatisfaction with quality of life was stronger for women who
reported high levels of social support than for women who reported low levels of social
support. It also indicates that the differentiation among the three levels of social support
were more pronounced at lower levels of difficult life circumstances, and less distinct
when women reported a high number of difficult life circumstances. These findings
suggest that women’s satisfaction with the amount and quality of social support may not
necessarily bufler the effects of daily hassles on their dissatisfaction with quality of life.
Higher levels of social support may minimize the effect of difficult life circumstances on
dissatisfaction with quality of life when stress levels are low, but the impact of high
social support diminished at higher levels of stress.

While social support did appear to moderate the relationship between difficult life
circumstances and dissatisfaction with quality of life, no other significant interactions
were detected. These findings indicate that having high levels of social support did little
to buffer the extent to which women’s stress levels affected their psychological well-

being. Furthermore, when there was evidence to support a moderating effect of social

115

support (i.e., on the relationship between difficult life circumstances and dissatisfaction
with quality of life), the pattern of that interaction contradicted the common assertion that

social support buffers the impact of high stress levels.

116

CHAPTER 4

DISCUSSION

Mary of Results

The present study had two primary goals. The first goal was to clarify the
relationship between intimate partner violence and women’s psychological and physical
health. The second goal was to examine the extent to which a woman’s income level
impacts the effect of abuse on her physical and psychological health. In addition to these
two goals, the. present study was designed to examine the extent to which women’s
satisfaction with their social support moderated the effects of stress on their psychological
health. A conceptual path model of the hypothesized relationships was presented in
Figure 1.

The model proposing complex direct and indirect relationships among abuse,
injmies, stress, psychological health, physical health, and income was strongly supported
by women’s experiences. Tests of the moderating effects of income and social support
yielded mixed results. The direct and mediating relationships were tested using structural
equation modeling techniques, and a series of hierarchical multiple regression analyses
were conducted to test moderating relationships. Structural equation modeling
techniques revealed that the proposed path model of direct and mediating relationships
provided an acceptable fit to the observed data (variance/covariance matrix). All except
one of the ten hypothesized relationships tested were significant and accounted for 71%

of the variance in physical health problems women reported.

117

The results of this study clearly demonstrated that intimate partner violence has a
resounding impact on women’s psychological and physical health. More importantly, the
results of this study helped to clarify the process by which intimate partner violence
jeopardizes women’s psychological and physical health. Abuse was found to affect
women’s physical health in two ways: 1) through the injuries women experienced and 2)
through the combined effects of stress and psychological health problems (depression,
suicide ideation, and dissatisfaction with quality of life). While both processes
contributed to women’s experiences of physical health problems, the joint mediating
effects of stress and psychological health problems accounted for more variance in
physical health problems than did injuries. Abuse-related injuries may impact women’s
physical health to some extent, but the stress associated with surviving an intimate
partner’s violence places women at far greater risk for compromised psychological and
physical health.

Another significant contribution of the present study was that it differentiated the
effects of poverty on women’s health from those due to abuse. The results demonstrated
that income level exerted a minimal impact on the relationship between intimate partner
violence and women’s psychological and physical health. Women with higher levels of
income reported significantly lower levels of stress (B = -.13), yet they were no more
likely than women with lower levels of income to report lower levels of physical health
problems. Furthermore, the direct effect of abuse on women’s stress levels was five
times greater than the direct effect of income. These findings suggest that the effects of

abuse on women’s stress and physical health supercede those due to poverty.

118

While the results of the present study did not support assumptions that income
would have a strong direct impact on women’s stress and physical health, there was some
' evidence to suggest that having a higher income buffers the extent to which stress affects
psychological health problems. The extent to which women’s income level moderated
the relationship between stress and psychological health problems was complex. At high
levels of stress, women with higher income levels were less likely to report
dissatisfaction with their quality of life than were women with lower income levels.
When reporting high levels of stressful life events, women with higher income levels
were also less likely to experience high rates of depression than were women with lower
income levels. However, income did not moderate the effect of stress on suicide ideation
or the effect of difficult life circumstances on women’s rates of depression.

Finally, the present study clarified the extent to which women’s satisfaction with
their social support impacts the effects of abuse on women’s psychological health. It was
hypothesized that social support would moderate the relationship between stress and
psychological health problems. Contrary to the finding that women’s income level
moderated the effects of stress on psychological health, there was little evidence to
support the hypothesis that women’s satisfaction with their social support buffered the
effects of stress on their rates of depression, suicide ideation, or dissatisfaction with their
quality of life. Women’s satisfaction with their social support fiom friends and family
did not moderate the effects of stressful life events or difficult life circumstances on
women’s rates of depression or suicide ideation, nor did it moderate the effect of stressful
life events on women’s dissatisfaction with their quality of life. Social support did appear

to moderate the relationship between difficult life circumstances and women’s

119

dissatisfaction with their quality of life. However, the pattern of regression lines
indicated that the benefit of social support was greater at lower levels of stress than at
higher levels of stress. At high levels of difficult life circumstances, women with high
rates of social support were no more likely to report less dissatisfaction with their quality
of life than were women with low rates of social support.
Major Descriptive Findings
As expected, approximately half (52%) of the sample had been physically and/or
sexually assaulted by an intimate partner or ex-partner within six months prior to their
interview. Most “abused” women had experienced multiple forms of physical abuse.
Nearly all of the women in the “abuse” group reported that a partner or ex-partner had
pushed, shoved, or grabbed them, and more than half had said that they had been kicked,
punched, or choked. In addition to being physically assaulted in other ways, one out of
three women had been raped by her partner or ex-partner. For many women, the physical
and/or sexual assaults occurred at least two or three times a month. These findings
» coincide with reports from previous research on the number, severity, and frequency of
physical assaults by intimate partners (Cascardi & O’Leary, 1992; Eby, 1996; Sato &
Heiby, 1992; Sutherland .et al., 1998).

All women who indicated they were in an intimate relationship or who had been
in contact with an abusive ex-partner during the previous six months were asked
questions about psychological abuse. Most women said that their partners or ex-partners
had used at least one form of psychological abuse, and eight forms of psychological

abuse were endorsed by more than half of the women. Considering that 10% of these

women had not been physically assaulted by an intimate partner or ex-partner within the

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previous six months, these findings indicate that many women had experienced
psychological abuse even though they had not been physically harmed. They also suggest
that various forms of psychological torment often accompany physical abuse. Eby (1996)
found similar results when comparing a community sample of “abused” and “non-
abused” low-income women. Since previous researchers have indicated that batterers use
a variety of tactics to establish power and control in a relationship, and that many of the
tactics involve some form of emotional or psychological abuse that may either precede or
accompany physical assaults, these findings were not surprising.

For the most part, the physical health problems women experienced were similar
to those reported in previous studies (Eby, 1996; Kerouac et al., 1986; Sutherland et al.,
1998). Sixty-one percent of the women in the current study rated their general health
status as good 0r excellent, which was slightly higher than the reported 55% of women
from a shelter population (Kerouac et al., 1986). Women in the current study reported an
average of 16 physical health symptoms. The most common physical health symptoms
experienced were low energy, sleep problems, headaches, muscle tension, back pain, and
fatigue. The rate at which women experienced each symptom coincided with previous
estimates from a community sample of low-income women (Eby, 1996) and a sample of

- women who recently left a battered women’s shelter (Sutherland et al., 1998).

In addition to the physical health symptoms, women also experienced a wide
range of chronic health problems such as allergies, arthritis, and repeated or long-term
infections. The number of women who had chronic health problems such as allergies
(45%) and arthritis (20%) was nearly four times higher than the number reported in a

PWVious study of a shelter population (Kerouac et al., 1986). This discrepancy is most

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likely an artifact of the recruiting strategy and selection bias. The newspaper
advertisements described the study as research about women’s health issues. It is
possible that women who were suffering from chronic health problems had a special
interest in the research and elected to participate. Because of the advertisement, more
women with chronic health problems may have agreed to participate in this study than in
other studies that were not presented as health related.

In regards to women’s psychological health, rates of depression, suicide ideation,
and dissatisfaction with quality of life were considerably lower than previous studies.
Women in the current study indicated that they were generally satisfied with the quality
of their lives. Sixty-three percent of the women were at least mildly depressed, with 19%
moderately depressed, and 30% severely depressed. Previous rates of depression among
shelter populations and women who recently left a shelter were slightly higher (Campbell
et al., 1995; Cascardi & O’Leary, 1992; Sato & Heiby, 1992). However, Campbell et
al.’s (1997) community sample of battered women (recruited through newspaper
advertisements and bulletin board postings) had depression rates that were slightly lower
than the current population. Their figures indicated that 40% of the sample were at least
moderately depressed, whereas 49% of the women in the current study were considered
moderately depressed.

Prevalence rates for depression among women in the general p0pulation are
typically lower than those found in studies of battered women. For example, we would
eXpect to see that rates of depression were higher among shelter populations because of
their living situation as well as their immediate state of crisis. Most women who seek

safe shelter from an abusive partner do so as a last resort. They often leave their homes

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with little more than the clothes they were wearing at the time of the assault. While in the
shelter, they must deal with the loss of their home and their personal possessions. They
must also deal with decisions for their future, like where they are going to live. Women
who are not residing in a shelter may deal with the same types of issues, but the need for
resolution may not appear as imminent.

Forty-one percent of the women in the current study said they had thought about
ending their lives within the six months prior their interview. Of the twenty-two women
who had attempted suicide, 19(86%) had been assaulted by an intimate partner or ex-
partner. The rate of suicide attempts among the “abused” group was considerably lower
than rates found in previous research on battered women (Stark & Flitcraft, 1988).
However, these findings do indicate that the women who had been abused by an intimate
partner or ex-partner were at a much greater risk for suicide than were women who had
not been assaulted.

In terms of stress, the women in the current study experienced an average of six
difficult life circumstances and nine stressfill life events. The most common forms of
stress were related to financial issues such as long-term debts, problems with their credit
rating, and having less money than usual. Eby (1996) reported similar results in her
comparative study. Problems with credit rating, long-term debts, and substandard
housing were the most commonly cited stressors among the low-income women in her
study. While it was expected that women in the current study would report fewer or at
_ least different types of stressors (i.e., due to the inclusion of women from higher income
levels), it is also likely that women from all income levels experience financial problems.

Interestingly, substandard or unaffordable housing was not one of the more common

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issues for women in the current study, but it was for the low—income women in Eby’s
study. Inadequate housing is a common stressor for low-income women and a primary
risk factor for many health problems.

Percent poverty rates for the entire sample were computed to estimate women’s
income level. While nearly equivalent rates of women fell within the low-income range
or the middle-income range, the average monthly household income (194% poverty level)
was slightly below the low-end of the middle-income range. This finding indicates that
most of the women had household incomes well below what was anticipated.
Unfortunately, that means that the current study did not include as broad a range of
income levels as would have been needed to clearly differentiate the effects of income on
women’s stress and health fiom those attributable to experiences of abuse. There are two
possible explanations for this finding.

First, it is possible that the percent poverty rates inaccurately represented
women’s financial status. The percent poverty rates were calculated using US. Census
poverty threshold figures, which are derived from average household income estimates.
Since the average household income estimates are heavily influenced by men’s annual
income (i.e., head of household), it is possible that the poverty thresholds used in
calculating the sample’s percent poverty rates were too high. This would mean that when
compared to household estimates, the women’s incomes in this study placed them at
lower percent poverty levels than if compared with poverty thresholds based on annual
female household incomes. For example, in 1996 the median household income earnings
was $35, 492, but for female householders the median income was $16,398. Sixty-two

percent of the women in the current study were considered female heads of household

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(i.e., not living with or married to a partner). The median annual household for the
women in this study was higher than the national population (i.e., $19,200), yet their
percent poverty rates indicated they were on average slightly above low-income range. In
essence, this means that the women in the current sample may in fact accurately represent
women from both low-income and middle-income groups.

An alternative explanation for the apparent restricted range of incomes has to do
with the recruiting strategy. All women were recruited using newspaper advertisements
and flyers. It is possible that this passive recruitment strategy limited access to women
fiom higher income levels. They may have been reluctant to participate in a study about
domestic violence and health. Social stereotypes typically characterize intimate partner
violence as a low-income issue. Women from higher income groups may have been
unwilling to discuss their experiences because of the stigma attached to the issue. A more
active approach might have been more successful in encouraging women to talk about
their experiences.

Even though the income range was not as broad as expected, the current study did
improve upon previous researcher’s efforts to differentiate the effects of abuse from those
due to poverty. Less than 40% of the, sample reported incomes at or below poverty
(100% poverty threshold) and approximately 40% reported incomes that were considered
above low-income (>200% poverty threshold). The income range was also sufficient to
detect significant moderating effects of income on the relationship between women’s
experiences of stress and their rates of depression and dissatisfaction with their quality of

life.

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Path Model of Hypgthesized Relationships among Constructs

To Wh_at extent does intimate partner violence affect women’s physical health?

 

To better understand the process by which intimate partner violence affects women’s
physical health, eight direct and indirect relationships were hypothesized. The first three
hypotheses implied direct relationships between abuse and injuries, injuries and physical
health problems, and a mediating effect of injuries on the relationship between abuse and
physical health problems.

First, it was hypothesized that abuse would have a direct effect on women’s
experiences of injuries. The results demonstrated that abuse did have a moderate impact
on the number of injuries women reported. Women who reported high levels of abuse
had more injuries than did women who reported lower levels of abuse. Subsequently, the
number of injuries women reported was positively related to their rate of physical health
problems. Women who reported higher numbers of injuries reported higher rates of
physical health problems than did women with fewer injuries. Finally, the number of
injuries women sustained was found to partially mediate the impact of abuse on women’s
health problems. This finding suggests that the extent to which women experience abuse-
related health problems depends, in part, on the number of injuries they sustain when
physically assaulted. Women who sustained fewer injuries were less likely to report high
rates of physical health problems than were women who sustained greater numbers of
injuries. These findings seem to support previous assumptions about the effect of injuries
on battered women’s physical health (Alpert, 1995; Berrios & Grady, 1991; Council on
Scientific Affairs, AMA, 1992; Eby et al., 1995; Goldberg & Tomlanovich, 1985; Haber

& Roos, 1985; McCauley, et al., 1995; Randall, 1990; Sutherland et al, 1998). However,

126

it is important to note that injuries had a small mediating effect on the relationship
between abuse and physical health problems. Abuse-related injuries, alone, did not
adequately account for women’s physical health problems. This finding was not
surprising; the model contained an alternate explanation for the relationship.

Interestingly, when the structural model was tested, the residual covariance
estimates indicated a unique relationship between the number of injuries women
sustained and their rate of suicide ideation. It is possible that some other factor common
to both variables, such as a reduced ability to escape the violence, could account for their
relationship. Women who reported high rates of injuries would have less physical ability
to escape a partner’s violence or to protect themselves. Similarly, women who sustained
greater numbers of injuries may have felt that suicide was the only escape option
available to them. Another possibility may be that women who scored higher on the
measure of suicide ideation had attempted suicide at least once and therefore, may have
had greater likelihood of sustaining injury from the suicide attempt. In both cases, the
cross-sectional nature of the research design precludes us fiom drawing any conclusions
about the direction of the relationship — i.e. that women’s rates of injuries were caused by
their suicide attempts or that women’s thoughts and attempts of suicide were due to the
number (and/or severity) of injuries they sustained. Therefore, it would be premature at
this point to assert a theoretical significance to the relationship.

The remaining five hypotheses proposed relationships between abuse and physical
health that were mediated by women’s levels of stress and psychological health. The first
of these hypotheses suggested a direct relationship between women’s experiences of

abuse and their levels of stress. The results demonstrated a strong positive relationship

127

between abuse and stress, indicating that women who experienced high levels of abuse
reported higher rates of stress than did women whom experienced lower levels of abuse.
Commensurate with Eby’s (1996) study results, this finding clearly demonstrates that
intimate partner violence is stressfill for women. Previous researchers have assumed that
the physical violence would be stressful in itself. The descriptive findings of the current
study suggest that an intimate partner’s violence may exacerbate or even cause other
sources of stresssuch as financial insecurity, housing instability, problems with
employment, and arguments with neighbors, fiiends, and family members. When
responding to questions about difficult life circumstances and stressful life events, less
than one third of the entire sample reported that they had been victims of a violent crime
such as rape or assault, and 31% said they had experienced regular arguments with their
partner. These proportions were much lower than would be expected since more than
half the sample had been physically assaulted within the six months prior to the
interview. These findings suggest that while some women identified with the
stressfirlness of the violence they experienced, other abuse-related factors may have been
more salient stressors for the majority of survivors.

The extent to which battered women’s experiences of specific stressors differ
from women who have not survived intimate partner violence is not clear and deserves
further investigation. However, we do know that the dynamics of intimate partner
violence extend beyond the physical assaults, and the results of the current study clearly
demonstrate that a violent partner’s determination to assert power and control in a

relationship strongly impacts survivor’s stress levels.

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The second hypothesis, that women with high levels of stress would report higher
rates of psychological health problems, was continued as well. The results of structural
equation modeling techniques demonstrated a strong positive relationship between stress
and psychological health. Concomitant stress levels explained an estimated 83% of the
variance in women’s rates of psychological health problems (i.e., depression,
dissatisfaction with quality of life, and suicide ideation). These findings suggest that
women’s levels of stress have a considerable impact on their psychological health.
Similar results have emerged in previous research not specifically related to intimate
partner violence (Kendler et al., 1995; USDHHS, 1993a, 1993b; Vilhjalmsson, 1993) and
in studies specifically addressing the health effects of abuse (Campbell et al., 1997; Eby,
1996)

A third hypothesis was examined to determine the extent to which women’s levels
of stress mediated the relationship between abuse and psychological health. The results
indicated that stress had a strong mediating effect on the direct relationship between
abuse and psychological health (i.e, when including women’s stress levels in the model,
the relationship between abuse and psychological health problems was no longer
significant). That women’s stress levels significantly mediated the relationship between
abuse and their rates of depression, suicide ideation, and dissatisfaction with their quality
of life is an important finding for a couple of reasons. First, it confirms previous
researcher’s contentions that it is the stress of surviving intimate partner violence that
places women at risk for psychological health problems. Several researchers have
proposed a stress-response theory to explain the long-term residual impact of abuse on

women’s psychological health (Browne, 1992; Campbell et al., 1997; Eby, 1996; Jaffe et

129

al., 1986; Koss, 1990), yet few have empirically tested this assumption. Finding a
significant mediating effect is a key first step toward empirically substantiating the stress-
response theory.

Second, women’s responses on the stress measures demonstrated that intimate
partner violence wreaks havoc in women’s lives beyond what they experience physically.
Much of what women identified as stressful did not specifically relate to the violence they
experienced, but did relate to financial, relationship, and employment issues. This
strongly suggests that a survivor’s psychological health is jeopardized by the detrimental
impact the violence has on other parts of her life — her financial security; her relationship
with neighbors, fiiends, and family members; and her ability to secure employment.
Demonstrating that the mediating effect of abuse-related stress on women’s psychological
health encompasses much more than the violence itself is another key step toward fully
understanding the extent to which intimate partner violence compromises women’s
livelihood.

Two final hypotheses were examined to determine the effect of abuse-related
stress on women’s physical health. The first hypothesis suggested a direct relationship
between women’s psychological and physical health. The second hypothesis indicated
that women’s psychological health mediated the relationship between women’s stress
levels and their rates of physical health problems. That is, women’s stress-related levels
of depression, dissatisfaction with quality of life, and suicide ideation would explain the
high rates of physical health problems women experienced when assaulted by an intimate

partner.

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The results demonstrated a strong positive relationship between women’s
psychological and physical health. Similar findings have been documented well in
previous research (Betrus et al., 1995; Hays et al., 1995; Judd et al., 1996; Leino &
Magni, 1993; Lewinsohn et al., 1996; Sutherland et al., 1998; Von Korff et al., 1993; Von
Korff & Simon, 1996). In addition, women’s psychological health was found to partially
mediate the relationship between stress and physical health. These findings suggest two
things. First, while women’s stress levels affect their experiences of physical health
problems, concomitant rates of psychological health problems impact the strength of the
relationship between stress and physical health. The stress associated with surviving
intimate partner violence has been shown to have a resounding impact on women’s levels
of depression, suicide ideation, and dissatisfaction with their quality of life (Eby, 1996).
Since previous research has demonstrated that there is a strong connection between
psychological and physical health, it was not surprising to find that the impact of abuse-
related stress on women’s physical health was partially explained by the psychological
health problems they also reported.

On the other hand, these findings also indicated that women’s rates of depression,
suicide ideation, and dissatisfaction with their quality of life did not firlly account for the
relationship between abuse-related stress and physical health problems. This means that
the relationship between stress and women’s physical health is more complex than was
initially proposed. For example, it is possible that women’s stress had a direct impact on
their physical health as well as an indirect effect. Health psychologists and medical
researchers have shown that individuals with elevated stress levels are more susceptible

to cardiovascular heart disease (CHD) and various infectious diseases even when

131

controlling for psychological health problems (Adler & Matthews, 1994). Research on
the physiological mechanisms that directly link stress to diseases is still relatively new,
yet there is evidence to suggest that for some people, stress increases blood pressure and
heart rate and may even decrease their immune system’s ability to fight infectious
diseases (see Adler & Matthews, 1994). Subsequently, these physiologic responses to
stress have been linked with long-term health problems such as myocardial ischemia,
angina, and upper respiratory infections.

Determining whether or not the variance in women’s rates of physical health
symptoms and general health status were due to specific physiological mechanisms was
beyond the scope of the current study. However, exploratory ad hoc analyses were
performed to examine whether including a direct path between stress and physical health
problems would improve model fit. The assumption was that a significant direct
relationship between stress and physical health, even when controlling for the mediating
effect of psychological health problems, would provide some evidence of a physiologic
response to stress. The results of the ad hoc analyses indicated that including a direct
path between stress and physical health did n_ot significantly improve the model’s fit to
the data. While women’s stress levels may have increased their susceptibility to health
problems, the results of the ad hoc analyses provided little evidence to indicate that
physiologic responses accounted for a significant portion of the variance in their rates of
physical health symptoms and general health status. Perhaps other factors such as health-
related behaviors (e. g., smoking, diet, exercise, and alcohol use) played a more crucial

role in determining the physical health outcomes of stress. Clearly, the relationship

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between stress and women’s physical health is a complex issue that warrants further

investigation.

 

To what extent does women’s income impact the relationship between abuse and

their physical health? Three hypotheses were tested to examine the extent to which a
woman’s income impacted the relationship between abuse and physical health. First, it
was hypothesized that income would have a direct negative effect on women’s stress
levels; women with lower income levels (percent poverty levels) would report higher
levels of stress than would women with higher income levels. Second, it was
hypothesized that income level would have a direct negative effect on women’s rates of
physical health problems;’women with lower income levels would report higher rates of
physical health problems than would women with higher income levels. Third, the model
suggested that women’s income levels would buffer the impact of stress on their
psychological health.

The results indicated that income did have a negative effect on women’s stress
levels; women with higher incomes reported significantly less stress than did women with
lower incomes. This finding is consistent with previous research about the effects of
income on stress (Belle, 1990; Fuller et al., 1993; Mcleod & Kessler, 1990; Thoits, 1982)
and suggests that women’s financial status determined somewhat the extent to which they
experienced stressful life events and daily hassles. However, the small magnitude of the
direct relationship between income and stress (B = -. l 3) also indicates that the variance in

women’s stress levels was not fully explained by their financial status.

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Interestingly, while living in poverty seems to have predisposed women to higher
levels of stress, it did not directly impact the extent to which they reported physical health
problems. Previous researchers have postulated that living in poverty increases
individual’s susceptibility to various infectious diseases, chronic health problems, and
other illnesses through substandard and crowded housing conditions and exposure to
toxic substances. Furthermore, low-income women have limited access to quality health
care and preventive services, often receive delayed treatment for illnesses, and rarely have
a regular sources of medical care (Bindman et al., 1995; Kington & Smith, 1997;
Weissman et al., 1991). Combined, these factors have led researchers to assume a direct
relationship between poverty and compromised physical health. Contrary to this
assumption, the results of the current study indicated that low—income women were no
more likely to report higher rates of physical health symptoms or lower general health
status than were women withahigher incomes. This contradiction with previous research
may be due to several factors.

First, it is possible that there wasn’t sufficient variance in women’s income levels
to detect significant association between income and physical health problems. As noted
earlier, most of the women’s annual household incomes were within low- and middle-
income ranges. Only two-percent of the women reported incomes above the middle-
income range. The overrepresentation of women living in poverty or at the low-end of
the middle-income range might have reduced the likelihood of finding a significant
relationship. However, while there was a higher proportion of women who reported low-
and middle-incomes as compared to those who reported higher incomes, there was

sufficient variance to detect a significant correlation between income and general health

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status (r = -.29) as well as income and physical health symptoms (r = -.27) (see Table 14.
Uncorrected Correlation Matrix of Observed Variables).

Another possible explanation for the lack of corroboration between the current
study’s findings and those of previous research might have to do with differences in the
way income level is operationalized. In the current study, income level was
operationalized as a measure of women’s annual household income and weighted
according to the number of people it supported. Previous researchers commonly used
multiple indicators to ascertain participant’s income level (i.e., socioeconomic status):
education level, employment status, housing stability, occupation, access to a car, and
health insurance (Stronks et al., 1997). While researchers have established a significant
correlation between income and these other indicators of socioeconomic status (e.g.,
Stronks et al., 1997), there is a possibility that a woman’s household income, alone, does
not sufficiently account for the health problems she experiences.

Other income-related factors such as having a job, owning a house, and having a
higher level of education may have a greater impact on women’s health than their actual
household income. For example, Stronks et al. (1997) found that the high rates of
unemployment among low-income individuals explained a large portion of the variance
in their perceived general health and number of chronic health problems. Since these
same factors have been commonly used by previous researchers to differentiate income
levels, perhaps the socioeconomic inequalities of health status were due to a variety of
issues strongly related to a participant’s household income, but not to the actual income

itself. Perhaps using a broader conceptualization of income level - one that incorporated

135

factors such as employment status, education level, and housing stability — would have
yieldedfindings more consistent with those of previous research.

The extent to which women’s income levels moderated the effect of stress on their
psychological health remains unclear. The results indicated that a woman’s income level
buffers the effect of stressful life events on levels of depression and dissatisfaction with
their quality of life. The patterns of the interaction effects were as expected; the effect of
stress on women’s levels of depression and dissatisfaction with their quality of life were
much greater for women with lower income levels than for women with higher income
levels. A similar pattern emerged between women’s experiences of diffith life
circumstances and dissatisfaction with their quality of life. Having greater income
appeared to minimize the effect of stress on women’s psychological well-being — at least
with respect to their experiences of depression and dissatisfaction with their quality of
life. Intuitively, these findings make sense. Having a greater income may not prevent
stressful events fi'om happening, but it may provide women with access to resources
needed to resolve the stressful situation. Knowing that resources are available, or
perceiving the stressful event as a temporary occurrence may protect women from the
negative effects of stress. Conversely, living on poverty-level incomes not only restricts
women’s options for resolving stressful situations, but it may also negatively influence
the way women perceive their quality of life during periods of high stress - especially if
the situation is considered long-term.

A woman’s income level did not appear to buffer the extent to which stress

impacts her thoughts or attempts of suicide. No significant interaction effects were found

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when the moderating effect of income on the relationship between stressful life events or
difficult life circumstances and suicide ideation was assessed.

To summarize, income level appeared to have little direct impact on the
relationship between abuse and women’s physical and psychological health. Women’s
experiences of abuse accounted for more of the variance in stress levels than did percent
poverty rates, and women with higher income levels were no more likely to report lower
rates of physical health problems than were women with poverty-level incomes. There
was some evidence to suggest that having a higher income buffers the relationship
between stressful life events and women’s rates of depression and dissatisfaction with
their quality of life. Combined, these findings suggest that income may serve a more
indirect fimction than a direct one.

Six separate regression equations were examined to determine the moderating
effect of social support on the relationship between stress and psychological health. Of
the six analyses, only the interaction between social support and difficult life
circumstances revealed a significant moderating effect on the relationship between
difficult life circumstances and women’s dissatisfaction with their quality of life. The
pattern of regression lines indicated a negative buffering effect; the impact of high social
support was stronger at low levels of stress than it was at high levels of stress. Although
this finding contradicts the traditional conceptualization of a buffering effect, similar
“negative effects” have been found in previous research related to chronic strain
(Cummins, 1988) and job-related stress (Ganster, Fusilier & Mayes, 1986; Kaufman and
Beehr, 1986). Perhaps the emotional and tangible support fiiends and family can provide

to women when they are dealing with fewer daily hassles (e. g., long-term debts, problems

137

with credit rating, not enough privacy, frequent illnesses, etc.) isn’t enough to address
women’s needs when they are dealing with many daily hassles. This may be particularly
relevant for women who are surviving intimate partner violence.

The results of the present study demonstrated that surviving intimate partner
violence is very stressful for women, and that the dynamics surrounding a partner’s
violence extend beyond the violence itself to other factors in women’s lives — especially
their relationships with family and fiiends. Having social resources available to address
some of the issues associated with daily circumstances may alleviate the effects of those
hassles on women’s perceptions of their quality of life, but may not be sufficient to
nullify the detrimental effects their partner’s violence. Furthermore, survivors often
noted that while they could “lean on” fiiends and family for emotional and tangible
support to address daily problems, they were less likely to receive the kind of support
they needed if they sought assistance regarding their partner’s violence. Sometimes
emotional and financial support would be provided on a conditional basis (i.e., only if
they left the assailant) or in a judgmental fashion (e. g., “I don’t know why you put-up
with it.”).

Overall, the present study provided little empirical evidence to support a buffering
theory of social support. Instead, the findings seemed to suggest that the alternative
“main effects” theory more adequately represented this sample’s experiences; social
support exerted a significant direct inverse effect on rates of depression, suicide ideation,
and dissatisfaction with quality of life regardless of stress levels in all but one of the six
analyses. Similar findings were reported in Eby’s (1996) study on low-income women;

she found no evidence to support a buffering role of social support, but did reveal a direct

138

effect. Therefore, while it appears that having satisfactory social support may be
beneficial to women’s psychological well-being, more research is needed to clarify the
extent to which having adequate social support addresses the complex issues faced by
survivors of intimate partner violence.

Methodological Limitations

The present study helped to clarify the relationship between intimate partner
violence and women’s psychological and physical health. First, the results demonstrated
that stress is a key factor determining the extent to which abuse impacts women’s health
outcomes. Women who had been assaulted by an intimate partner or ex-partner reported
significantly more injuries than did “non-abused” women, but those injuries provided
little explanation for the health problems women experienced. Second, the results
indicated that while a woman’s low-income status may contribute to her level of stress
and subsequent health problems, having higher levels of income does little to buffer the
consequences of violence. These findings seem to confirm previous assumptions about
the process by which intimate partner violence compromises women’s psychological and
physical health. However, several methodological issues limit the interpretation and
generalizability of the results.

One methodological limitation of the current study was the restricted range of
income. One goal of the present research was to examine the extent to which women’s
income level impacts the effect of intimate partner violence on psychological and
physical health. To achieve this goal, specific strategies were employed to recruit women
from various income levels. Women from both low-income and middle-income groups

were successfully recruited to participate in the study. However, the actual range of

139

household incomes (i.e., percent poverty) within the middle-income group was much
lower than originally anticipated. Most of the women representing the middle-income
group had incomes at the low end of the income range for that group. This
methodological flaw limits the interpretability and generalizability of the results for two
reasons. First, the lack of variability in income levels created a skewed distribution in the
data. The existence of a non-normal distribution may have reduced the likelihood of
detecting a significant relationship between income and physical health. On the other
hand, the zero-order correlation matrix (see Table 14, Uncorrected Correlation Matrix of
Observed Variables) revealed significant relationships between income and all three
physical health indicators. These relationships disappeared when combined with other
relationships in the structural model. Therefore, the extent to which the skewed
distribution impacted the likelihood of detecting a relationship between income and
physical health outcomes, once the full model was tested, remains unclear.

Second, the restricted range of income may limit the generalizability of the
research findings. A key criticism of previous research was that much of what we know
about the effects of abuse on women’s health has been derived from studies of low-
income women. One could not assume that similar concerns existed for middle or high-
income women. While this study substantially improves our understanding about the
effects of poverty on the relationship between abuse and women’s health, it provides
limited information about the experiences of women in the higher income ranges.

The recruitment strategy represents another potential methodological limitation of

the cm'rent study. The strategy used to recruit participants limited both the interpretation

and generalizability of results in two ways. First, while the newspaper advertisements

140

were a successful tool for encouraging women to participate in the study, this strategy
limited random selection of study participants. Only those women who saw the
advertisements and were willing to discuss their health issues and/or experiences of abuse
were likely to participate in the study. This means that the generalizability of results may
be limited to those women who had access to a newspaper and who wanted to talk about
their experiences. While it is difficult to ascertain the degree to which their experiences
of abuse or health problems differ from women who didn’t participate, it would be short-
sighted to assume that the results of this study can be generalized to all battered women.

Second, the newspaper advertisements may have been more effective in recruiting
women fi'om higher income levels than women fi'om high-income levels. Although
researchers and advocates note that intimate partner violence affects women from all
income levels, social stereotypes suggest that domestic violence is predominately a low-
income problem. The stigma associated with intimate partner violence may deter women
with higher incomes from publicly disclosing their experiences. Newspaper
advertisements may have been too passive an approach to encourage these women to talk
about their partner’s violence. A more effective strategy may be to actively recruit
women through physician’s offices or other less public settings.

A third methodological limitation was the cross-sectional nature of the research
design. Although the cross-sectional design clarified the process by which intimate
partner violence effects women’s health problems, it also restricts our ability to assert
causal direction among the relationships. The results demonstrated that abuse had a
strong impact on women’s stress levels and that stress was highly associated with both

psychological and physical health problems. However, the extent to which intimate

141

partner violence resulted in elevated stress levels or that abuse-related stress caused the
health problems remains unclear. For example, it is possible that women’s stress levels
were exacerbated by their health problems. It is also difficult to ascertain the extent to
which women’s experiences of stress were directly caused by a partner’s violence,
indirectly associated with abusive episodes, and/or exacerbated by the abuse.
Clarification of these issues would require a longitudinal design.

Impflmons for Intervention, Policv, and Future Research

Intervention gn_d Policy. Despite the methodological limitations, the results of the
current study did highlight several implications for intervention, policy, and firture
research. One key finding of the current study was that women’s stress levels were a
substantial link determining the effects of abuse on women’s psychological and physical
health. This finding indicates that one way to reduce the deleterious health effects of
intimate partner violence is to alleviate related stressors. Eliminating the violence from
women’s lives would be the best way to alleviate ongoing stressors and subsequent health
problems. In addition, domestic violence survivors may benefit from proactive
community-based interventions that are designed to identify and address their unmet
needs.

Mobilizing community resources to fulfill women’s unmet needs in addition to
reducing the violence in their lives may effectively reduce levels of depression, suicide
and other psychological health concerns and prevent the onset of various physical health
problems. Increasing the amount and quality of women’s social support may directly
impact their psychological well-being to some extent, but there was little evidence to

suggest that friends and family provided the kind of support survivors needed when

142

dealing with their partner’s violence. Further research is needed to fully understand the
complex dynamics of intimate partner violence and how both formal and informal
support systems can effectively reduce the detrimental effects of abuse on women’s
psychological and physical health. However, the results of the present study do strongly
support a comprehensive community response.

Injuries were found to mediate the effect of abuse on physical health problems,
however the impact of those injuries as less pronounced than the impact of stress. This
finding has strong implications for health care practitioners who rely on visible injuries
identify and treat domestic violence survivors. Battered women often seek medical
attention for numerous health problems that appear unrelated to any specific injury or
predisposing health condition. In many cases, a physician may be the only person
women feel comfortable talking to about their partner’s violence. This provides health
care providers with an opporttmity to identify domestic violence survivors and to provide
information about helpful community resources. If physicians rely on the presence of
injuries to question women about violence, they may miss the chance to provide valuable
assistance. As important, they may misdiagnose the underlying cause of the health
problems or provide treatment options that could actually jeopardize women’s physical
and psychological well-being.

Health care providers can increase the likelihood of early identification and
intervention by utilizing a more comprehensive screening procedure for all female
patients. Such a procedure would entail sensitively asking women about experiences of
domestic violence on a routine basis, but especially in cases where women present

multiple health complaints in lieu of injuries. Similarly, health care providers can

143

improve their response to domestic violence survivors by educating themselves on the
dynamics of abuse as well as on relevant resources available in their commmrities.

Future research. Although the current study expanded our understanding about
the process by which abuse effects women’s psychological and physical health, there are
several areas that need further exploration. First, the extent to which women’s income
level impacts the stress battered women experience remains unclear. A broader range of
incomes was included in the current study to address this issue, but it may have been
insufficient to fully differentiate the effects of poverty from those of intimate partner
violence. This may have been due to the recruitment strategy. Future researchers may
elect to use more proactive methods of recruiting women from higher income levels.

Second, more longitudinal research is needed to fully understand how the
dynamics of an abusive relationship leads to elevated stress levels in women’s lives. It
seems logical to assume that repeated assaults would be stressfirl for women. However,
other factors indirectly related to the violence may exacerbate the stress already present in
women’s lives.

Third, further research is needed to determine the long-term impacts of abuse-
related stress on women’s health. While the present study demonstrated that high levels
of stress associated with intimate partner violence was the primary factor determining
women’s psychological. and physical health outcomes (i.e., compared to injuries), the
cross-sectional nature of the research design limits our ability to fully understand how
these relationships change over time. It is clear that higher levels of abuse were
associated with higher levels of stress and that high levels of stress were associated with

higher rates of depression, suicide ideation, and dissatisfaction with quality of life. The

144

use of structural equation modeling techniques rather than straight correlational analyses
strengthened the directional interpretation of these relationships. However, they also
highlighted the complex nature of these relationships, particularly with respect to the
mediating effect of stress; for example, do women’s stress levels increase in response to
the increased rate of their partner’s violence or does it increase in a cumulative fashion?
Does the abuse cause the increase in daily hassles, exacerbate already stressful living
circumstances, or both? To what extent is the relationship between psychological well-
being and women’s stress levels reciprocal? Will reducing the stress in women’s lives
counteract the impact of violence on her health? Examining how these relationships
change over time would provide a more comprehensive understanding about the effects
of intimate partner violence on women’s health.

Finally, further research examining the reciprocal nature of the relationship
between physical and psychological health outcomes would enhance our understanding
about the resounding impact of intimate partner violence on women’s overall health. For
example, it is possible that a reciprocal relationship exists between the physical and
psychological health outcomes or that physical health outcomes may mediate the effects
of stress on women’s levels of depression, suicide ideation, and dissatisfaction with their
quality of life. The findings of the current study do suggest that community-based
response initiatives should include interventions that address the psychological well-
being of battered women as well as those that focus on their physical health. In addition,
longitudinal research may help to explicate the complex relationships among abuse-

related stress, physical health outcomes, and psychological well-being.

145

APPENDICES

146

APPENDIX A

Flyer and Newspaper Advertisements

147

ATTENTION WOMENII

We May Need Your Help!

The MSU Women’s Health Project is looking for women
who are between 18 and 45 years old.

We need women who are willing to take part in a
confidential interview about numerous aspects of their
health and life circumstances. By participating in this
confidential interview, you will help our efforts to make
Lansing more responsive to your needs as well as the needs
of other women in your community.

Women who qualify will be paid for their valuable time
and information

For more information on how you can help,

call 353-8867

We are available Monday - Friday fiom 9:00am to 7:00pm.

Your participation is completely confidential.

 

 

148

 

 

HAVE YOU BEEN HURT BY SOMEONE YOU LOVE?

We May Need YourHelp!

IF you are a woman between 18 and 45 years old
AND ,
IF you’ve been pushed or grabbed or slapped or hit or kicked (or worse) in the last 6

months, even if only once, by someone you’ve dated or been in a relationship with,

Please call the MSU Women’s Health Study to take part in a confidential interview
about your life and health. Please help us make your community more responsive to
your needs as well as the needs of other women in your community.

Women who participate will be paid for their time.
For more information on how you can help,
‘ call 353-8867

We are available Monday 4 Friday from 9:00am to 7:00pm.
Your participation is completely confidential.

 

149

 

HAVE YOU BEEN HURT IN A
RELATIONSHIP?

Violence affects the lives of women from ALL income
levels. YOUR experiences are important to us!

. IF you have an annual household income that is greater than
$16,500

. IF you are a woman between 18 and 45 years old

. IF you’ve been pushed or grabbed or slapped or hit or kicked (or
worse) in the last 6 months, even if only once, by someone
you’ve dated or been in a relationship with,

Please call the MSU Women’s Health Study to take part in a
confidential interview about your life and health. Please help us
make your community more responsive to your needs as well as
the needs of other women in your community. Women who
participate will be paid for their time.

We are available Monday - Friday fiom 9:00am to 7:00pm.
Your participation is completely confidential.

For more information on how you can
heqL
call 353-886 7 0R 1-800—500—2416

 

 

150

M.S.U. WOMEN’S STUDY
Wishes to Talk with You!

m

We would like to talk with middle income women who are 45 years or younger.
We want to learn about various aspects of your life including your health,
relationships, and stress.

The interview lasts approximately 1 and a 1 / 2 hours and is absolutely
confidential. You will be compensated for your time.

Your unique experiences are important.

Call us Monday through Friday from
9:00 am to 7:00 pm so that we can schedule a convenient time to talk.

We can be reached at 432-3673.

W

151

M.S.U. WOMEN’S STUDY
Wishes to Talk with You!

m

We want to learn about various aspects of your life including your health,
relationships, and stress. We would like to speak with women who:

9 are between the ages of 18 and 45
e have an annual household income of $12,00 or less

The interview lasts approximately 1 and a 1/ 2 hours and is absolutely
confidential. You will be compensated for your time.

Your unique experiences are important!

Please call us Monday through Friday from 9:00 am to 7:00 pm so that we can
schedule a convenient time to talk.

We can be reached at:
432-3673 or 1-800-500-2416

m

152

APPENDIX B

Recruitment Script and Screening Form

153

Wmen hailed/fl; project

Flyer/Advertisement Recruitment

WHEN A WOMAN TELEPHONES INQUIRING ABOUT THE STUDY:

Allow me to tell you a little about the project. As you may know, Michigan State
University conducts much of its research in the Lansing community in an effort to
address key local issues. The Women’s Health Project is following this tradition by
talking with Lansing women about their health and life circumstances. For example, one
of the things that we would like to better understand is the general health of women who
have been physically harmed by an intimate partner or ex-partner. Would it be possible
for me to ask you a couple of questions in order to determine if you can participate in this
study?

1. Could you tell me where you found out, about us?

(Please read these questions slowly and record all responses on a Personal Contact

F mm)

2. What is your current relationship status?
(IF SHE IS CURRENTLY IN A RELATIONSHIP OR IS DATING SOMEONE
GO TO QUESTION 4. IF SHE INDICATES THAT SHE IS CURRENTLY
N_QI IN A RELATIONSHIP OR IS 13191 DATING ANYONE GO TO
QUESTION 3.)

3. Have you been involved in a relationship or dated someone in the last six
months?

4. We are interviewing women between 18 and 45 years old, do you fall within this
age range? (YES/NO)

(IF SHE RESPONDS, "NO, " SHE IS N__O_T ELIGIBLE/QUALIFIED FOR THIS
STUDY):

I’m sorry but at this time we are only accepting women who have been physically
harmed by a partner or ex-partner within the past six months and who are between the
ages of 18 and 45. We want you to know, though, that we really appreciate your interest
in our project. Thanks for giving us a call.

(IF SHE SAYS, "YES," CONTINUE WITH SCRIPT)

5. Have you been physically harmed by a partner, ex-partner or someone you have
dated in the past six months? By this I mean, anytime in the past six months
when you might have been grabbed, pushed or shoved, slapped, kicked,

physically restrained or any other physical act that may have harmed you?
(YES/NO)

154

(IF THE WOMAN RESPONDS, “NO,”)

I ASK IF SHE HAS EXPERIENCED ANY OTHER TYPE OF PHYSICAL
HARM THAT WAS NOT LISTED.

I ASK IF SHE HAS HAD ANY CONTACT WITH HER EX-PARTNER IN
THE PAST 6 MONTHS - IF SHE SAYS “YES,” ASK IF HE/SHE EVER
GRABBED, PUSHED, SHOVED, OR USED SOME OTHER PHYSICAL
FORCE AGAINST HER DURING THAT TIME

I ASK HER HOW LONG IT HAS BEEN SINCE HE PARTNER OR EX-
PARTNER HAS PHYSICALLY HARMED HER

(IF SHE REPORTS THAT SHE HAS NOT HAD ANY TYPE OF PHYSICAL ABUSE,
SHE IS NOT ELIGIBLE/QUALIFIED FOR THIS STUDY):
I’m sorry but at this time we are only accepting women who have been physically
harmed by a partner or ex-partner, or someone they have dated within the past six
months and who are between the ages of 18 and 45. We want you to know,
though, that we really appreciate your interest in our project. Thanks for giving
us a call.

(IF THE WOMAN RESPONDS, "YES," GO TO #6)

6. Are you experiencing any harm now? YES NO-) [When did your partner or
ex-partner physically harm you last: (date)]

(IF “YES” OR DATE IS WITHIN LAST SIX MONTHS, SHE IS ELIGIBLE FOR
THIS STUDY):

I’d like to give you a little more information about the study and how your participation
can benefit women throughout the Lansing area. As I mentioned earlier, the Women's
Health Project was developed so that we could better understand how specific life
circumstances affect women's health and well-being. There has been a lot of research on
women’s health issues over the past 20 years, yet very few health studies exist where
women have been asked about their unique life circumstances and experiences. We think
this is an important step toward effectively addressing the health needs and concerns of
women. Before we can begin to improve the way women's health issues are being
addressed in the Lansing area, we need to know what affects women's health. This is
why we are asking women to talk with us about their unique experiences. Your
experiences can help us to understand how certain life circumstances affect women’s
health. Do you have any questions so far?

We are asking women to schedule a convenient time for us to ask several questions about
their health and life circumstances. The interview is completely confidential, and will
take approximately two hours to complete. It may be more or less depending on your
own unique circumstance. Every woman who is interviewed will be reimbursed $3 0.00
for her time. We feel that your time is valuable and we would like to compensate you in

155

some way for taking the time to talk with us. And by agreeing to participate in this
confidential interview, we think that you can help us make Lansing more responsive to
your needs as well as the needs of other women in the community.

Does this sound like something you would be interested in doing?

(1F SHE SAYS THAT SHE IS INTERESTED, SCHEDULE THE INTERVIEW. IF
SHE SAYS THAT SHE IS NO LONGER INTERESTED, ASK HER IF SHE COULD
TELL YOU HER REASONS FOR DECLINING. THANK HER FOR HER TIME AND
CONSIDERATION)

156

PARTICIPANT CONTACT FORM

1. How did you find out about us? News Ad (Be specific):
Other:

 

2. What is your current relationship status?

3. Have you been involved in a relationship or dated someone in the past 6 months?

YES NO
4. We are interviewing women between 18 and 45. Do fall within this age range?
YES NO
(ONLY if she is ELIGIBLE)
Let's go ahead and schedule the interview at a time and location that works best for you.
Day/Date: Time: AM PM

 

 

Since you will be asked several personal questions about your health and life
circumstances, the location should be a place that is private and where you will feel
comfortable. We conduct interviews at a variety of locations. Most of our interviews
are done at the American Red Cross. They provide space for us weekday mornings and
evenings as well as on the weekends. If the American Red Cross does not work for you,
it is possible to meet on campus or at your home.

Location:

 

Your interviewer’s name is . and she will contact you
within 24 hours before your interview just to confirm the time and location, if that’s okay
with you.

Could I have your name and phone number?

Name: Phone Number:

 

When is the best time of day to get hold of you? AM (hours) __ PM (hours) ___'_

Is there a time when it is inconvenient for her to call you at this nmnber?

 

If she cannot reach you at the number you gave, is there another number or way for her to
get hold of you?

(write as much information as you can about getting in touch with her - use back)

The project number is (517) 432-3673. You’re welcome to leave a message at any time
if someone is not here when you call. Thank you so much, , for calling us.

157

APPENDIX C

Interviewer Training Syllabus and Training Schedule

158

Syllabus:

PSY 490: Independent Study with The Women's Health Project

SUPERVISOR:

Cheryl Sutherland

104 Baker Hall

353-8867(w); 337-3248(h)
Office Hours: by appointment

COURSE PURPOSE:

This course is the first in a two semester sequence of conducting field research.
The overall course sequence was designed to broaden your knowledge about the
relationship between stressful life circumstances and women's health issues; to provide
you with the necessary skills in recruitment and interviewing techniques, data collection,
data coding, and computer data entry; and to give you general experience in conducting
research In community settings.

The first semester of the course sequence is an introduction to the Women' S
Health Project. We will explore women's psychological and physical well-being within
the context of topics such as Women in the Workforce, Social Role Conflicts, Women
and Personal Safety, and Stress: Effects on Women's Health. More importantly, students
will receive extensive training in recruiting and interviewing skills, and will be expected
to complete several case interviews. The second semester of the sequence will focus on
completion of interviews along with further discussion of stress, social support, women's
health, and issues related to conducting community research.

FORMAT:

. This course will involve several components. These components include: weekly
training, readings, and discussion of relevant concepts; homework; interview case
responsibility; and weekly supervision of interview progress. We will meet twice a week
for about a total of 3 hours throughout the first semester. We will meet once a week
throughout the second semester. There will be no midterm or final for this course,
however, we will meet both registration and finals weeks.

Weekly training, readings. and discussion. Readings have been assigned for the
first seven weeks of training. Students are expected to do the readings each week pgig to
class and come to class prepared to ask questions and discuss what they've read. Part of
your grade will be based on your class participation. Because we will soon be out in the
community interviewing women, it is important that we know you have prepared each
week. Please feel free to ask any and all questions that you may have, no question is too
silly or too small to be discussed.

159

 

Case responsibility. Your cases are the women you are interviewing each week. These
will be assigned on an as needed basis approximately halfway through the first semester.
Efforts will be made to equalize the workload and number of cases that each student will
have, although obviously students who have signed up for more credits will be
conducting more interviews. It is hoped that you will receive an average of two
interviews per week. No student will receive a case until the supervisors have
determined that you are ready to begin interviewing. Case responsibility will constitute
the most significant part of your grade after training has ended. Several components of
case responsibility will be evaluated. These include:

1) Maintaining confidentiality

2) Contacting the interviewee and screening for her eligibility for the study

3) Conducting the interviews correctly and on time

4) Coding the interviews correctly and on time

5) Reporting your case to your supervisory group and handing in all materials on time

Homework. There will be weekly homework assignments for this class. During
training, homework assignments will include weekly readings, discussion topics, thought
papers, practice interviews and screening procedures, and current events. After training,
homework assignments will simply be your case responsibility and current events. Your
homework is important because it was designed to better help you master the material.
You must complete your homework assignments on time and in full. Assignments not
turned in on time or complete will not be given full credit.

 

Weekly supervision. Once you have been assigned a case, class will consist of
current events and weekly supervision. Attendance is mandatogv and participation a
must. All interview materials should be brought to class completely coded, with any
, questions you may have had clearly documented. In this way, your supervisory group
will be able to help you in the most efficient way. Supervision may include any or all of
the following components: listening to and coding other students' interviews, discussing
issues surrounding interviewing and woman battering, brainstorming additional
recruitment strategies and efforts, making decisions about coding rules, and reviewing
and role—playing various scenarios; Our group is designed so that everyone can give each
other feedback and suggestions, we would like it to be interesting and fun, as well as
instructive.

160

GRADING CRITERIA: »

Due to the unique nature of this two semester course, the grading criteria may be
different from those of other classes you have taken. Please be sure that you fully
understand the grading criteria as outlined, as no exceptions will be made.

Attendance and Class participation. During training, 50% of your grade will be
based on your attendance in class and your class participation. Attendance is critical in a
class such as this because we only meet twice a week, and each week we will discuss a
new topic and learn another aspect of the interviewing process. Therefore, attendance is
mandatory. If you miss more than one class, you will fail the course. If you _n_1_ust miss
class, it is imperative that you contact your supervisor within one day of class so that I
can meet with you to make up what you missed. Failing to do so will earn you zero
credit for that week. It is also imperative that you come to class on time and do not make
plans to leave class early. Tardiness will also result in a grade reduction for that week.
Class participation will be expected every week and includes sharing current events,
asking questions, discussing the readings, discussng other issues or concepts, and
actively listening and providing feedback to your colleagues. After training is completed,
30% of your grade will be based on your attendance and your class participation.

Homework. During training, the other 50% of your grade will be based on your
homework assignments. This includes doing the weekly readings, your discussion topics,
thought papers, bringing in current events articles to share, and turning in practice
interviews on time and in full.

Case resmnsibility After training is over, 70% of your grade will be based on
your case responsibility for each of the cases to which you are assigned. Please see
Criteria for Calculating Case Responsibility. This includes completion of interviews by
the agreed upon date and promptness of handing in data Case responsibility further
includes correctly coding the interviews before coming to class. In addition, interviewers
must demonstrate a reasonable amount of diligence and flexibility in attempting to
contact interviewees and setting up interviews. Grades will be reduced if the entire
interview packet is not turned in at the designated class meeting.

All interviewers are expected to conduct themselves in a professional manner
with all women. This includes keeping scheduled appointments, being on time to
appointments, conducting quality interviews, and treating all women with respect and
courtesy.

 

"Please Note: Random checks will be done with the women to verify that they received
their money, that you were on time for your appointment, and that you conducted the
interview in an appropriate manner.

If circumstances arise that prevent the accomplishment of any of the above-
mentioned criteria, it is the interviewer's responsibility to keep her supervisor informed
and up—to-date on any problems that may exist. This should be done as soon as the
problem arises, and n_o_t when the interview is past due.

EXCEPTIONS TO THE GRADING CRITERIA:

l6l

1) Anyone violating confidentiality during the Course of the semesters will
automatically be terminated as an interviewer and will receive a 0.0 for each term of
participation. This means not discussing your case with anyone, including family,
roommates, and partners. Even if you share information without revealing the woman's
name, this is still considered a violation of confidentiality. This also means not having
anyone accompany you to the woman's house, even if it is to drop you off. Please be sure
to keep your interview folders out of sight of everyone. Also please conduct phone
conversations with women from a private location. The M people you can discuss
cases with are those in your supervisory group.

2) Your grade for the first semester will be recorded as "incomplete" on your report
card. You will receive separate grades at the end of your second semester, my one
averaged grade. Should you drop out or be terminated before your commitment date, you
will receive a 0.0 for each semester of participation. If you need documentation of your
grade for a job, graduate school, or financial aid, just ask and we will provide this to you.

3) We reserve the right to not assign cases to interviewers whom we feel have not
demonstrated an adequate grasp of the interviewing techniques or the interviewing
process. Should this occur, you will be terminated from the project and will receive a 0.0
for each semester of participation. We will not take such action without making every
effort on our part to resolve the problem(s) first.

162

CRITERIA FOR CALCULATING CASE RESPONSIBILITY

As indicated earlier, a percentage of your weekly grade is comprised of case

responsibility. This encompasses the following components: 1) making a diligent effort
to complete your interview on time; 2) filling out your tape, progress report, and
interview correctly and completely; and 3) following project guidelines when conducting
and completing your interviews. Case responsibility grades will be calculated in the
following way:

4.0:

3.0:

2.0:

1.0:

0.0:

Interview is completed on time or the most diligent effort was made to do so.
Cassette tape, progress report, and interviews are filled out with no errors.
Interview was completed with no errors. (If you have coding questions that you
ask in class, your grade will not be reduced)

Interview is completed on time or a diligent effort was made to do so. Cassette
tape, progress report, and interviews are filled out with less than 3 minor errors.
Interview was completed with fewer than 2 errors.

Interview is either not completed on time due to a lack of diligent effort on the
part of the interviewer, and/or cassette tape, progress report, and interviews are
filled out with 3-6 minor errors, and/or interview was completed with 2-5 errors.

Interview is either not completed on time due to negligence on the part of the
interviewer, and/or cassette tape, progress report, and interviews are filled out
with 7-8 minor errors, and/or interview was completed with 6-7 errors.

Interview is either not completed on time due to lack of any effort on the part of
the interviewer, and/or cassette tape, progress report, and interviews are filled out
with 9 or more minor errors, and/or interview was completed with 8 or more
errors. ‘ ‘

163

Introduction
Week 1

Welcome

Overview of the Women's Health Project and the role of the interviewer

Review Syllabus and Training schedule

Agreement to Interview for the Project

Review homework for next week

READINGS FOR NEXT WEEK (Women in the Workforce):

1)

2)

3)

4)

5)

6)

Nelson, D.L., Quick, J.C., Hitt, MS, and Moesel, D. (1990). Politics, lack of
career progress, and work/home conflict: Stress and strain for working women.
Sex Roles, 2_3_(3/4), 169-185.

Matthews, K.A. and Rodin, J. (1989). Women's changing work roles: Impact on
health, family, and public policy. Amefiqm Psychologist, 514(11), 1389-1393.

Amatea, E.S. & Fong, ML. (1991). The impact of role stressors and personal
resources on the stress experience of professional women. Psvchologv of Women

Quarterly, _1_5, 419-430.

Reifinan, A., Biemat, M., & Lang, EL. (1991). Stress, social support, and health
in married professional women with small children. Psvchologv of Women

MEQBIMS-

Garcia, SA. (1989). My sister's keeper: Negative effects of social welfare and
affirmative action programs on black women. Sex Roles, 21(l&2), 25-43.

Spaights, E. & Whitaker, A. (1995). Black women in the workforce: A new lOok
at an old problem, Journ_al of Black Studies. 25(3), 283-296.

HOMEWORK:

1) Bring in one article/current events on women in the workforce.
2) Thought paper: 2 pages typed (no more or less please) on the readings
3) Interview one woman from community about work experiences as related to

the readings
4) Prepare discussion of readings

164

Women in the Workforce
Week 2

Current Events

Talk about Readings and thought papers

Review homework for next week

READINGS FOR NEXT WEEK (Social Role Conflict):

1)

2)

3)

4)

5)

6)

Barnett RC. and Baruch, GK. (1985). Women's involvement in multiple roles
and psychological distress. Journal of Persogalitv and Social Psychology, 42(1),
135-145.

Barnett, R.C., Havidson, H., & Marshall, N.L. (1991). Physical symptoms and
the interplay of workand family roles. Health Psychology, _l_Q(2), 94-101.

Katz, M.H. and Piotrkowski, CS. (1983). Correlates of family role strain among
employed black women. Family Relations, 3_2(3), 331-339.

McBride, A. B. (1990). Mental health effects of women' 5 multiple roles.
American Psychologist, 4_5(3), 381 -.384

Pugliesi, K. (1989). Social support and self-esteem as intervening variables in the
relationship between social roles and women's well-being. Commqu Mental
Health Journal, 25(2), 87-100.

Hays, PA. and Zouan', J. (1995). Stress, coping, and mental health among rural,
village, and urban women in Tunisia. International Journal of Psychology, 39(1),
69-90.

HOMEWORK:

1) Bring in at least one article/current events on a women and social (multiple)
roles.

2) Thought paper: 2 pages typed on the readings

3) Prepared discussion of readings

4) Interview one woman about social (multiple) role issues

165

Women and Multiple Roles
Week 3

Current Events

Talk about Readings and thought papers

Discuss interview

Review homework for next week

READINGS FOR NEXT WEEK (Women and the Global Economy):

 

 

 

1) Discrimination Against Women in the Global Economy (1992). WIN, 1_8_(l), 9-
10.

2) Corcoran, M., Duncan, G. J ., & Hill, M. S. (1984). The economic fortunes of
women and children: Lessons from the panel study of income dynamics. Signs:
Journal of Women in Culture and Sociefl, 19(2), 232-248.

3) Heath, J .A. & Ciscel, DH. (1988). Patriarchy, family structure and the
exploitation of women's labor. Journ_al of Economic Issues. 22(5), 781-794.

4) Amott, T. & Matthaei, J. (1988). The promise of comparable worth: A socialist-
feminist perspective. Socialist Review, 18(2), 101-116.

5) Zambrana, RE. (1988). A research agenda on issues affecting poor and minority
women: A model for understanding their health needs. 137-160.

6) Belle, D. (1990). Poverty and women's mental health. American Psvchologist,
£0), 385-389.

HOMEWORK:

1) Bring in one article/current events on women and finances or economy.
2) Thought paper: 2 pages typed on the readings

3) Prepare discussion of readings

4) Interview one woman about financial issues

166

Women and the Global Economy
Week 4

Current Events

Talk about Readings and thought papers

Discuss Interview

Review homework for next week

READINGS FOR NEXT WEEK (Women and Personal Safety)

Browne, A. (1993). Violence against women by male partners: Prevalence,

 

 

 

 

 

 

 

1)
outcomes, & policy implications. American Psychologist, 48(10), 1077-1087.

2) Heise, L. (1993). Violence against women: The missing agenda. In M.
Koblinsky, J. Tirnyan, & J. Gay (Eds), The Health of Women: A Global,
Perspective, pp. 171-187.

3) Okun, L. (1986). History. In Wom_2_m Abuse: Facts Replacing Mm,

pp.1-10.

4) Finkelhor, D. & Yllo, K. (1985). The myth and reality of marital rape. In
License to Rape: The Sexual Abuse of Wives pp. 13-36.

5) Gondolf, E. (1988). The survivor theory. In Battered Women as Survivors. 11-
25.

6) Goodman, L. A., Koss, M. P., & Russo, N. F. (1993). Violence against women:
Physical and mental health effects. Part I: Research findings. Applied and
Preventive Psvchologv. 2, 79-89.

HOMEWORK:

1) Bring in one article/current events on a women and personal safety.
2) Thought paper on the readings

3) Prepare discussion of readings

4) Interview one woman about personal safety issues

167

:Women and Personal Safety
Week 5

Current Events

Talk about readings and thought papers

Discuss interview ’ 1

Discuss homework assignment

READINGS FOR NEXT WEEK (Women's Health Status)

1) Elliot, 8.]. (1995). Psychosocial stress, women and heart health: A critical
review. Social Science and Medicine. 49(1), 105-115.

 

2) . Lempert, L. B. (1986). Women's health problems: A review of the literature.
flealth Care for Women Intem_ation_al, 1, 255-275.

3) Woods, N.F., Lentz, M., & Mitchell, E. (1993). The new woman: Health-
promoting and health-damaging behaviors. Health Care for Women International,
1_4, 389-405. -

4) Driscoll, M., Cohen, M., Kelly, R, Taylor, D., Williamson, M., & Nicks, G.
(1994). Women and HIV. In Alice J. Dan's (ed.), Reframing Women'; Healg;

Multidisciplinary Research and Practice. Sage Publications: Thousand Oaks,
CA., 175-186.

HOMEWORK:
1) Bring in one article/current events on the effects of stress on women's health.
2) Thought paper on the readings
3) Prepare discussion of readings

168

Stress: Effects on Women's Health
Week 6

Current Events

Talk about readings and thought papers

Discuss how practicing Eligibility/ Screening and phone calls went

Review first 1/3 (up through Social Support Section) of the WHP Questionnaire - please
take detailed notes

Practice asking questions in-class

Review homework for next week (tape screening for eligibility; fill-out
worksheet)(practice and tape first 1/3 of the interview)

READINGS FOR NEXT WEEK (Women's Health Care - Faulty Systems?):

 

 

 

l) Dahl, R.W. (1992). Women's mental health care - into the '908. Perspectives in
Psychiatric Care. 28(4), 29-31.

2) Davis, K. (1995). Editorial: The federal budget and women's health. American
Journal of Public Health, _8_5(8), 1051-1052.

3) Hawkins,'J.W. and Aber, CS. (1988). The content of advertisements in medical
journals: Distorting the image of women. Women & Heal—th, 14(2), 43-59.

4) Patient-doctor relationship

5) Women and their physicians

6) Mongella, G. (1995). Global approaches to the promotion of women's health.
Science. 269(11), 789-790.

HOMEWORK:

1) Thought paper (same as always) on the readings.
2) Practice with someone different from class and turn in interviews and tape
next week. Write down any and all questions and bring to class.

 

169

Women's Health Issues
Week 7

Current Events
Talk about Readings and thought papers
Discuss how practicing first 1/3 of interview went

Review second 1/3 (up through Stress Section) of the WHP Questionnaire - please take
detailed notes

Practice asking questions in-class

Review homework for next week (tape screening for eligibility; fill-out
worksheet)(practice and tape second 1/3 of the interview with a different student from
class)

READINGS FOR NEXT WEEK (Cultural Sensitivity:Women of Color)

1) Ehrenreich, B. (1991). Two, three, many husbands. In G. Kaufman (Ed.), 1p
Stitches: A Patchwork of Feminist Humor and Satire, pp. 27-31. ‘

t

 

2) Gordon-Bradshaw, R. H. (1987). A social essay on special issues facing women
of color. Women and Health. _l_2, 243-259.

3) Helms, J. E. (1992). Various selections from A Race is a Nice Thing to Have.

4) Lockhart, L. & White, B. W. (1989). Understanding marital violence in the black
community. Journal of Interpersonal Violence, 4(4), 421-436.

5) McIntosh, P. (1989). White priviledge: Unpacking the invisible knapsack. Peace
and Freedom, 10-12.

HOMEWORK:

1) No thought papers or discussion questions

2) Current Event article on cross-cultural issues

3) Complete reading assignment & prepare questions for class

4) Practice second 18 (Health & Stress section) of WHP interview with a
different person from class

5) Turn in interview and tape during class next week. Write down all questions
and comments about interview to discuss during class.

170

Cultural Sensitivity/W omen of Color
Week 8

Guest Speaker - workshop on cultural sensitivity
Current Events
Discuss reading assignments
Talk about how practice of second 1/3 of interview went
Review final 1/3 of the interview - take detailed notes
Discuss homework assignment - practice entire interview with a different person from
class. Turn in interviews and tape next week; written summary of course so far.
(LAST WEEK OF READINGS!!) Values, empathy, effective communication skills
packet
HOMEWORK:
1) This time entire interview will be practiced from beginning to end. Turn in
tape, interview, and additional forms next class period, with any questions that
may have come up.

2) 1-2 page summary about your thoughts on the course so far
3) Current Event on any topic related to women's health

Empathy and Values

Week 9
Current Events

Discuss Readings

Class exercises and discussion: values, empathy, effective communication skills
Review additional paperwork to be filled out: consent form, reimbursement voucher
Discuss mock project interview homework

Schedule 30 minute conferences with your supervisors to review progress, strengths, and
weaknesses before class the next week.

HOMEWORK:
1) Bring in current events articles related to the project
2) Meet with your supervisor

171

Week 10

Discuss and review major issues for mock-interviews
Review general issues of interviewer's responsibilities, What To Do If?....
Review tracking techniques

HOMEWORK:
1) Bring in article for current events
2) First interviews or tasks related to recruitment

Week 11

Case supervision
Discuss interviews

HOMEWORK:
** Bring in article for current events
** Interviews and recruitment as needed

Weeks 12 — 16 > case supervision; interviews to be turned-in
Friday prior to class so we can get feedback to you in a timely
fashion.

172

APPENDIX D

Participant Agreement Form

PARTICIPANT AGREEMENT
MSU WOMEN'S HEALTH PROJECT

The Women's Health Project is a research study conducted through Michigan State
University designed to better understand the different aspects of women's physical and
emotional health. You will be interviewed one time, for which you Will be paid $30.00.
It is expected that the interview will take approximately two hours. We feel it is
important to know exactly what you are agreeing to, so it is outlined below:

1. My involvement in this research study has been fully explained to me and I am
volunteering to participate. I realize that I may discontinue my participation at
any time Without penalty.

2. I agree to be interviewed by the Women's Health Project. I understand that I will

be paid $30.00 for completing the interview. I understand that I will be asked
questions about the social support I receive, abuse experienced (if applicable), and
my physical health, including questions about drug and alcohol use and at-risk
sexual behavior. I understand I may choose not to answer certain questions
without penalty.

3. I understand that any information I provide to anyone involved with The
Women's Health Project will be held in the strictest confidence and that my
anonymity will be protected. I understand this to mean that anyone involved with
the project may not disclose my participation in the project in any way.

4. I understand that I may receive results of this project, if I desire, after its
completion by calling or writing the Women's Health Project (Whose business
card I've received).

OPTIONAL:

I agree to have the interview tape recorded to ensure accuracy of information. I
understand that I can request that the tape recording be stopped at any time. I also
understand that this cassette tape will be held in the strictest of confidence, that my name
or any identifying information will not be recorded or marked on the tape, and that it will
be destroyed after the completion of the research study.

YES__ NO

 

 

 

Participant Signature Project Staff Date

174

APPENDIX E

Women’s Health Study Interview

175

RespondentlDil

’I/I/omen Lfiafl project
Interview

 

Name

0kay,we'realmostreadytostan. Ijustwantyoutoknowthatalloftheinformationthat
youhawgivalmethmhasmyidenfifymgmfomafimmigsuchasymnnamephonemmba,
and address, will be filed in a separae folder with only your identification number on it. This top
pageoftheinterviewwillalsobefiledinthatfolder. ’I'heaculalinterview,thathasallofthe
informationthatyouareabouttotell me, hasno identifying information on itatall. The only
thingontheinterviewisyouridentificationmnnber. So,thereisnowaymatifsomeonewereto
lookatthisinterviewfimttheywouldbeabletotellwhoyouwerefi'omtheinformationhere.
Okay? . . .

The Women's HealthProjectiSaresearchsuldythatisinterestedinmlkingwithwomen
abouttheirhealth. DeSpitetherecentincrease inresearchrelatedtowomen's health, we know
little about the relationship between specific life circumstances and women's overall well-being.
In order for us to effectively address the health needs of Lansing Area Women, we need your
help. The information you provide is crucial to our understanding of women's health issues.
Therefore, we will be asking you about various health concerns that you have right now, in
addition to asking you about other aspects of your life that may be affecting your health.

Do you have any questions before we get started?

176

RespondentIDit

 

InterviewerID#
Time Interview Started

 

Firstl'djlntliketoaskyou some general questionsabomyourself. Later, I'llbeasldngseveral
querfionsabomevunsthatmayhaveoocmredwifllinthepastsixmomhsorsinee

1. How would you describe your pm marital/relationship status?

MARRIED, LIVING TOGETHER .............................. 1
MARRIED, SEPARATED .................................... 2
(GO TO #1:)

DIVORCED ............................................... 3
(GO TO #11:)

GRLFRIEND/BOYFRIEND, LIVING TOGETHER ............... 4
GIRLFRIEND/BOYFRIEND, NOT LIVING TOGETHER .......... 5
DATING. NOT GIRLFRIEND/BOYFRIEND ......... - ........... 6
NOT CURRENTLY DATING ANYONE ........................ 7
OTHER (_L ) .................................. 0

 

 

 

 

la. Are you in a relationship with someone new now?

 

YES (explain: ) ............................ l
: NO . .. ..................................................... 2
(not applicable) ............................................. 8

2. How many children do you have? (INCLUDES CHILDREN BY BIRTH, ADOPTION,
GUARDIAN SHIP, AND REMARRIAGE OR LIVE-IN RELATIONSHIP)

(IF NO CHILDREN, GO TO #3)
2a. What are their ages? (INDICATE NUMBER IN EACH AGE RANGE: NO
CHILDREN = 88)
UNDER FIVE YEARS OLD
5 TO 12 YEARS OLD
13 TO 18 YEARS OLD
OVER 18 YEARS OLD

(IF ALL CHILDREN ARE GROWN, GO TO #Zc)
2b. What type of custody do you currently have of your children?

 

FULL ................................ 1
(IN COURT PROCESS) TEMPORARY ......................... 2
(DIVORCED: EQUAL CUSTODY) JOINT ............................... 3
(NO CUSTODY) NONE ............................... 4

(CHILDREN ARE GROWN) ............. 5
OTHER( 3 ............. o
No CHILDREN ........................ 8

177

 

Ea)

Responds-111m

 

a

2c. How many of your children are currently living with you?
(SI-IE HAS NO CHILDREN) ............ 88

(IF NO CHILDREN LIVING AT HOME, GO TO #3)

(ASKQNLX IF #ZC IS LESS THAN #2)
2c1. How old are the children who arecrn-rently living with you?

UNDERFIVEYEARSOLD
5T0 12YEARSOLD

13 TO I8YEARSOLD
OVER I8YEARSOLD

2d. Raising children is a large responsibility. In the very least, caregiving may
involve preparing meals, arranging doctor appointments, assisting with
homework, and providing adult supervision. In some families several people
pitch in to take care of 100% of the responsibilities. In other families, only one
persondoesitall. Inmfarnily,whatpercentofthe childraisingdutiesdoygu
take care of?

%

(IF LESS THAN 100%) Who takes care of the other percent of childcare

 

 

 

responsibilities?
%
%
%
In the last six months, have you been employed?
(GO To #3:.) YES ....... A ................................... 1
(GO TO #3d) NO . .‘ ......................................... 2
. 3a. (IF YES) Are you employed right now?
YES .......................................... 1
NO ........................................... 2
(not applicable) ................................. 8

3b. What type of work do/did you do? (IF EMPLOYED IN PAST 6 MONTHS)

 

(NOT EMPLOYED IN PAST SIX MONTHS = 8)

178

 

 

 

 

RespondentID#

 

 

4
3c. Do/did you work full-time, part-time or temporarily (seasonal; ofi‘ and on)?
(FULL TIME = 35 HOURS PER WEEK OR MORE)
FULL-TIME ................................... l
PART-TIME ................................... 2
TEMPORARY .................................. 3
(not applicable) ................................. 8
3d. Do you receive any of the following benefits?
ems ELSE NONE DK MA
MEDICAL INSURANCE .............. l 2 3 7
DENIAL INSURANCE ............... 1 2 3 7
EYE CARE ......................... 1 2 3 7
SICK LEAVE ....................... 1 2 3 7 8
MATERNAL LEAVE ................. 1 2 3 7 8
OTHER ( _ ) ..... ' l 2 3 7 8
Are you currently a student?
(GO TO #4a) YES .................................... 1
(GO TO #5) NO ..................................... 2
4a Part-time or full-time?
' PART-TIME ............................. l
FULL-TIME ............................. 2
(not applicable) ........................... 8
What‘s your current educational level?
LESS THAN HIGH SCHOOL ............... 1
HIGH SCHOOL GRAD/ GED ............... 2
SOME COLLEGE ......................... 3
VOCATIONAL/TRADE SCHOOL ........... 4
BACHELOR'S DEGREE ................... 5
POST-BACHELOR'S DEGREE .............. 6
OTHER ( i ................ 0

 

179

6. IknowalotofpeOple don't liketo talk aboutthe amount ofmoneythey make‘but it can
be related to their health status. Would you mind telling me your amt gross household
monthly income? (MAKE SURE THIS INCLUDES ANY GOVERNMENT
ASSISTANCE, CHILD SUPPORT, JOB EARNINGS, DIVIDENDS, AND
INCOME OF HER PARTNER - IF APPLICABLE)

JOB EARNINGS IMONTH
OTHER INCOME .- - ~ IMONTH L-
AVERAGE MONTHLY INCOME = i .. / MONTH

6a How many people does this monthly income support?

7. Howmuchofthisincomedoygudirectlybringintothehomeratherthananotheradult

Respondth

 

5

 

 

 

 

 

 

 

(INCLUDE CHILD SUPPORT AS HER INCOME)?

 

PROBE TO ENSURE
ACCURACY OF RESPONSE

 

 

(U' NOT INVOLVED IN A RELATIONSHIP RIGHT NOW, GO TO #9)

NONE OF THE INCOME ...................... l l

1/4 OF THE INCOME OR LESS ................ 2
BETWEEN 1/4 AND 10 OF TIIE INCOME ....... 3
”2 OF TILE INCOME ......................... 4
BETWEEN 1/2 AND 3/4 OF THE INCOME ....... 5
3/4 OR MORE OF THE INCOME BUT NOT ALL . . 6
ALL OF THE INCOME ....................... 7

 

8. How much of this income does your (husband/boyfriend/partner) contribute? (IF SHE
BROUGHT IN ALL OF THE INCOME, MARK "1")

9. Do you have regular access to a car?

NONE OF THE INCOME ...................... 1
1/4 OF THE INCOME OR LESS ................ 2
BETWEEN 1/4 AND 1/2 OF THE INCOME ....... 3
1/2 OF THE INCOME ......................... 4
BETWEEN 1/2 AND 3/4 OF THE INCOME ....... 5
3/4 OR MORE OF THE INCOME BUT NOT ALL . . 6
ALL OF THE INCOME ....................... 7
(not applicable - No Partner) .................... 8

180

ReepondentlDIIl

 

6
10. Asforyourcurrent living situation, do yourent, own yourhome, orhave some other living
arrangements?

RENTING APT. OR HOME .................... 1
RENTING A ROOM .......................... 2
OWN/BUYING YOUR HOME ................. 3
STAYING W/FRIENDS/RELATIVES ............ 4
OTHER( 1 ................ 5

 

11. Howmanyotheradultsliveinthesamehomeyou'rein?
(HOMELESS .................... 88) *

12. How many children live in the same homeyou're in?
(HOMELESS .................... 88)

 

13. What is you date of birth? _/_/__

14. What is your race or ethnic background?

 

181

III.

 

“In T

RespondentlD#

 

01' [LED . .

Inthissectionoftheinterview,Iwanttofindomhowyoufeelabomvariouspartsofyomlife.
Pleasetellmethefeelingsyouhavenownaldngmaccomwhathashappenedinthemsix
monthsmdwhatyouexpectmthemfim.(HANDPARHCIPANTGREENCARD#l)

OutliiscardaretheanswersthatI'd likeyoutogiveme. I'llbeaslcingyouabomalistofthings.
Afierlaskyoueachquestion, pleasetellmewhatansweronthiscardgivesflrebestsmnmaryof
how you feel: either "EXTREMY PLEASED", 'PLEASED", "MOSTLY SATISFIED“,
"EQUALLY SATISFIED AND DISSATISFIED", I'MOS'I'LY DISSATISFIED”, "UNHAPPY",
or "TERRIBLE", depending on how you feel about that part of your life. If you feel that a
question doesn't apply to you, just let me know.

15.

16.

17.

l8.

19.

20.

21.

22.

~ How do you feel about the amount of ftm and enjoyment you have? ............

l = BUREMELY PLEASED
. 2 = PLEASED
3 = MOSTLY SATISFIED
4 = EQUALLY SATISFIED AND DISSATISFIED
5 = MOSTLY DISSATISFIED
6 = UNHAPPY
7 = TERRIBLE
9 = refused to answer

First, a very general question. How do you feel about
your life overall? ....................................................

In general, how do you feel about yourself? . . .' ............................

How do you feel about your personal safety? ..............................

How do you feel about the responsibilities you have for members of your family? .
How do you feel about what you're accomplishing in your life? ................

How do you feel about your independence or freedom, that
is, how free you feel to live the kind of life you want? .......................

How do you feel about your emotional and psychological well-being? ..........

How do you feel about the way you spend your spare time? ..................

182

Respondent ID#

 

8

S '15 S . _ , ‘ _
Nowl'mgoingtoaskyousomeqmtionsabomhowyoufeelabomthekindofsmportandhow
youfeelabmntheammmtofsupportthatyougetfi'omfiiendsandfamily. (GREENCARDfl)

AMforeechofthequesfionsinthefollowingsectionl'dlikeyoutousetheGREENCARD
#1. Ifyou feel like aquestion doesn't apply,justletmeknow.

1 = EXTREMELY PLEASED

2 = PLEASED " -

3 = MOSTLY SATISFIED -. '-

4 = EQUALLY SATISFIED AND DISSATISFIED
5 = MOSTLY DISSA’I'ISFIED

6 = UNHAPPY

7 = TERRIBLE

9 = refused to answer

The first couple of questions have to do with companionship.
24. In general, how do you feel about the mom; of companionship that you have? . . . __
25. In general, how do you feel about the quality, of companionship that you have? . . . __

Okay, thanks. Now I'm going to ask you about a different kind of help that you may receive from
others called ”advice and information". This means being able to count on folks to provide you
with advice and information about IRIS—Q1111 matters, such as problems with yom' children,

spouse. or dealing with a personal situation. It can also be getting advice or information about
m, such as finding a job or a place to stay, where to find furniture or other material goods,
and things like that.

26. In general, how do you feel about the 3mm of
advice and information that you receive? .................................

27. In general, how do you feel about the mug of

advice and information that you receive? ................................. __
The next couple of questions have to do with another type of support called "practical
assistance," for example, people you can count on to help you get things or do things. These are
people that you can count on to be dependable when you need help, or that you can cormt on to
do a favor for you, like take you someplace you need to go, watch your kids, loan or give you
small amounts of money or something you need.

28 . In general, how do you feel about the amount of practical assistance
that you receive? ....................................................

29. In general, how do you feel about the Quality of practical assistance
that you receive? ....................................................

183

Respondent”

 

l = EXTREMELY PLEASED

28 PLEASED

38 MOSTLY SATISFIED

48 EQUALLY SATISFIED AND DISSATISFIED
5= MOSTLY DISSATISFIED

6= UNHAPPY

7= TERRIBLE

9 8 refused to answer ..

Nowl'dliketoaskyouabomthe"emotional support”thatyoureceive. Thiscanmeanbeing
abletocountonsomeonetolistentoyouwhenyouwanttotalkabomsomethingpersonakor
feelingthattherearepeopleinyomlifewhoreallycareabomyou.

30.

31.

In general, how do you feel about the m ofemotional
support that you receive? ..............................................

In general, how do you feel about the quality of emotional
support that you receive? .............................................. _

This last group of questions have to do with the "financial assistance” you may receive or have
available to you. This can mean being able to count on someone to loan or give you large
amounts of money when you need it. For example, these would be people who could help you
pay monthly bills if you were to lose part or all of your income.

In general, how do you feel about the 3mm of financial assisance that

is available to you? ....................................... . ............
Sometimes, people may provide financial assistance when you need it, and they do it in a
way that makes you feel good. Other times, people may provide financial assistance in a
way that makes you feel inadequate or bad. In general, how do you feel about the quality
or appropriateness of financial assistance that is available to you? ..............
Now, for the _last question about social support, how do you feel, 9351311,

about the amount and quality of the support and help you receive from others? . . .

184

Respondent“

 

10

H ”U . . _
Ihecenerdsaiesofquesfionsuemeammfindommoreabomyomphysicalhealth. Firstlwill
askseveralqueetionsabomyomgeneralhealthstatus. Then,Iwillaskifyouhaveexperienceda
varietyofphysiealhealthproblemsatsomepointdm'ingyourlifetime. Ifyoudon'tfeelthata
question applies to you, please just let me know.

35. Okay, let's begin with a few questions about your general health. How would you
describe your germal state of health right now? Would you say it is:

EXCELLENT ........................... '1 ............ 1
GOOD ................ ' ............. 2
FAIR ............................................... 3
POOR ............................................... 4

36. Many women may experience a variety of physical health problems at some point dtn'ing
their lifetime. Some problems last a long time (several years), others occur for a short
period oftime (few weeks), then eitherdisappearorrecur. Pleasetell me ifyoumhad
any of the following health problems, even if you aren't having the problem anymore?

mm
W W KO

 

 

 

 

High Blood Pressure .................. 1 2 3
Heart/Circulation Problems ............. 1 2 3
Arthritis ............................ 1 2 3
Allergies ............................ 1 2 3
Diabetes ............................ 1 2 3
Excessive Weight Gain or Loss .......... l 2 3
(2-3 lbs/wk for 3 months)

Eating Disorder ...................... 1 2 ' 3
Cancer (specify: I . . l

(dtn'ation: )

Repeated or Long-term Infections

(specify: ) . . l 2 3
(duration most recent: )

Have you had any other health problems . . 1 2 3

that 1 did not mention?

37. Do you currently have a physical health problem or disability that makes it difiicult for
you to do the things you want or need to do?
(GO TO #3711) YES ............................... - ..... 1
(GO TO #38) NO ..................................... 2

 

37a. What is the physical health problem or disability?

 

185

RespondentlD#

 

ll

38. Nothavealistofspecificsymptomsandwouldlikeyoutoanswerhowmuchyouhave
experiencedtheseinthelastsixmonths, orsime

(USE PINK CARD #3 AND MARK ALL RESPONSES IN COLUMN A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR COLUMN B: FOR COLUMN 2:
1=NEVER (EX-PWCI') (Pm)
2=ONCEAMONTH ORLESS 1=YES l=YES
3820R3TIMESAMONTH 2=NO , .- 2.4.10
4 3 ONCE OR TWICE A WEEK 8 = 001 applicable 8 3 mt applicable
583OR4TIMESAWEEK 9=noanswer 9=noanswer
6 = MORE THAN 4 TIMES A (explain why) ' (explain why)

WEEK (# 57) (#70)
. A B C
Sleep problems (can't fall asleep,wake up in the
middle of the night or early in the morning) . . . . / /
Nightmares ................................. / /
Back pain. .................................. / /
Constipation ................................ / /
Dizziness .................................. / /
Diarrhea ................................... / /
Faintness .................................. / /
Constant fatigue ............................. / /
Migraine headache ........................... / /
Headache ................................. / /
Nausea and/or vomiting ...................... l /
Acid stomach or indigestion .................. / /
Stomach pain .............................. / /
Ulcers .................................... / /
Hot or cold spells ........................... / /
Hands trembling ............................ / /
Heart pounding or racing ..................... / /
Poor appetite .............................. / /
Shortness of breath when not
exercising or working hard ................ /
Numbness/tingling in parts of your body ......... / /
Choking sensations ......................... / /

 

186

RespondentID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. FOR COLUMN B: FOR COLUMN C:

”NEVER (Ex-Mar) . (Partner)

28ONCEAMONTHORLESS 1=YES l=YES

3820R3TIMESAMONTH 2=NO 28NO

4 = ONCE 0R TWICE A WEEK 8 = not applicable 8 = not applicable

$=3OR4TIMESAWEEK 9=noanswer 9=noanswer

6 8 MORE THAN 4 TIMES A (explain why) . (explain why)

WEEK
A ‘ B 9

Feeling weak all over ........................ / /
'Painsinyom'heartorchest ................... / /

Feeling low in energy ........................ / /

Blurred vision .............................. / /

Muscle tension or soreness ................... / /

Muscle cramps ............................. / /

Severe aches and pains ....................... / /

Ringing in your ears ...................... p. . . / /

Pelvic pain ................................ / /

Vaginal bleeding or discharge

(other than your period) .................. / /

Painful intercourse .......................... / /

Rectal bleeding ............................. / /

Bladder infections .......................... / /

Painful urination (passing water) ............... / /

 

187

RespondentID#

 

13
39. Nowl‘mgoingtogothroughalistofcommontypesofinjuriespeoplemayexperience.1

muldlikeyoutoanswerhowmuchyouhaveexperiencedtheseinthehstsixnonths,
orsince :

(USE PINK CARD #3 AND MARK ALL RESPONSES IN COLUMN A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR COLUMN B: FOR COLUMN 9:
l=NEVER (Ex-Partner) , (Partner)
28ONCEAMONTHORLESS lgygs lgygs
3=20R3TIMESAMONTH 2=NO 2=NO
4=0NCE 0R TWICEAWEEK 8 =notapplicable 8=notapplieable
5830R4TIMESAWEEK 9=noanswer 9=noanswer
6 8 MORE THAN 4 TIMES A (explain why) . (explain why)
WEEK .

A B C
A. Cuts, scrapes, or bruises ................ / /
B. Soreness without bruises ............... / /
C. Bums, including rug burns .............. / /
D. Loose or broken teeth .................. / /
E. ' Broken bones or fiactures .............. / /
F. Internal injuries ...................... / /
G. Strains or sprains ..................... / /
H. Dislocated joints . .................... / /
1. Pregnancy complications/miscarriage ..... / ./
(NO PREGNANCY in last 6 months = "8")

J. Knife or gunshot wound ................ / /
K. Permanent scarring .................... / /
L. Any other injuries not mentioned

( ) ..... / /

188

RespondentID#

 

l4

Inthisnextsetofquestionslwillaskyouaboutyouruseofalcoholanddrugs;ing]nding

W. Itisnottmcommonforpeopletousealcoholordmgsasawayofcoping
whensituationsbecomeverystressfulorasaformofrecreation. Pleaserememberthatallof

yommswerswfllbekeptsuicdyconfidenfialandanswerasumhfilflyaspossible.

40. First]havealistofsubstancesandwouldlikeyoutoanswerabomhowofienyouhave
used each of the following substances in the last six months, or since about

(USE PINK CARD #3, AND MARK ALL RESPONSES 1N COLUMN A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lam-IVER ' ‘ COLUMN 3: (Cngeg (gm 12‘
2 8 ONCE A MONTH OR LESS 1 8 YES -

1 8 INCREASED l 8 INCREASED
3820R3TIMESAMONTH 2=NO 28STAYED 28STAYED
48ONCE OR TWICEAWEEK 8 =not applicable 3.le AME
5830R4TIMESAWEEK 98 S S
6=MORETHAN4MSA “rm 38DECREASED 3=DECREASED

( ) 8 8notapplicable 8 =not applicable

WEEK 9 2 mm 9 = no anSWC!

9 8 refused to answer no
(#59) (#71)
A B C D

A. Nicotine (i.e. cigarettes) .......... / / /
B. Alcohol‘(any use at all) .j. ..... ,. ,. . / A / /
C. Marijuana..i..5... ............. I" / /
D. Non-prescribed or street drugs.

such as cocaine, crack, Speed.

uppers, heroin, LSD ............. / / /
E. Sedatives, hypnoucs. tranquilizers.

or painkillers .................. / / /
F. Anti-depressants ................ / / /
G. Inhalants, such as astluna relievers . / / /

 

 

41.(IF SHE HAS USED SEDATIVES, HYPNOTICS, TRANQUILIZERS, or PAINKILLERS)
Were the sedatives, hypnotics. tranquilizers, or painkillers prescribed by a doctor?

YES ..... . ................ 1
NO ...................... 2
(not applicable) ............ 8

189

RespondentID#

 

15

42.([F SHE HAS USED ANTI-DEPRESSANTS)
Were the anti-depressants prescribed by a doctor?

' YES ..................... 1
NO ...................... 2
(not applicable) ............ 8

43.([F SHEHASUSED INHALANTS)
Weretheinhalantsprescribedbyadoctor?

YES ..................... 1
NO ...................... 2
(not applicable) ............ 8

IF ALL OF THE SUBSTANCES (MA-G) EQUAL 1, GO TO #45,
AND MARK '8' IN COLUNIN B.

IF SHE HAS USED ANY OF THE SUBSTANCES, CONTINUE
WITH #44, AND MARK ANSWERS IN COLUMN B:
INTRODUCE THE QUESTION BY SAYING:

 

44. Some people turn to the types of substances 1 just mentioned when situations become very
mm for them. Now I will go back to the list of substances I mentioned earlier, and ask if you
have used any of them to relieve stress in the past six months.

(GO BACK To THE BEGINNING or THE LIST. FOR EACH ITEM THAT SHE REPORTED
USING. W ASK HER IF SHE HAS USEB THAT SUBSTANCE To RELIEVE

STRESS IN THE PAST SIX MONTHS. MARK ALL OF THESE ANSWERS IN COLUMN 3. IF
SHE HAS NOT USED A PARTICULAR SUBSTANCE IN THE PAST SIx MONTHS, MARK "8"

IN COLUMN B.)

45. Would you consider yourself to be an:

 

 

 

 

ALCOHOLIC ............................... 4
ASK EACH HEAVY/ PROBLEM DRINKER ............ . . . . 3
RECOVERINO ALCOHOLIC .................. 2
NO PROBLEMS WITH ALCOHOL ............. 1 (GO To #47)

46. Have you ever received treatment for alcohol abuse in the past six months?

(GO TO #46a) YES ..................... 1
(GO TO #47) NO ...................... 2
(not applicable) ............ 8

190

47.

48.

49.

RespondentlD#

 

 

 

 

 

16
46a. Whattypeoftreatmenthaveyoureceived? '-
INPATIENT ..................... 1
OUTPATIENT ................... 2
ALCOHOLICS ANONYMOUS ..... 3
(not applicable) .................. 8
Would you consider yourself to be:

ADDICTEDTODRUGS ........ . ....... ..4

ASK EACH HEAVY/PROBLEM DRUG USER ................. 3
RECOVERING FROM AN ADDICIION TO DRUGS . . 2
NO PROBLEMS WITH DRUGS ................... 1 (GO TO #49)

Have you ever received neatment for drug abuse in the past six months?

(GO TO #48a) YES ..................... 1
(GO TO #49) NO ...................... 2
(not applicable) ............ 8

48a. What type of treatment have you received?

INPATIENT .. .................... 1
OUTPAIIENT ................... 2
NARCOTICS ANONYMOUS ...... 3
(not applicable) .................. 8

It is not unusual for some pCOple to think about suicide when life becomes very difl'icult for
them. Because this is one aspect of your overall health and well-being, I‘m going to ask a few
questions about suicidal thoughts and feelings you may have experienced in the last six months.

How Often have you thought about ending your life in the past six months?
(USE PINK CARD #3)

NEVER ................................. 1 (IF "NEVER", GO TO #50)
ONCE A MONTH OR LESS . ................ 2
2' OR 3 TIMES A MONTH .................. 3
ONCE OR TWICE A WEEK ................ 4
'3OR4TIMESAWEEK .................... 5
MORE THAN 4 TIMES A WEEK ............ 6

49a. Have you told someone else you wanted to end your life in the past six months?

 

YES .............................. 1 --—> HOW MANY TIMES?
NO ............................... 2 (888 if NO or not applicable)
(not applicable) ..................... 8

191

 

RespondeIItIDIIIl

17
49b. Have you tried to end your life in the past six months?
YES ............. . ...... - ........... 1 ---> HOW MANY TIMES? __
NO ............................... 2 (888 if NO or not applicable)
(not applicable) . . . ..- ................ 8

S C . .

50. Nowl‘dliketoaskyou abomalistofproblemsthateanbe-commOnfor-somewomen. Theseare
dificult Situations or circumstances that may make you life more troublesome. For each
question I ask, I'd like you to decide if it is a problem for you. You can simply tell me ”YES” or
"NO”. Someofthesemay not applytoyou,buttobeconsistent,weneedtoaskthemof
everyone. If any of these questions make you Imcomfortable, or don‘t apply to you, just let me
know. ' .

‘IF NOT W IN A RELATIONSHIP, SKIP ITEMS WITH ASTERISK AND .
. MARK '8' .
RES NQ MA
A. Does you work or school interfere with you family life? . . . . l 2 8
(IF NOT WORKING OR IN SCHOOL 8 8)

* B. Does you partner's work or school interfere

with you family life? ................................. 1 2 8
C. Have you been hospitalized in the past year
for any reason - accident or illness? ..................... 1 2 8
" D. ls you partner away from the home more than
half of the time because of a job or other
reason? ............................................ 1 2 8
E. Do you have long-term debts. i.e. more

than 2 yeus? ....................................... 1 2 8
F. Do you have problems with you credit rating? ............. l 2 8
G. Do you get hassled by bill ‘ .

collectors or collection agencies? ....................... 1 2 8
H. Have you been looking for a job and have

not been able to find one? ............................. 1 2 8

* I. Are you having regular arguments or conflicts
with you present partner or steady girl/boy-fi'iend? ......... 1 2 8

192

RspondentlDil

 

Areyouhaving some sortofprobls-withany

one of your former spouses or partners .................... l 2 8
Do you lave trouble with you landlord? ...... ‘ ............ l 2 8
(IF NOT RENTING 8 8)’ . ’
Haveyouhadfiequentillnessesthispastyear? ........ ‘ ..... -. 1 .2 8
Do you feel you do not have enough privacy? ............... ' l 2 8
Do you have people living with you, relatives

orfiiends,thatyou wish weren't there? .................... 1 2 8
Do you have neighbors who are unfriendly

or are giving you problems? ............................ 1 2 8
Do you or someone in you household have a

longterm illness? ..................................... 1 2 8
Would you say that you are living in a place

that is Imsatisfactory or more than you can afford? ........... 1 2 8
Does you partner have a problem with alcohol or drugs? ..... 1 2 8
Does someone in you household other than you

(or you partner) have a problem with alcohol

or drugs? ............................................ 1 2 8
IS someone (other than a current partner)

abusing you in any way? ............................... 1 2 8
Is you partner in jail? ................................. l 2 8
Are you without a phone at you present home? ............. 1 2 8
Are any of you children experiencing learning problems or

other school problems that require you to consult with

the teacher or other school officials? ...................... l 2 8
Are any of you children having serious

emotional or behavioral problems at home, such

as repeated nightmares, tantrums, or outbusts? ............. 1 2 8

193

Respondent”

 

19

51. Now,I'dliketoaskyouaboudifi‘erenteventsthatmayhavehappenedto-youinthelutsix
months. SomedmesougmsuesslevdcaninfluenceflleWaywedunkandfeelabmHan
eventthathappenedawhile ago. Tohelpyourememberhowyoufeltmjhemmm
mrdlikeyoutotellmewhenitoccured. Then,thinkingbacktothatdate,tellmehow
upsettingorsnessfilltheeventwasforyou (HANDPARTICIPANTORANGECARD#5)
Thesearetheanswersl'dlikeyoutouse. Agaimsomeofthesemaynotapplytoyoubutobe
consistem,weneedtoaskthemofeveryone. IftheydonotapplytoymLpleaseletmeknow.

IF THERE WAS MORE THAN ONE OCCURRENCE OF AN EVENT, RECORD THE MOST
RECENT ONE. IF THE PARTICIPANT DID NOT EXPERIENCE AN EVENT, LEAVE THE DATE
COLUMN BLANK AND MARK ”8". IF A WOMAN CANNOT REMEMBER THE EXACT DATE,

ASK HER TO ESTIMATE.

I'd like to start with a few questions about you serious relationships.

In the last six months have you:
A. Started a steady dating relationship? ..........
B. Ended a steady dating relationship? ...........

C. Married or started a long-term
committed relationship? ....................

D. Separated or ended a long-term
committed relationship? ....................

E. Reconciled a marital or romantic relationship? . .

F. Had increased arguments with you
spouse or partner? ........................

G. Moved to a new town or neighborhood? ......

H. Learned that you partner or spouse
was unfaithful to you (i.e. was having an affair)?

194

ccccccccc

000000000

1 8 NOT AT ALL STRESSFUL

2 8 A LITTLE STRESSFUL

3 8 MODERATELY STRESSFUL
4 8 VERY STRESSFUL

5 8 EXTREMELY STRESSFUL

8 8 not applicable

STRESS

Respondent”

 

20

IF THEREWAS MORE'I'HAN ONE OCCURRENCE OF ANEVENLRECORDTHEMOST
RECENT ONE. IF THE PARTICIPANT DID NOT EXPERIENCE AN EVENT, LEAVE THE DATE
COLUMN BLANK AND MARK ”8".

l 8 NOT AT ALL STRESSFUL

2 8 A LITTLE STRESSFUL

3 8 MODERATELY STRESSFUL
4 8 VERY STRESSFUL

5 = WY STRESSFUL
8 8 not applicable
mass
MQflR ammo
In the last six months have you:
I. Had an afi‘air? ..................................... /

J. Had a serious argument with a friend
or neighbor? ...................................... /

K. Started any kinds of classes at school? This

includes adult learning, commutity education, community

college, etc. ...................................... /
L. Stopped attending school? ........................... /

M. Started a new job or experienced a
big change in you curent job? ....................... /

N. Has you partner or spouse start a new
job or experienced a big change in
their current job? .................................. /

0. Been fired or laid off from you job? ................... /

P. Had you partner or spouse been fired, laid
off or quit their job? .............................. / _—

Q. Had new troubles with you boss or

other people at work? ............................... _/_
R. Retired? ......................................... _/_
S. Had you partner or spouse retire? ..................... _/___

195

RespondentIDIV

 

21

IF TEERE WAS MORE THAN ONE OCCURRENCE OF AN EVENT,-RECORD«TI-E MOST
RECENT ONE. IF THE PARTICIPANT DID NOT EXPERIENCE AN EVENT, LEAVE THE DATE
COLUMN BLANK AND MARK "8".

In the last six months have you:

T.

Quit you job? ....................................

Okay, let's talk a bit about you family. In
the last six months have you:

U.

V.

BB.

Had or adopted a child? .............................

Had trouble with you partner's
or spouse's family members? .........................

Had trouble with one of you family
members? (not you partner or spouse) .................

Had a new person move into you home? ...............
Had any serious illness or injuries? ....................

Had any serious illness or injuries
happen to you partner or spouse? .....................

Had any serious illness or injuries
happen to one of you children? .......................

Had any serious illness or injuries
happen to any other family members? ..................

196

l 8 NOT AT ALL STRESSFUL

2 8 A LITTLE STRESSFUL

3 8 MODERA‘H-lY STRESSFUL
4 8 VERY STRESSFUL

S 8 EXTREMELY STRESSFUL

8 8 notapplicable

STRESS
MQflB. m

RespondemlDil

 

22

IF THERE WAS MORE THAN ONE OCCURRENCE OF AN EVENT,‘RECORD TIE MOST
RECENT ONE. IF THE PARTICIPANT DID NOT EXPERIENCE AN EVENT, LEAVE TIE DATE
COLUMN. BLANK AND MARK ”8".

l 8 NOT AT ALL STRESSFUL
2 8 A LITTLE STRESSFUL
3 8 MODERATELY STRESSI-‘UL
4 8 VERY STRESSFUL
S 8 EXTREMELY STRESSFUL
8 8 not applicable
STRESS
MQZXR ' RAIINQ
In the last six months have you:
CC. Had a miscarriage or stillbirth? ....................... _/_
DD. Found out that you’re tmable to
have children? .................................... _/__
EE. Started menopause? ................................ _/__
FF. Had any sexual difficulties? .......................... _/_
GG. Experienced the death of a child? ..................... _/___
HH. Experienced the death of a partner or spouse? ............ _/_

II. Experienced the death of an other
close family member? .............................. _/_

JJ. Experienced the death of a close

fi'iend? .......................................... _/__
KK. Experienced the death of a pet? ....................... _/____
These next questions have to do with you finances. In the
last six months have you:
LL. Had less money than usual? .......................... _/_
MM. Taken on a major purchase? .......................... _/_
NN. Started receiving public assistance? .................... _/_
00. Had you utilities shut off? .......................... _/_

197

Respondent”

 

23

IF TIERE WAS MORE THAN ONE OCCURRENCE OF AN EVENT, RECORD THE MOST
RECENT ONE. IF THE PARTICIPANT DID NOT EXPERIENCE AN EVENT, LEAVE THE DATE
COLUMN BLANK AND MARK ”8".

l 8 NOT AT ALL STRESSFUL
2 8 A LITTLE STRESSFUL
3 8 MODERATELY STRESSFUL
4 8 VERY STRESSFUL
.5 8 EXTREMELY STRESSFUL
8 8 not applicable

, STRESS
MQLXR ammo

PP. Been without phone service .......................... _/_
Finally, let's talk about you legal status.
In the past six months have you:

QQ. Been involved in a law suit or any legal action? . . . .I ...... _/_

RR. Had your driver’s license taken away
by the police or court? .............................. /_

SS. Been a victim of property damage or theft? .............. /

Tl". Been a victim of violent crime. such
as rape or assault? ................................. /

UU. Been arrested or convicted of a

serious crime? .................................... _/_
W. Received a jail sentence or probation? .................. _/_
WW. Been released from jail? .......... ' .................. '__/_
XX. Had you children taken away from you

or been threatened with having you

children removed from you home? .................... _/_

198

Respondent”

 

24

52. Lift-LEW

Inthisnextseetionoftheinterview,lwillbeasldngseveralqtmtionsaboutspecificexperieneesor
circtnnstaneesyoumayhavehadduingyoulifehtime. Weareinterestedinleamingmoreabouhow
MWafleGMmm'SMMmdyouamaimeeemveryimpommm Some
ofthesequestionsmaynotapplytoyou,butobeconsistengweneedtoukthemofeveryone. Ifanyof
these questions make you feel tmcomfortable, or don‘t apply to you, just let me know.

Thefirstooupleofquestionsreferto specific lifeciretnnstaneesthatmayhaveoectmedduingyou
adulthood.

52A. During you adult life, have you ever taken care of a friend or family “her who sufier(s) a
terminal or long-term illness (e.g., cancer)?

YES ........................ 1 ‘
N0 ......................... 2 (GO TO #523)

Can you tell me more about this experience and how it has afi‘ected you life?

(ERQBE: RELATIONSHIP TO PERSON, DURATION; HOW AFFECTED OTHER
RELATIONSHIPS, EMPLOYMENT, HOUSING ARRANGEMENTS; WERE THERE
RESOURCES IN THE COMMUNITY SHE COULD RELY ON FOR HELP; DID SHE
GET THE HELP SHE NEEDED/WANTED) '

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D relationship to person 0 duration (when & for how long) D other relationships D employment
D housing D support from family & friends D community resouces

199

Reepondentlmf

 

25

528. During you adult life, have you ever gone through an extendedperiod of time-when you didn't
have enoughmoneytobuyfoodorpayyoubills?
YES ........................ l -
N0 ......................... 2 (GOTO#52

Canyon tell me more aboutthis experience andhowithasafl‘ected you life?

(ERQBE: WHO WAS INVOLVED, DURATION; HOW AFFECTED OTHER
RELATIONSHIPS, EMPLOYMENT, HOUSING ARRANGEMENTS; COULD SHE
RELY ON FRIENDS AND FAMILY FOR HELP; WERE THERE-RESOURCES IN THE
COMMUNITY SHE COULD RELY ON FOR HELP; DID SHE GET THE HELP SHE
NEEDED/WANTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D duation (when & for how long) 0 who was involved D other relationships D employment
D housing D support from family & friends Dcommrmity resources

200

ReepondentID#

 

26

52C. Duingyouadutfife,haveyoumbeenflnutem¢physieaflyhame¢umflyamdted
byapannerorat-parmer? Thisinclrrdesmyfimewhenyoumighthavebeengrahbeipushedor
shoved,shppeikickfiphysicaflyrestaineiumyoflmphysiealactMoouldhavehmed
you. Thiscandsobemyfimewhmsexuflacfivitymyhavebemfueeiflmkmymnl
activitybyapartnerorex—partnerthatyoudidnotwamtohappen,btndid.

YES ........................ 1
NO ......................... 2 (GO TO #521»

Canyoutellmemore aboutthisexperieneeandhowithasafl'ectedyoulife?

(BRQBE: RELATIONSHIP TO PERSON, DURATION; HOW AFFECTED OTHER
RELATIONSHIPS, FEELINGS OF PERSONAL SAFETY, EMPLOYMENT, HOUSING
ARRANGEMENTS; COULD SHE RELY ON FRIENDS AND FAMILY FOR HELP; WERE
THERE RESOURCES IN THE COMMUNITY SHE COULD RELY ON FOR HELP; DID
SHE GET THE HELP SHE NEEDED/WANTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D relationship to person D duration (when & for how long) D in last six months D other relationships
D personal safety D employment D housing D support from family & fi-iends D comm. rescues

201

Respondent ID#

 

27

52D. Duhgyouaduhhfemaveyoumbeendueatenedmhysieallyhannedumny
assaulted byafiiendoracquaintanee? Thisincludesanytimewhenyoumighthavebeen
grabbeipmhedushovdslappeikickedphysimflymsuameiumyothaphysiealaa
thateouldhavehannedyou. Thiseanalsobeanytimewhensexualactivitymayhavebeen
fomdmmhmysamalacfivitybyafiiendoracquamraneemnyoudidmtwmm
happmbtndid

YES ........................ 1
NO ......................... 2 (GO TO #SZE)

Canyoutell me more aboutthis experience andhowithas afi‘ectedyoulife?

(ERQBE: RELATIONSHIP TO PERSON, DURATION; HOW AFFECTED OTHER
RELATIONSHIPS, FEELINGS OF PERSONAL SAFETY, EMPLOYMENT, HOUSING
ARRANGEMENTS; COULD SHE RELY ON FRIENDS AND FAMILY FOR HELP;WERE
THERE RESOURCES IN THE COMMUNITY SHE COULD RELY ON FOR HELP; DID
SHE GET THE HELP SHE NEEDED/WANTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D relationship to person D duation (when & for how long) D in last six months D omer relationships
D personal safety D employment D housing D support from family & fi'iends D comm. resouees

202

Respondent”

 

28

52B. Duingyouammme,haveywmbemmreame¢physicaflyhmed,usexmuyassmflwd
byastranger? Thisincludesanytimewhenyoumighthavebeengrabbed,pushedorshoved,
slappei kicked, physically restrained, or any other physical actthat could have lmmed you.
Ihiscmalwbemyfimewhmsexuflaefivhymyhawbeenfmced,mmis,mysexuflacfivity
byasuangertlntyoudidnotwanttohappembutdid.

YES ........................ 1
NO ......................... 2 (GO TO #521!)

Canyoutellmemoreabouthisexperienceandhowithasafi’eetedyoulife?

(£3935: RELATIONSHIP TO PERSON, DURATION; HOW AFFECTED OTHER
RELATIONSHIPS, FEELINGS OF PERSONAL SAFETY, EMPLOYMENT, HOUSING
ARRANGEMENTS; COULD SHE RELY ON FRIENDS AND FAMILY FOR HELP; WERE
THERE RESOURCES IN THE COMMUNITY SHE COULD RELY ON FOR HELP; DID
SHE GET THE HELP SHE NEEDED/WANTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D relationship to person D duation (when & for how long) D in last six months D other relationships
D personal safety D employment D housing D support from family & fi'iends Dcomm. resources

203

RespondentlD#

 

‘29

NowI‘dfikemmmefomfiomyouwmmmdmmmaMcWMmayhave
meumammmmmm

52F. Duhgyouchildhoodhadyoumbemsmmflyhmedbyaclosefimflymanbu,mhfiw,or
closefamilyfi'iend? Tlntis,didsomeoneyoutrusteveraskorforeeyoutodoanysernral
activities. By sexual activity, I mean anything that would involve sexual parts of you body.
Thiswouldincludeanylcindofsexualexpomrre,touching,orintercousethatsomeoneyou
trustedinvitedorforwd (i.e.,anysexualactivitythatyou did notwanttohappen,btrtdid).

YES ........................ 1
NO ......................... 2 (GO TO #526)

Canyoutellmemoreabouthisexpetienceandhowithasafl'ectedyoulife?

(ERQBE: RELATIONSHIP TO PERSON, AGE IT FIRST HAPPENED, DURATION; HOW
AFFECTED OTHER RELATIONSHIPS, FEELINGS OF PERSONAL SAFETY; DID SHE
FEEL SAFE TELLING ANYONE ABOUT IT? COULD SHE RELY ON FAMILY AND
FRIENDS FOR HELP? WERE THERE RESOURCES IN THE COMMUNITY SHE COULD
RELY ON FOR HELP; DID SHE GET THE HELP SHE NEEDED/WANTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D relationship to person D age-time it first occued D duration (how long it last) D other relationships
D personal safety D tell anyone D support fi'om family & friends Dcomm. resouces

204

 

RespondentIDfil
30

526. Duhgyouchfldhoodhadyoumbeensexmflyhmnedbysomwmoflrermmadoufamfly
member,relative,orclosefamilyfiiend? Thatisdidsomeoneelseeveraskorforceyoutodo
any sexual activities. By sexual activity, again I mean anything that would involve sexual parts
ofyoubody. Thiswouldincludeanybdofsemmlexposuemuchingmrmousethat
someone else invited or forced (i.e., any sexual activity that you did notwant to happen, but did).

YES ........................ 1
NO ......................... 2 (GOTO#53)

Canyoutellmemore aboutthisexperienceandhowithasafi'ectedyourlife?

(PROBE: RELATIONSHIP TO PERSON, AGE IT FIRST HAPPENED, DURATION; HOW
AFFECTED OTHER RELATIONSHIPS, FEELINGS OF PERSONAL SAFETY; DID SHE
FEEL SAFE TELLING ANYONE ABOUT IT? COULD SHE RELY ON FAMILY AND
FRIENDS FOR HELP? WERE THERE RESOURCES IN THE COMMUNITY SHE COULD
RELY ON FOR HELP; DID SHE GET THE HELP SHE NEEDED/WANTED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D relationship to person D age-time it first occued D duation (how long it last) D other relationships
D personal safety D tell anyone D support from family & fi'iends D comm. resouces

205

ReepondentID#

 

31

[IF SHE HAS HAD ANY CONTACT WITH AN ABUSIVE H-PARTNER DURING THE PAST
SIX MONTHS (Check #SZC) ASK QUESTIONS #53 THRU # 59] -

[IF SHE HAS N91 BEEN ABUSED BY AN EX-PARTNER DURING THE PAST 6 MONTHS
(Check #SZC) SKIP TO QUESTION #60, page 36]

53. YousaidbefomMmu—parm”(spouse)hadbeenthreatenmguahmingyoumthelastsix
months. I'dliketoask youafew more specific questionsaboutthatexperience. Isthisokay?

Ihavealistofsomethingssomepeople dotoannoyorhuttheirex-parmers. Theoeme
emotionalldndsofthingsthatcanhappeninanyrelatiomhip. Usingthiscard(SI-IOW
YELLOW CARD #2), could you tell me how ofieninthe last 6 mouths—did any of
these things to annoy or hurt you?

18NEVER

28RARELY

38SOMETIMES

48OFTEN

88notapplicable

98(refusedtoanswer)

A. How often has he/she accused you of having or
wanting other sexual relationships ................................

Told you about other sexual relationships he/she wanted or was having
in order to hurt you ............................................

Tried to control you money .....................................

I”

Tried to control you activities ....................................
Lied to you or deliberately misled you .............................
Called you names ..............................................
Ignored or made light of you anger ...............................
Ridiculed or criticized you in public ...............................
Criticized you family or friends to you ............................
Harassed you family or friends in some way ........................
Discouraged you contact with family or fiiends ......................
Threatened to hurt you family or friends ...........................
Used threats to try and have sex with you ...........................
Broken or destroyed something important to you .....................

zzrwerzowmpo

206

 

54.

RespondentlDié

 

32

18NEVER
28RARELY
38SOMETIMES
48OFI'EN
88notapplicable
98(refusedtoanswer)

.

Abusedorthreatenedtoabusepetstohmtyou ...... ° .................
(NO PETS 8 "8")

Punishedordeprivedthechildrenwhenhe/shewasangrywithyou ......
'I'hreatenedtotakethechildrenawayfi'omyou.. .....................
Left you somewhere with no wayto gethome .......................
Threatenedtoendtherelationshipifyoudidn'tdowhathe/shewanted . . ..
Tried to force you to leave you home ..............................
Threatened to commit suicide when he/she was angry with you ..........

.0

CHEDPOT"

Has ever physically harmed you in the last 6 months, or since ________?
This includes any time when you might have been grabbed, pushed or shoved, slapped, kicked,
physically restrained. or any other physical act that could have harmed you. This can also be any
time when sexual activity may have been forced, that is, any sexual activity you did not want to
happen, but did.

(GO TO #54:) YES ..................................... 1
(GO TO #57) NO ...................................... 2
(not applicable) ............................ 8

Respondent”

 

33

54a. Nowl have'list ofdiflaerrttypesoffiolencewomenhaveacperiencedfiomtheirex—

8.x.ornwposr?

.OTVQIZSF‘W’"

partners. Iwonderifyoucouldteflmeasbestasyoucanremember,howmanytimesin

 

thelastsixmonths ' didanyofthefollowtng' thing“ toyou:

(USING PINK CARD #3)
NEVER .......................... l
ONCE A MONTH OR LESS ......... 2
2 OR 3 TIMES A MONTH ........... 3
ONCE OR TWICE A WEEK ......... 4
3 OR 4 TIMES A WEEK ............. 5
MORE THAN 4 TIMES AWEEK ...... 6
(not applicable) .................... 8
(refused to answer) .................. 9

How often did he/she break you glasses or tear you clothing ...........

Pushed or shoved you ..........................................

Grabbed you ..................................................

Slapped you with an Open hand ...................................

Hit you with a fist .............................................

Kicked you ...................................................

Threw something at you .........................................

Aside from throwing. how often did (he/she hit you with an object ........

Tried to hit you with an object .....................................

_ Drove recklessly, so that you felt scared or endangered ................
Choked you ..................................................
Bumedyou..‘ ..................... .....

Tied you up or physically restrained you in some way ' .................
Beat you up I ..................................................
Forced any sexual activity you didn‘t want to happen ..................
Threatened you with a gun or knife ................................
Used a gtm or knife against you ...................................

208

 

55.

RecpondentIDiie

 

 

 

34
Haveyoueverbecomepregmminthelastsixmonflzs «-‘ '?- -

(GO TO #55:) YES ............................................... 1
(GO TO #56) NO ................................................ 2
not applicable ....................................... 8

55a (IF YES) Did ever physically harm you during this pregnancy?
YES ............................................... 1
NO ................................................ 2
not applicable ....................................... 8

56. For some people,whensomwnehasbeenviolmhcanchmgethewaytheybehaw. Usingthe
WHITECARDagain,doyouthinkthat___'sviolencehasmadeyoumorelikelyto:

 

57.

NOW YOU WILL BE GOING BACK TO THE W page 119 T0
COMPLETE COLUMN B: INTRODUCE THIS QUESTION BY SAYING:

(USE WHITE CARD #4) NW A VERY
NQNE LIIILE SQME m MA

A. Trytokeephim/herfromgettingmad ......... 1 2 3 4 8
B. Try to keep him/her happy .................. 1 2 3 4 8
C. Let him/her have his/her own way ............ l 2 3 4 8
D. Avoid him/her at certain times

(when drinking, after work) ................. l ' 2 3 4
E. Avoid disagreeing with him/her .............. 1 ' 2 3 4
F. Anything else? ........ l 2 3 4

 

 

Now I'd like to ask you how you think the harm you've experienced has afi'ected your health.
This is still something that we don't know very much about, and you can help us by telling us
how you think your health has been affected. I'm going to go back to the physical health
symptoms and injuries I asked you about earlier. I simply want to know which physical health
problems and injuries you think are a result of your abuse. You can say "YES” or "NO”.

(GO BACK Tom. WHICH IS THE BEGINNING OF THE HEALTH QUESTIONS.
FOR EACH ITEM SHE REPORTED IN COLUMN A, ASK HER IF SHE FEELS IT WAS
A RESULT OF THE ABUSE SHE EXPERIENCED. IF SHE REPORTS "YES", MARK "I"
IN COLUMN B, IF SHE SAYS "N0", MARK "2" IN COLUMN B. IF SHE HAS NOT
BEEN BOTHERED AjLALL BY A SYMPTOM OR INJURY , MARK "8" IN COLUMN B
FOR N/A.)

209

RecpondentID#

 

35
58. How many times in the past six months did you seek medical treatment because of injuries from
9

 

(INDICATE EXACT NUMBER)
' (not applicable ............ 888)

58a. Howmanytimecinthattime perioddoyouthinkyourequiredmcdical attentionbccause
of such injuries but didn't receive it?
(lNDICATE EXACT NUMBER) . . .
(not applicable .............. 888)

GO BACK TO THEWSECTION, page 14, TO MARK ANSWERS
IN COLUMN c: INTRODUCE THe/she QUESTION BY SAYING:

 

   

59. Now I'd like to ask you how you think the abuse you've experienced has afi’ected your use of the
substances you mentioned earlier. For example, you may feel that the abuse you've experienced
has caused you to smoke more. Or, you may feel that the amomit you smoke has not changed as
a result of the abuse you've experienced. Please remember that there are no right or wrong
answers, we are just interested in what you think For this next question, I would like you to tell
me whether you think your use of each of the above substances has increased, decreased, or
Stayed about the same as a result of the abuse you've experienced.

(GO TO PAGE 14W. FOR EACH
ITEM THAT SHE REPORTED USING, AWL. ASK HER IF SHE FEELS HER USE
OF THAT SUBSTANCE HAS INCREASED, DECREASED, OR STAYED ABOUT THE SAME
AS A RESULT OF THE ABUSE THAT SHE HAS EXPERIENCED. MARK ALL OF THESE
ANSWERS IN COLUMN C. IF SHE HAS NOT USED A PARTICULAR SUBSTANCE IN THE
PAST SIX MONTHS, MARK "8" IN COLUMN (2.)

Thanks for answering those questions about your ex-partner. Now I'd like to shift our focus to talk about
your mm relationship.

210

RespondentID#

 

. 36
60. Justtomakemrel‘mclearaboutyoucurentrelationshipstann,yousaidthatyouare

(IF MARRIED, LIVING TOGETHEKGIRLFRIENDIBOYFRIEND, OR DATING ONLY ONE
PERSON GO TO # 60a)

(IF CASUALLY DATING MORE THAN ONE PERSON, GO 'TO #60b)
(IF NOT DATING ANYONE, GO TO #72, page 44)

Relationships can have both positive and negative efiects on women's health. In order for me to
WMy,mhealmissms,ludnmedmgathumommfumafionabouyoupusond life. I'd
like to start by asking you some questions about you relationship(s) in the past six months.

60a. lwiUbeaskingasefiesofpersonalquesdomabomyoumm'ent(spouse,pumer,
boyfriend, girlfiienddatingparmer). Becausefliesearepcrsonalquestions, itmayseem
lessawkwardformetorefertothispersonbyname. Whatwouldyoulikemetocallthis
person? Istherearealorfakenamelcanuse? (NAME) (GOTOKI)

(ASKQNLX IF SHE MENTIONS MORE THAN DATING PARTNER)

60b. I'm going to ask a series of personal questions about the (dating) relationship that is, or
hasbeen,themostimportanttoyou. Becausetheeearepersonalquestions, itmayseern
less awkward for me to refer to this person by name. What would you like me to call this
person? Istherearealorfakenamelcanuse? .(GOTOKI)

61. How long have you known ?

(WRITE EXACT NUMBER OF MONTHS)
(not applicable = "888")

61a How long were you/have you been in a (dating) relationship with ?

(WRITE EXACT NUMBER OF MONTHS)
(not applicable = "888")

(IF IN DAME RELATIONSHIP, GO TO #62)

61b. How many separations, if any, have you had fiom since you
relationship began? (IT IS DEFINED BY AT LEAST AN OVERNIGHT SEPARATION
WHERE YOU THOUGHT THE RELATIONSHIP WAS OVER OR ENDING)

(ACTUAL NUMBER) ..........................................

(not applicable = "888")
(IF NO SEPARATIONS, GO TO #62)

211

 

RespondentID#

 

37
61c. (IF SEPARATIONS) How long did you most recent separation last?
(ACTUAL NUMBER OF DAYS.) ...........................
(not applicable = ”88888")

61d (IFSEPARATIONS) Womenhavedifi‘erentreasonsforgoingbacktoparmersthey‘ve
separatedfrom Thelasttimeyougotbacktogether,whatinfluencedyoudecision?

Using this WHITE CARD, how much of a role, if any, did the following play in you

 

 

 

 

 

decision: (USEWHITECARD #4) A VERY
NONE LIIIIE SOME. MIKE-I NA
A. Love .............. 1 2 3 4 8
B. Fear of him/her ...... 1 2 3 4 8
ASK 55C“ c. Financialissues ...... 1 2 3 4 8
D. Forthe kids ......... 1 2 3 4 8
E. Believing s/he'd change 1 2 3 4 8
P. Feeling lonely ....... 1 2 3 4 8
G. Other____ .. 1 2 3 4

Okay, now that I know a little more about you relationship status, I'd like to ask some questions about
the relationship itself. Let’s begin with some general questions about you involvement with

62.

I have a list of some things people do to make us feel better about ourselves and cm (dating)
relationships. Using this card (SHOW YELLOW CARD #2), could you tell me how often in
the last six months or since (date), (name) did any of these things
to make you feel good about youself'?.

l = NEVER

2 = RARELY

3 = SOMETIMES

4 = OFTEN

8 = not applicable

9 = (refused to answer)

How often has he/she complimented you intelligence ................
How often has he/she spoken kindly of you friends ..................
How often has he/she encouaged you to spend time with you fiiends . . .
Wanted to know how you day went ..............................
Spent quality time with you children .............................
Complimented you physical appearance or sexual attractiveness .......
Listened to you side of an argument or discussion ...................
Asked for your opinion about personal matters ......................

FEOTUFUUOSI’?

RespondentlD#

 

38

1=NEVER
2=RARELY
3=SOMETIMES
4=OFTEN
8=notapplicable
9=(refusedtoanswer)

I. Asked for you opinion about finances ............................
J. Spokenkindlyaboutyourelatives.............. ....... i ..........
K. Asked about you feelings or needs ...............................

Now,I‘mgoingtoasksomequestionsabouthingsparmersdotoharmusormakeusfeelbadabou
ourselves. As you may know, (dating) relationships often have both positive and negative qualifies to
them. Inorderforustobetterunderstandhowrelationshipsafi‘ectwomen‘shealth,wencedtoexplore
the negative as well as positive aspects of you (dating) relationship.

63. I have a list ofsome things some pe0ple do to annoy or but their intimate or dating partners.
These are emotional kinds of things that can happen in any relationship. Using this card (SHOW
YELLOW CARD #2), could you tell me how ofien in the last 6 months __ did any of
these things to annoy or hurt you?

1 = NEVER

2 = RARELY

3 = SOMETIMES

4 = OFTEN

8 = not applicable

9 = (refused to answer)

A. How often=has he/she accused you of having or
wanting other sexual relationships ................................

Told you about other sexual relationships he/she wanted or was having
in order to hurt you ........ '. ...................................

F”

Tried to control you money .....................................
Tried to control your activities ....................................
I Lied to you or deliberately misled you .............................
Called you names ..............................................
Ignored or made light of you anger .............................. ‘.
Ridiculed or criticized you in public ...............................
Criticized you family or fi'iends to you ............................

rnmnnrfipo

Harassed you family or friends in some way ........................

213

65.

RespondentID#

 

39

1=NEVER'
2=RARELY
3=SOMETIMES
4=OFTEN
8=notapplicable
9=(refusedtoanswer)

Discouraged you contact with family or fiiends ......................
Threatened to hurt you family or fiiends ...........................
Usedthreatstotryandhavesexwithyou ...........................
Broken or destroyed something important to you .....................
Abusedorthreatenedtoabusepetstohutyou .......................
(NO PETS = ”8") .

' Punished or deprived the children when he/she was angry with you ......
Threatened to take the children away fi'om you .......................
Left you somewhere with no way to get home .......................
T'hreatenedtoendtherelationshipifyoudidn'tdowhathe/shewanted . .
Tried to force you to leave you home ..............................
Threatened to commit suicide when he/she was angry with you ..........

923??“

HWF’OT"

9'3

Have you ever been threatened by in any way? By that I mean any time he/she
may have said or did things that made you feel scared or in danger, whether in person, over the
phone, through the mail. or through other people.

YES ....................... 1
NO ........................ 2
(not applicable) .............. 8
Have you ever been physically harmed by ? This includes any time when you

 

might have been grabbed. pushed or shoved, slapped. kicked, physically restrained, or any other
physical act that could have banned you. This can also be any time when sexual activity may
have been forced, that is. any sexual activity you did not want to happen, but did.

(GO TO #6511) YES ....................... 1
(GO TO #72) NO ........................ 2
(not applicable) .............. 8

65a How long after you became involved with did he/she first physically harm you?
(ACTUAL NUMBER OF DAYS) ........... __
(not applicable = "8888")

 

214

RespondentID#

 

40

FOR WOMEN WHO HAVE EXPERIENCED W BY CURRENT
PARTNER, GO TO #72, page 44.

FOR WOMEN WHO HAVE BEEN W BY
CURRENT PARTNER, CONTINUE WITH #66.

66. (SHOW PINK CARD #3) Now let'stalk only aboutthepast 6months, orsince
Howmanytimesinthelastsixmonthshas threatenedyouinanyway?
Usingthedefinitionlrcadcarlier,thatmeanssaidordidthingsthatmadeyoufeelscaredorin
danger, whetherinperson, overthe phone, throughthemaihorthroughotherpcople.

 

NEVER .................................................... l
ONCE A MONTH OR LESS ................................... 2
2 OR 3 TIMES A MONTH .................................... 3
ONCE OR TWICE A WEEK .................... ‘ ............... 4
3 OR 4 TIMES A WEEK ...................................... 5
MORE THAN 4 TIMES A WEEK ............................... 6
(not applicable) .............................................. 8
(refused to answer) .......................................... -. 9

67. Now I have listof different types of violence women have experienced fiom their partners. I
wonder if you could tell me, as best as you can remember, how many times in the last six months
did any of the following things to you:

 

(USING PINK CARD #3)
NEVER .......................... l
ONCE A MONTH OR LESS ......... 2
2 OR 3 TIMES A MONTH ........... 3
ONCE OR TWICE A WEEK ......... 4
3 OR 4 TIMES A WEEK ............. 5
MORE THAN 4 TIMES AWEEK ..... 6
(not applicable) .................... 8
(refused to answer) .................. 9

A. How often did he/she break your glasses or tear you clothing ...........

B. Pushed or shoved you ..........................................

C. Grabbed you ..................................................

D. Slapped you with an open hand ...................................

E. Hit you with a fist .............................................

F. Kicked you ...................................................

G. Threw something at you .........................................

215

 

 

41
NEVER ....................... 1
ONCE A MONTH OR LESS ...... 2
2 OR 3 TIMES A MONTH ........ 3
ONCE OR TWICE A WEEK ...... 4
3 OR 4 TIMES A WEEK .......... 5
MORETHAN4TTMESAWEEK .. 6
(not applicable) ................. 8
(refused to answer) ............... 9
H. 7 Aside fiom throwing, how often did he/she hityou with anobject . . . . ..
I. ' Triedtohityouwithanobject . . . .._ ...............................
J. Drove recklessly, so that you felt scared or endangered ................
K. Choked you ..................................................
L. Buried you ...................................................
M. Tied you up or physically restrained you in some way .................
N. Beat you up .................... . .............................
O. Forced any sexual activity you didn't want to happen ..................
P. Threatened you with a gun or knife ................................
Q. Used a gur or knife against you ...................................
(IF SHE HAS NOT BEEN PHYSICALLY HARMED. MR. GO TO #70)
67. Have you ever become pregnant since knowing ?
(GO TO #67:) YES ............................................... 1.
(GO TO #68) NO ................................................ 2
not applicable ....................................... 8
67a. (IF YES) Did he/she ever physically harm you when you were pregnant?
YES ............................................... 1
NO ................................................ 2
not applicable ....................................... 8

216

68.

69.

RespondentID#

 

42

(IFSHEHASBEENHARMEEME) Whenanindmatepumerisfirstviolentsometimes
it’sastnprise, sometimesitisn't, sometimesyou'remoreangrythanyouarescared,sometimes
you'remorescaredthanangry. Iwanttotalktoyouabouwhatyouresponsewas. Usingthe
WHITECARDcanyoutellmewereyou:

(USEWHITECARDM) NW A VERY

N_QNE LIlflLE SOME. MIICH NZA

A. Angry; ........................ 1 2 3 4 8

B. Scared ........................ 1 2 ‘ 3 4 8
c. Worried it wouldhappenagain ..... 1 2 3 4 8

D. Convinced it wouldn'thappenagain . 1 2 3 4 8

E. surprised .‘ ...................... 1 2 3 4 8

1 2 3 4 8

 

F. Other .......

(IF SHE HAS‘BEEN HARMED, HER) For some people, when someone has been violent, it
can change the way they behave. Using the WHITE CARD again, do you think that ___'s
violence has made you more likely to:

(USE WHITE CARD #4) NO/ A VERY
NONE LIIILE SOME MIIEH NIA
A. Try to keep him/her fiom getting mad ......... l 2 3 8
B. ~Try to keep him/her happy . .................. 1 2 3 4 8
C. Let him/her have his/her own way ............ l 2 3 4 8
D. Avoid him/her at certain times
(when drinking, after work) ................... l 3 8
E. Avoid disagreeing with him/her .............. l 3 8
F. Anything else? - ........ l 3

 

 

 

70.

NOW YOU WILL BE GOING BACK TO THE W [”89 11, TO
COMPLETE COLUMN C: INTRODUCE THIS QUESTION BY SAYING:

RecpondentID#

 

43

 

Now I'd like to ask you how you think the harm you've experienced has afiected your health.
Thisisstill somethingthatwedon'tknowvu-ymuchabout, andyoucanhelpusbytellingus
howyouthinkyomhealthhasbeenafl'ected. I'mgoingtogohacktothephysical health
symptoms and injuries I asked you about earlier. I simply want to know which physical health
problems and injuries you think are a result of your abuse. You can say "YES” or "NO".

(GO BACK TOIAGILII. WHICH IS THE BEGINNING OF THE HEALTH QUESTIONS.
FOR EACH rrEM SHE REPORTED 1N COLUMN A, ASK HER IF SHE FEELS IT WAS
A RESULT OP THE ABUSE SHE EXPERIENCED BY HER PARTNER IF SHE REPORTS
"ms", MARK "I" IN COLUMN c. IF SHE SAYS "N0", MARK "2" IN COLUMN 9. IF
SHE HAS NOT BEEN BOTHERED ALALL BY A SYMPTOM OR INJURY , MARK ”8"
IN COLUMN 9 FOR N/A.)

70a. How many times in the past six months did you seek medical treatment because of
injuries from ?

(INDICATE EXACT NUMBER)

(not applicable ............ 888)

70b. How many times in that time period do you think you required medical attention because
of such injuries but didn't receive it?

(INDICATE EXACT NUMBER)

(not applicable ............ 888)

218

 

 

71.

co BACK TO THE WSECUON. page 14. To MARK ANSWERs
IN COLUMN DI INTRODUCE THE QUESTION BY SAYING:

RespondentID#

 

 

NowI'd liketoaskyouhowyouthinktheabuseyou've experiencedhasafl’ectedyomuseofthe
substances you mentioned earlier. For example, you may feel that the abuse you've experienced
hascausedyoutosmokemore. Or,youmayfeelthatflreamomtyousmokehasnotchangedas
a result of the abuse you've experienced Please remember that there are no right or wrong
answerswearejustinterestedinwhatyouthink.Forthisnextquestiomlwouldlikeyoutotell
mewhetheryouthinkyouruseofeachoftheabovewbsmceshasmaeaseddecreased,or
stayedaboutthesameasaresultoftheabuseyou'veexperienced.

(GO TO PAGE 14W. FOR
EACH ITEM THAT SHE REPORTED USING, WALL, ASK HER IF SHE
FEELS HER USE OF THAT SUBSTANCE HAS INCREASED, DECREASED, OR
STAYED ABOUT THE SAME AS A RESULT OF THE ABUSE THAT SHE HAS
EXPERIENCED. MARK ALL OF THESE ANSWERS IN COLUMN D. IF SHE HAS
NOT USED A PARTICULAR SUBSTANCE IN THE PAST SIX MONTHS, MARK "8"
IN COLUMN D.)

In this next section, I would like to ask you some questions about how often you receive medical care.

72.

Have you visited an emergency ward in a hospital for yourselfin the past six months?

(GO TO #72a)YES ..................... l ---> HOW MANY TIMES?
(GO TO #73) NO ...................... 2 (88 IF NO)

72a. (IF YES AND WOMAN HAS BEEN ABUSED IN PAST 6 MONTHS) How many of
these visits would you say were related to any abuse you may have experienced?
(INDICATE EXACT AMOUNT ................... _
(not applicable) ........................ = "888"

Have you visited a medical doctor for an emergency for yourselfin the past six months?

(GO TO #73a)YES ..................... 1 --> HOW MANY TIMES?—
(60 TO #74) NO ...................... 2 (88 IF NO)

73a. (IF YES AND WOMAN HAS BEEN m IN PAST 6 MONTHS) How many of
these visits would you say were related to any abuse you may have experienced?
(INDICATE EXACT AMOUNT ................... __
(not applicable) ........................ = "888"

219

 

74.

75.

76.

RespondentID#

 

45

Haveyouvisiteda-medicaldoctorforaroutinecheck-uporappointmemforyom'selfinthepast
sixmonths? .

(GO To #74a)YES . .................... 1 —>HOWMANYTIMES?__
(GO To #75) NO ...................... 2 (88 IF NO)

74a (IFYBSANDWOMANHASBEENABHSEDINPASTGMONTHS) Howmanyof
thesevisitswouldyousaywerenlatedtoanyabuseyoumayhaveexpaienced?

(INDICATE EXACT AMOUNT
(not applicable) ........................ ="888"

Have you viSited a psychologist, therapist, or psychiatrist in the past six months?

(GO To #75.)YES ..................... 1 ...> HOWMANY‘I'IMES?
(GO To #76) NO ...................... 2 (88 IF NO)

75a. (IF YES) Who referred you to this person?

YOURSELF ................................... - ....... l
FRIEND/FAMILY ..................................... 2
SHELTER WORKER .................................. 3
MEDICAL DOCTOR ................................. .. 4
EMERGENCY WARD DOCTOR ........................ 5
COURT ORDER (JUDGE) .............................. 6
OTHER(___) .................................... 7
not applicable ......................................... 8

75b. (IF YES AND WOMAN HAS BEEN ABUSED IN PAST 6 MONTHS) How many Of

these visits would you say were related to any abuse you may have experienced?
(INDICATE EXACT AMOUNT ...................
(not applicable) ........................ = ”888"

 

What type of medical insurance do you currently have?

PRIVATE INSURANCE ................................ l

MEDICAID/MEDICARE ............................... 2

NONE .............................................. 3
220

at!

 

RespondentID#

 

45

Thankyousomuchfortakingthetimetoanswertheqtmtionsforthispartoftheinterview. We
appreciateallofyourinput. Isthereanythingintheinterviewthatyouhadquesfionsabomorwomdlikc
toaskmeabomorotherthingsyouwantedtotalkabommatldidn'task?

 

 

 

 

 

 

 

 

(Thank you, these are very important issues to address.)

For the next part of the interview, I would like you to take some time to complete several quesu'ons on
your own. (IF INVOLVED WITH A MAN, HAND HERTHE ORANGE; IF INVOLVED WITH A
WOMAN, HAND HER THE GREEN SECTION OF THE INTERVIEW) Again, I want to remind you
that everything you report on this section of the interview is completely confidential. Your answers will,
in no way, be attached to any identifying information about you.

While you are completing this section of the interview. I will scan through the section we just finished to

be sure that I have asked every question and that I have accurately coded your answers. When you finish
with the written section, I will do the same thing.

AFTER SHE HAS COMPLETED WRITTEN SECTION OF THE INTERVIEW, MAKE SURE THAT
YOU HAVE THOROUGHLY ADDRESSED ALL OF HER CONCERNS.

Time interview ended
Length of oral interview

221

“1‘51! 1 -

 

 

Respondent ID #

 

’I/l/Omen iitzélea/t/t project

Interview - Written Section

Thank you for completing the first part of the interview. The information you gave is very
important to us. In this section we'd like to know some things that may be more dificult to talk
about. Just like the first part of the interview, the answers you give will help us understand more
about women's health issues. To help you feel more comfortable about answering these
questions, I will give you a form that you can fill out on your own While you are answering the
questionsonthisform, Iwillcheckthepartwejustfinishedtomakesurethatlaskedevery
question and coded your answers correctly.

Ifyou have any questions about this section of the interview, please feel flee to ask. Do you have
any questions before you start? ‘

222

 

Respondent ID #

 

Thank you for answering all of those questions and Sharing that information with us. Now we
have a list of the ways you might have felt or behaved in the last week. We would like to know
how often you have felt any of these ways in the past week. Please circle the number that best
describes how often you felt this way.

1 = RARELY OR NEVER (LESS THAN ONE DAY)
2 = SOME OR A LITTLE (1-2 DAYS)

3 = OCCASIONALLY (34 DAYS)

4 = MOST OR ALL THE TIIVIE (5-7 DAYS)

Wthered by things that usually don't bother you ...... l 2 3 4
B. You did not feel like eating; your appetite was poor ........... 1 2 3 4
C. You felt that you could not Shake Off the blues even with

help from your family or friends ....................... . . l 2 3 4
D. You felt that you were just as good as other peOple ........... 1 2 3 4
E. You had trouble keeping your mind on what you were doing . . . . I 2 3 4
F. You felt depressed .................................... l 2 3 4
G. You felt that everything you did was an efi'ort ............... 1 2 3 4
H. You felt hopefiil about the fixture ......................... l 2 3 4
I. You thought your life had been a failure .................... 1 2 3 4
J. You felt fearful ....................................... 1 2 3 4
K. Your sleep was restless ................................ l 2 3 4
L. You were happy ...................................... 1 2 3 4
M. You talked less than usual .............................. 1 2 3 4
N. You felt lonely ....................................... l 2 3 4
0. People were unfiiendly ...... i. : ......................... 1 2 3 4
P. You enjoyed life ...................................... 1 2 3 4
Q. . You had crying spells .................................. l 2 3 4
R. You felt sad ......................................... 1 2 3 4
S. You felt that people dislike you . . .. ....................... 1 2 3 4
T. You could not "get going” .............................. I 2 3 4

223

 

Respondent ID #

 

3

These questions will help us better understand more about at-risk sexual behavior. Some women

may be at-risk for sexually transmitted diseases or the AIDS virus, and we need to know how this
might afi‘ect their overall health. We know that some of the questions may not be easy to answer,
but in order to understand all of the health risks that women may face, we need to ask everyone to
try to answer them as accurately as possible.

1. Have you been sexually active in the past six months?

YES ................. 1 (PLEASEGO TO QUESTION #2)
NO .................. 2 (IF NO, PLEASE SKIP TO QUESTION #9)

2. How many sexual partners, including your current partner and any others, have you had in
the W?

PLEASE WRITE EXACT NUMBER HERE

 

3. Who has been included in your list of sexual partners in the gag six months?
(PLEASE CIRCLE "YES” OR "NO" FOR EACH)

. YES _Q
SEX WITH MY LOVER/SPOUSE .................... 1 2
CASUAL SEX PARTNER(S) ........................ 1 2

2

ONE TIME ANONYMOUS SEX PARTNERS ........... 1

4. Have you paid money or received money for sex in the gag six months?

YES....' ................ 1
NO ..................... 2

5. How 9133 have any of your partner(s) ever used threats to try and have sex with you in
the past six months?

NEVER ................. 1
ONCE .................. 2
TWICE ................. 3
3-10 TIMES .............. 4
11-20 TIMES ............. 5

MORETHANZOTIMES 6

6. How often have any of your partner(s) used physical force to have sex with you in the
ast 'x mont s?
NEVER ..... . ........... l
ONCE .................. 2
TWICE ................. 3
3-10 TIMES .............. 4
11-20 TIMES ............. 5

MORETHANZOTIMES 6

224

 

Respondent ID #

 

7. Has your partner engaged in high-risk behaviors (such as unprotected sexual intercourse,
oral sex, and/or sharing needles) with a person who is HIV -positive or has the AIDS virus

in the past six months?

YES .................... 1
NO ..................... 2
DON'T IG‘IOW ........... 7

 

8. Have you engaged in high—risk behaviors (such as unprotected sexual intercourse, oral
sex, and/or sharing needles) with a person who is HIV—positive or has the AIDS virus

in the W?
YES .................... 1
NO ..................... 2
D OW ........... 7
9. Have you gv_er been tested for the HIV -virus?
(GO TO #9a) YES .......... 1
(IF NO, STOP INTERVIEW HERE. THANK YOU) NO .......... 2

. 9a. What led to your decision to be tested: PLEASE BE SPECIFIC.

 

 

 

 

 

 

9b. Have you been tested for the HIV-virus in the gag six months?
YES ................... 1
NO .................... 2

Thank you for answering these very personal questions. If you have any questions about why
we’re asking these questions, or if you'd like any more information, please just ask.

225

 

APPENDIX F

Guide to Community Resources

226

Wmen 'zfiaJélea/t/t lava/ect

Guide to Community Resources

CHILDREN AND FAMILY SERVICES

Black Child and Family Institute
Wide range of opportunities for children
of all races and ethnic backgrounds, no
fee required

Boys and Girls Club
Anyone 7-17 can become a member for
$5.00 a year - provides positive experiences
for kids; dinner proVided Tuesday through
Friday - some transportation is available

Family Growth Center
Child care in two and a half hour sessions,

Parent support groups, and education classes

FOOD AND SHELTER SERVICES
Department of Social Services
Economic Crisis Center (ECC)
Greater Lansing Food Bank
Must be in need of emergency help,
provides one week of emergency food
Harvest House

No restrictions or limitations; food baskets,

227

487-3775 E

394-0455

 

371-4350
(Downtown Lansing)

3 71-1347
(Mt. Hope Center)

3 5 1 -6641
(East Lansing)

887-9400
337-2731

887-4314

487-3090

personal hygiene items, emergency shelter
referral, rent assistance, adult educational
programs, children's enrichment and tutoring
programs, day shelter, and counseling

Housing Resource Center
Helps homeless and nonhomeless people
who have problems with their landlord

Lansing Rescue Mission (shelter)

New Hope Center
Daytime Shelter
Overnight Shelter

HEALTH CARE SERVICES

American Red Cross Emergency Services
Shelter services, food, diapers, disaster
services; Medical Access Program and
prescription services

CADA (Council Against Domestic Assault)
Capital Area Community Service

Cristo Rey Community Center
Community kitchen, direct assistance
(provides groceries, personal needs,
payments for medicine, bus fare, and
partial rent), medical health clinic, health
services, employment and training services,
and substance abuse programs

Dental Referral Network

228

487-6051

485-0145

484-0176
484-1985

484-7461

372-5572

482-6281 '

372-4700

321-1991

 

Gateway Community Services

Health clinic; runaway services;

family and youth services including
substance abuse services and counseling
services; crisis intervention hotline;
student assistance program

Horizon Center
Inpatient
Outpatient

Ingham County Health Department
Adult Health Clinic
Child Health Services
Food Bank
STD Clinic
Women Infants & Children (WIC)

Services include an immunization clinic

. operated on a walk-in basis; cost for routine
immunizations 'is free, also available are
pediatric services and women's health
services (including PAP, pelvic and breast
exams, STD testing and treatment and
nutritional counseling) where pay is determined
by income.

Listening Ear Hotline
(has sexual assault counseling)

Sexual Abuse Hotline (24 hour)

Sexual Assault Info Network (SAIN)

229

3514000
(Abbott Rd.)

355-1 106
(Spartan Village)

332-1144 0
332-2180

887-4311
887-4302
887-4305
887-4314
887-4302 5'
887-4326

 

337-1717

1-800-234-0038

372-6666

LEGAL SERVICES

Friend of the Court 676-8429
Legal Aid of Central Michigan 485-5411
Michigan Coalition Against Domestic Violence 372-4960
National Domestic Violence Hotline l-800-333-SAF E
(7233)
Police: Lansing 332-1911

State 332-2521

RESOURCES FOR AIDS AND SUBSTANCE ABUSE

CADA (Council Against Domestic Assault) 372-5572
Questions about AIDS/HIV infection or
substance abuse (or anything)

Ingham County Adult Health Clinic 887-4302
Questions about HIV infection/AIDS
Anonymous Counseling/Testing
Questions about STD'sNenereal Disease

Hotline Telephone Number for AIDS Information 1-800—872-AIDS (2437)
This is the Wellness Network, Inc.
Spanish is available

Southland Counseling Center for Substance Abuse 393-0150
Questions about substance abuse

Referrals
Treatment

Hotline Telephone Number for Substance Abuse Information 1-800-342-0349

also the number for the Capital Area Substance Abuse
Commission (CASAC) line

230

 

 

ADDITIONAL RESOURCES
Gateway Community Services

Family Violence Prevention Helpline 1-800-996-6228
(1-800-99-NO ABUSE)
Anonymous 24-hour hotline

Parent Helpline 1-800-942-4357
Anonymous assistance to parents
For child abuse prevention

Runaway Assistance Program (“RAP” Line) 1-800-292-4517
Help for youth at risk and for their family and friends
who need assistance ‘

 

231

APPENDIX G

Standardized Residual Covariance Matrices for Measurement Models

232

 

 

 

 

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236

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