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Accepted Manuscript
Title: Intimate personal violence and caregiving: Influences onphysical and mental health in middle-aged women
Authors: Authors. Pablo Ferreira, Deborah Loxton, Leigh RTooth
PII: S0378-5122(17)30136-6DOI: http://dx.doi.org/doi:10.1016/j.maturitas.2017.05.001Reference: MAT 6817
To appear in: Maturitas
Received date: 16-3-2017Revised date: 2-5-2017Accepted date: 3-5-2017
Please cite this article as: Ferreira Authors Pablo, Loxton Deborah, Tooth LeighR.Intimate personal violence and caregiving: Influences on physical and mental healthin middle-aged women.Maturitas http://dx.doi.org/10.1016/j.maturitas.2017.05.001
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Title Page
Title
Intimate personal violence and caregiving: Influences on physical and mental health in
middle-aged women
Authors
Pablo Ferreiraa,c
Deborah Loxtonb
Leigh R Tootha, corresponding author; [email protected]
aSchool of Public Health, The University of Queensland, Brisbane, Queensland, Australia,
4072
bResearch Centre for Generational Health and Ageing, University of Newcastle, Australia,
2305
cCurrent affiliation: Servicio de Salud Metropolitano Norte, Santiago Chile
2
Highlights
Little research on how IPV and caregiving affect health of mid-age women.
Experiencing either associated with poorer physical and mental health.
Experiencing both associated with worse physical and mental health.
Both associated with twice the odds of depressive symptoms and perceived stress.
Possible accumulation or additive effect from experiencing both.
Abstract
Objectives: To investigate if women with a history of having experienced intimate partner
violence (IPV) who undertook caregiving would experience worse mental and physical health
compared to those without caregiving roles.
Study design and main outcome measures: IPV, caregiving history and data on covariates
were collected between 1996-2010 from 8453 participants in the Australian Longitudinal
Study on Women’s Health aged between 45 and 65 over the course of the study. Regression
analyses were used to analyse the association of IPV and caregiving (categorised as IPV+
caregiving, IPV+no caregiving, no IPV+caregiving, no IPV+no caregiving), with and without
adjustment for covariates, on mental and physical health-related quality of life (HRQOL),
depressive symptoms and perceived stress, measured in 2010.
Results: Experiencing IPV and being a caregiver was associated with poor health outcomes
on three of the four outcomes (depressive symptoms, OR 2.08, 95% CI 1.58, 2.75; stress, OR
2.11, 95% CI 1.55, 2.87; physical HRQOL β -2.39, 95% CI -3.34, -1.44; all p≤0.001, fully
adjusted) compared with not experiencing IPV or caregiving. On these outcomes, IPV and
caregiving combined had a stronger association than IPV or caregiving separately. For mental
3
HRQOL, a weaker association was found (OR 1.41 95% CI 1.02, 1.95, fully adjusted,
p=0.04).
Conclusions: This paper provides evidence for the cumulative health impact of stressful life
events, both those that are perpetrated against an individual (violence) and those undertaken
with a degree of personal agency (caregiving). The findings underscore the need to
understand the drivers of poor health, for clinicians to ask about life circumstances of patients
experiencing poor health, and for the provision of referral pathways for complex cases.
Key words: caregiving, intimate partner violence, physical health, mental health, stress,
middle-aged women
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1. Introduction
Informal caregiving and the experience of abuse or violence have important associations with
physical and mental health in women. Informal caregiving is care provide by family members
or friends and providing this type of care for a disabled or elderly person often peaks in mid-
life for women, and can have both positive and negative impacts on their mental health,
physical health and personal wellbeing [1]. While there are positive impacts from caregiving,
such as personal growth, strength, and resiliency [2,3], many studies show that caregivers
tend to have poorer mental [4] and physical health [5] compared to non-caregivers. Women
caregivers also experience problems related to their personal wellbeing, including their
personal development and interpersonal relationships. Indeed, research has demonstrated that
female caregivers have poorer social support [6]. The importance of considering the impact
of demographic characteristics as well as other social and economic roles performed by
caregivers on their health has been advocated [1]. Yet, in order to establish the impact of
caregiving it is also important to examine the life histories of women, to take account of past
traumatic or stressful events in order to understand the personal resources (or lack of) that
women might have when entering the caregiving relationship.
Some forms of abuse, intimate partner violence (IPV) in particular, have been associated with
poorer personal resources in women, such as an increased likelihood of financial stress [7],
lower education levels [8] and poorer social support [9]. Women who have experienced abuse
in childhood or adulthood are more likely to experience mental and physical health problems
and higher stress than other women [10-12]. Although health may improve once violence
ceases, the health and personal resource deficits attributable to violence may last for many
years, including larger utilization of medical care [13].
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Research on the consequences of informal caregiving for women tends to focus on the current
dynamics in the relationship between caregiver and care recipient, rather than on potential
past circumstances that might influence the capacity of women to undertake caregiving roles
and remain healthy [14]. No research to date has examined the impact of a history of IPV on
women caregivers’ health.
The present study aims to examine the associations between having a history of IPV, as well
as taking on caregiving, on mental and physical health-related quality of life (HRQOL) in
mid-aged women. Firstly we examined the associations between IPV and caregiving
separately on HRQOL. Secondly we examined how IPV and caregiving in combination were
associated with HRQOL. The principal hypothesis was that women with a history of IPV
who also undertake caregiving will have poorer HRQOL than women without such history.
2. Methods
2.1 Study population
Data were from the Australian Longitudinal Study on Women’s Health (ALSWH), a
population-based study of health and well-being in Australian women. Since 1996, self-
reported data on health, health service use, socioeconomic and personal information have
been collected approximately every three years from over 41,500 women in three cohorts:
those born 1973-78 (aged 18-23 in 1996); those born 1946-51 (45-50 years); and those born
1921-26 (70-75 years). The sample was randomly selected from the Medicare Australia
database, which covers all citizens and permanent residents of Australia. Informed consent
has been obtained at each survey, with ethical clearance obtained from the University of
Newcastle and the University of Queensland. Full details of recruitment and response rates
are published elsewhere [15]. This paper includes the 1946-51 cohort, who were surveyed six
times between 1996-2010 (Survey 1, 1996, N=13,714; Survey 2, 1998, N=12,338; Survey 3,
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2001, N=11,226; Survey 4, 2004, N=10,905; Survey 5, 2007, N=10,638; Survey 6, 2010,
N=10,011). For this paper, in order to capture all experiences of IPV data from participants
who completed all six surveys (N=8453, 61.6% of baseline sample) were used.
2.2 Measures
2.2.1 Outcomes
Two mental health measures were used. General mental health was measured with the mental
health subscale from the Short Form-36 (SF-36) [16]. The mental health subscale has 5-items
measuring anxiety, depression, emotional control and psychological health, with scores ≥53
indicating good mental health [17]. Depressive symptoms were measured using the Centre
for Epidemiological Studies Depression scale (CESD-10) [18] with scores of ≥10 indicating
possible depressive illness [19].
Physical health was measured using the Physical Component Summary score (PCS) from the
SF-36 [20]. The PCS is standardised to have a mean of 50 and standard deviation of 10.
Higher PCS scores reflect better physical HRQOL. The PCS was selected over the physical
functioning subscale of the SF-36 because it was the only measure of physical health used
and reflects a broader definition of physical HRQOL, namely, both physical function and
physical wellbeing.
Stress about own health, health of family members, work, living arrangements, study, money,
and relationships was measured with the Perceived Stress Scale. Developed using the
ALSWH 1973-78 cohort [21], it has been validated with the 1946-51 cohort [22]. Scores
range from 0 (not at all stressed) to 4 (extremely stressed), and can be dichotomised to reflect
no stress/stress.
For all outcomes, scores at Survey 6 were used.
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2.2.2 Exposure
A variable capturing the women’s experiences of IPV and caregiving was created with four
mutually exclusive categories; IPV and caregiving, IPV and no caregiving, no IPV and
caregiving, and lastly, no IPV and no caregiving. The IPV/caregiving exposure was created
using the following survey questions.
At Survey 5 (in 2007) the women answered “Have you ever been in a violent relationship
with a partner or spouse” (yes, no), followed by “If you have ever lived with a violent partner
or spouse, in which years did you experience violence” (response – I have never lived with a
violent partner or spouse, before 1996, 1996-1998, 1999-2001, 2002-2004, 2005-now).
At each survey, the women were asked “Do you regularly provide care or assistance (eg
personal care, transport) to any other person because of their long-term illness, disability, or
frailty?”. As this question was asked at multiple survey points, numerous options capturing
caregiving status and change in status were possible. In this paper we used a summary
measure of caregiving, that had been previously created using latent class analysis of
responses to caregiving questions over Surveys 3 to 6 (data from the first two surveys were
not used due to different response options (Survey 1) and data quality issues (Survey 2)) [23].
The latent class analysis produced three trajectories (latent classes) which yielded
probabilities describing: ’consistently highest’, ‘low then increasing’, and ‘consistently
lowest’ classes of caregiving. For this paper, the ‘consistently highest’ and ‘low then
increasing’ classes were combined into one class reflecting ‘caregiving’.
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2.2.3 Covariates
A number of covariates were used to adjust all final analyses (all covariates were assessed at
Survey 1 unless specified): relationship status (partnered, unpartnered), area of geographical
residence (major city, inner regional, outer regional/remote/very remote), perception of
ability to manage on available income (it is easy, not too bad, sometimes difficult, always
difficult/impossible), highest educational qualification (no formal, up to grade 10, grades 11
or 12, trade/certificate/diploma, degree/higher degree), social support [24] (assessed at
Survey 3) and optimism/resilience [25] (assessed at Survey 3). The earliest available
measures of each outcome were included to adjust for pre-existing status on these measures.
Thus, Survey 1 measures of the SF-36 scales and stress scale, and Survey 2 measures of the
CESD-10 were used.
2.3. Statistical analysis
Chi-square analysis and one-way ANOVA were used to investigate the differences in
characteristics between those included in, and excluded from, the study, as well to examine
bivariate associations between the exposure and the outcomes. Outcome scores on the
perceived stress scale showed moderate skewness and thus the scores were recoded into
no/somewhat stressed (89.3% of the sample) versus moderate/very/extremely stressed (11.1%
of the sample). The hypothesis was tested by stepwise logistic regression for general mental
HRQOL, depressive symptoms and perceived stress, and linear regression for physical
HRQOL. In step 1 the combined IPV and caregiving exposure was entered (unadjusted); in
step 2 the model was adjusted for covariates. To enable comparisons of regression estimates
for the IPV and caregiving exposure, complete case analyses were used in unadjusted and
adjusted analyses. Separate analyses were run for each outcome. Statistical analyses were
conducted using SAS Version 9.3 (SAS Institute, Cary, NC).
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3. Results
3.1. Participants in the ALSWH 1946-51 cohort
Of the 13,714 original women recruited in 1996, 8453 (61.2%) participated in all six surveys
and were used in this study (Fig. 1). Table 1 describes the 8453 included and 5262 excluded
women. The included women were less likely to have experienced IPV and more likely to be
a caregiver. Regarding the covariates, included women were more likely to be partnered, live
in regional areas, be able to manage on their available income, have higher educational
qualifications, and have higher social support and greater optimism/resilience. They were less
likely to have mental health problems (on both CESD-10 and SF-36) or experience stress and
had better physical HRQOL than the excluded women.
As shown in Table 1, 13% of women had experienced IPV and 32% reported caregiving.
When combined into the four level exposure, 4.5% of women reported both IPV and
caregiving, 8.6% reported IPV but no caregiving, 27.5% reported caregiving but no IPV, and
59.1% reported neither IPV or caregiving. Bivariate analyses revealed significant associations
between the combined IPV and caregiving exposure and the mental and physical HRQOL,
depressive symptoms and stress outcomes (Table 2) at both baseline and Survey 6: with
women who had experienced IPV and caregiving showing the poorest outcomes on all
measures.
The four plots in Figure 2 show the fully adjusted results of the hypothesis testing for each
outcome. The graphs present the regression estimates (odds ratios [OR] or beta coefficients
[β]) and their 95% confidence interval. In each analysis, ‘no IPV and no caregiving’ was the
reference category. The hypothesis, that women with a history of IPV who also undertake
caregiving will have poorer health outcomes than women without such history, was
supported for the depressive symptoms, physical HRQOL and perceived stress outcomes (all
p≤0.001, fully adjusted). The hypothesis was only weakly supported for the general mental
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HRQOL measure (p=0.04, fully adjusted) (see online Table for full unadjusted and adjusted
regression estimates). The plots in Figure 2B, 2C and 2D further show that women with a
history of IPV or caregiving (but not both) showed essentially similar regression estimates on
the outcomes: Compared to women with neither IPV nor caregiving they had poorer
outcomes, however, their outcomes were not as poor as women with both IPV and
caregiving.
For all outcomes the unadjusted regression estimates were substantially attenuated by the
addition of the covariates to the models (online Table). The greatest attenuations were from
addition of the baseline measures of each of the outcomes (regression estimate attenuations of
17% for general mental HRQOL, 19% for depressive symptoms, 40% for physical HRQOL,
46% for stress) followed by manage on income (attenuation between 18-21%) and the
personal resources of social support (attenuation between 9-13%) and optimism/resilience
(attenuation between 8-16%) (data not shown).
4. Discussion
To our knowledge, this study is the first to examine the association between a history of IPV,
subsequent caregiving, and later physical and mental HRQOL and stress using data collected
over time. The principal finding was that women with a history of IPV and caregiving were
more likely to have poorer physical HRQOL, as reflected by PCS scores an average of 2.5
units lower, and twice the odds of depressive symptoms and perceived stress than women
without such history. Experiencing either IPV or caregiving was also associated with lower
PCS scores and higher odds of depressive symptoms and stress, although the effects were not
as large as when both were experienced. Of note, essentially similar regression coefficients
were found for IPV and caregiving individually.
11
Our findings of poorer health among caregivers and those who had experienced IPV may
support our earlier stated contention that IPV might, through a reduction in internal and
external resources, lead caregivers to experience even worse health outcomes. We did not
have an apriori position on whether either IPV or caregiving would individually lead to worse
health outcomes compared to the other, and there is scant literature comparing both these life
events that could inform our thinking. Our findings, as shown graphically in Figure 2, suggest
that there may be an accumulation or additive effect from experiencing IPV and caregiving
that is greater than experiencing either in isolation.
The hypothesis was strongly supported for three of the four outcomes. The outcome with the
weakest support was the SF-36 mental health subscale. This may reflect that this is a more
general measure of mental health, with the more specific measure of depressive symptoms
(CESD-10) possibly being a more relevant outcome for the exposure.
The findings contribute to the growing body of evidence that suggests women in caregiving
roles have poorer overall health and higher stress levels than women not in a caregiving role
[4,5], and that women who experience IPV have poorer mental and physical HRQOL and
higher perceived stress than women with no history of IPV [5,9,10]. In one of the few studies
to examine abuse and caregiving, Kong and Moorman [26], found frequent depressive
symptoms in people who care for previously abusive or neglectful parents. Unlike these
authors we were not able to ascertain if the care recipient was the perpetrator of the IPV, nor
the relationship between the caregiver and care recipient, and hence were not able to do
further sensitivity analyses. Wuest et al [14] suggested that women caregivers who have been
previously abused by their spouses may assume the role of carer because of a sense of duty
and obligation. This could lead to constant emotional disturbances and impact even more on
these women’s mental and physical HRQOL [14].
12
The baseline scores on all measures indicated that women who reported IPV and/or
caregiving had poorer mental and physical HRQOL and higher depressive symptoms and
perceived stress at the beginning of the study (Table 2) than women without such history. In
particular women with IPV as opposed to caregiving seemed to have poorer health. However
even after adjusting for the women’s health at baseline, women experiencing IPV and
caregiving continued to have poorer health 14 years later. We examined this further in
descriptive sensitivity analyses. The majority of women reporting IPV (977 out of 1106,
88.3%) had experienced IPV prior to the baseline survey. These 977 women had poorer
baseline health (for e.g., 34% reported depressive symptoms versus 19% of women who did
not report IPV). The prevalence of depressive symptoms at Survey 6 for these 977 women
continued to be higher than the prevalence for women with no such history (29% versus
16%); findings consistent with others showing the long-term impact of IPV on women’s
health [13]. We found a higher percentage (45%) of women reporting baseline depressive
symptoms in the 89 reporting first IPV after baseline, ie from 1996 to 2001 (Survey 3).
However, as the first or baseline measure of depressive symptoms was from Survey 2 in 1998
this may reflect that the abuse was happening around the time the women were completing
the survey. We also descriptively examined health transitions in the outcomes between
baseline and Survey 6, and showed women experiencing both IPV and caregiving had the
highest percentage reporting the poorest health at both time points (i.e., 20% of women with
IPV+caregiving had depressive symptoms at baseline and Survey 6, compared to 7% without
IPV or caregiving, 10% with caregiving but no IPV, and 17% with IPV but not caregiving).
It is also worth noting that the associations between IPV and caregiving and health outcomes
were reduced by 9-21% when personal resources including social support and
optimism/resilience were included in the model. This may imply that the provision of
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services that augment personal resources could assist both women who have experienced IPV
and those who provide care [27].
This study had several limitations that may have contributed to our findings. The ALSWH
was designed to capture multiple aspects of women’s health and wellbeing, and not all
variables which may play an important mediating role in the relationship between IPV and
caregiving (such as caregiver-care recipient relationship, personality factors, type of
impairment of the care recipient) were measured. A meta-analysis by Pinquart and Sorensen
[5] found behaviour problems of the care recipient to be strongly associated with caregiver
health outcomes. Relatedly, the type of care recipient’s illness may greatly impact caregiver
outcomes. Differences in psychological and physical health between caregivers and non-
caregivers have been found to be considerably larger in dementia caregivers than in studies
that included a combination of caregivers [4]. Furthermore, predictors of mental HRQOL
may differ from those of physical HRQOL [5]. Regarding generalisability, the original
ALSWH sample has been compared with the 2001, 2006 and 2011 Australian Censuses and
2005 Australian National Health Survey. This reveals that while there is some
overrepresentation among these cohorts of women with higher socioeconomic status and
better health [28], the study remains broadly representative of Australian women. The sample
included in this paper were generally healthier than those who were excluded and had a lower
prevalence of reported IPV, which may have diluted the associations between IPV and the
outcomes. Misclassification in reporting IPV and caregiving status is also possible. Use of a
single, retrospective item might have resulted in underreporting of IPV, as past research
indicates that use of multiple items leads to increased identification of IPV [29], and some
women may not self-identify as ‘caregivers’. Strengths of the study were the large
community-based sample, longitudinal data collection and wide range of covariates.
14
In conclusion, we have identified that mid-age women who experience IPV or caregiving
have poorer health outcomes than women without such history, and that women who have
experienced both have worse HRQOL than women who have experienced either or none.
Pre-existing mental and physical health, socioeconomic factors and personal resources were
also important. This paper provides early evidence for the cumulative health impact of
stressful life events, both those that are perpetrated against an individual (violence) and those
that are undertaken with a degree of personal agency (caring). The findings underscore the
need to understand the drivers of poor health, for clinicians to ask about life circumstances of
patients experiencing poor health, and for the provision of referral pathways for complex
cases. Future research could examine the onset, progress and consequences of IPV over the
lifecourse, including Post Traumatic Stress Disorder, and its impact on caregiving and health
and healthcare needs including qualitative explorations of female caregivers experiences of
IPV to inform development of appropriate support and protection for those providing care.
The study from which the data comes, the Australian Longitudinal Study on Women’s
Health, is funded by the Australian Government Department of Health. The funding supports
the collection of data. The Australian Government Department of Health had no role in the
study design, analysis and interpretation of data, writing of this paper or in the decision to
submit this for publication.
Pablo Ferreira was involved in the initial conceptualisation and design of the study, data
analysis and writing. He was then involved in the writing of later drafts and approved the
final version.
Deborah Loxton contributed to the design, analysis plan, interpretation of data and writing
and approved the final version.
15
Leigh R Tooth is senior author on this paper. She supervised Pablo Ferreira and contributed
to the initial design, acquisition, analysis and interpretation of data. She conducted the data
analysis and led the writing during later stages. She approved the final version.
Acknowledgements
The research on which this paper is based was conducted as part of the Australian
Longitudinal Study on Women’s Health by the University of Newcastle and the University of
Queensland. We are grateful to the Australian Government Department of Health for funding
and to the women who provided the survey data. Pablo Ferreira was supported by a
University of Queensland 2012/2013 Summer Research Program Scholarship. The authors
thank Ms Ariel Lackoff and Ms Natalie Townsend for their assistance with literature reviews.
Pablo Ferreira was involved in the initial conceptualisation and design of the study, data
analysis and writing. He was then involved in the writing of later drafts and approved the
final version.
Deborah Loxton contributed to the design, analysis plan, interpretation of data and writing
and approved the final version.
Leigh R Tooth is senior author on this paper. She supervised Pablo Ferreira and contributed
to the initial design, acquisition, analysis and interpretation of data. She conducted the data
analysis and led the writing during later stages. She approved the final version.
16
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Figure 1 Caption: Flow diagram of samples for analysis of general mental health, depressive
symptoms, physical HRQOL and perceived stress.
Explanations of abbreviations used in Figure 1
IPV Intimate Partner Violence
SF-36 MH Short Form-36 mental health subscale
Women who completed Survey 1,
n = 13714
Withdrawn n = 1192
Deceased n = 487
Uncontactable / Did not return
survey/s n = 3582
Women who completed all Surveys
1 to 6, n = 8453
Final sample for analysis, n = 8425
Missing data on IPV, n = 28
N for analysis of SF-36
MH Subscale = 8108
(Missing data on
covariates, n = 317)
N for analysis of CESD-
10 Scale = 7673
(Missing data on
covariates, n = 752)
N for analysis of SF-36
PCS = 7686
(Missing data on
covariates, n = 739)
N for analysis of Stress
Scale = 8111
(Missing data on
covariates, n = 314)
21
SF-36 PCS Short Form-36 physical component summary score
CESD-10 Centre for Epidemiological Studies Depression scale – 10-item
22
Figure 2 Caption: Regression estimates and their 95% confidence interval for the effect of
the intimate partner violence and caregiving exposure on the outcomes - 2A General mental
health; 2B Physical HRQOL; 2C Depressive symptoms; 2D Perceived stress.
Explanations of abbreviations used in Figure 2
IPV Intimate Partner Violence
SF-36 MH Short Form-36 mental health subscale
SF-36 PCS Short Form-36 physical component summary score
CESD-10 Centre for Epidemiological Studies Depression scale – 10-item
OR Odds ratio
β Regression coefficient
95% CI 95 percent confidence interval
23
Table 1. Demographic, socioeconomic and health characteristics for ALSWH women born
1946-51 who were included and excluded in the analysis, and analyses of these
characteristics by inclusion status.
Included
N=8453
(61.2%)
Excluded
N=5262
(38.4%)
Analysis of
difference
between samplesc
Exposures N (%) N (%)
Experienced IPV
Yes
No
Missing
1106 (13.1%)
7319 (86.7%)
28 (0.3%)
427 (8.1%)
1724 (32.8%)
3111 (59.1%)
χ2(1) =62.5**
Caregiving
Yes
No
Missing
2712 (32.1%)
5741 (67.9%)
0
952 (18.1%)
2877 (54.6%)
1433 (27.2%)
χ2(1) =65.6**
Combined IPV and caregiving
IPV, caregiving
IPV, no caregiving
No IPV, caregiving
No IPV, no caregiving
Missing
380 (4.5%)
726 (8.6%)
2323 (27.5%)
4996 (59.1%)
28 (0.3%)
130 (2.5%)
297 (5.6%)
492 (9.3%)
1232 (23.4%)
3111(59.1%)
χ2(3) =71.5**
Covariatesa
Relationship status
Partnered
7179 (84.9%)
4132 (78.5%)
χ2(1) =86.9**
24
Unpartnered
Missing
1242 (14.7%)
32 (0.3%)
1094 (20.8%)
36 (0.6%)
Area of residence
Major city
Inner regional area
Outer regional/remote
Missing
2967 (35.1%)
3340 (39.5%)
2145 (25.4%)
1 (0%)
2033 (38.6%)
1874 (35.6%)
1353 (25.7%)
2 (0%)
χ2(2) =24.2**
Ability to manage on income
Impossible/Difficult always
Difficult sometimes
Not too bad
Easy
Missing
1036 (12.3%)
2328 (27.5%)
3625 (42.9%)
1430 (16.9%)
34 (0.4%)
994 (18.9%)
1594 (30.3%)
2017 (38.3%)
605 (11.5%)
52 (0.9%)
χ2(3) =185.7**
Highest educational qualification
No formal
≤ 10 years
11-12 years
Trade/certificate/diploma
Degree/Higher degree
Missing
1236 (14.6%)
2675 (31.6%)
1375 (16.3%)
1767 (20.9%)
1343 (15.9%)
57 (0.7%)
1246 (23.7%)
1642 (31.2%)
912 (17.3%)
832 (15.8%)
549 (10.4%)
81 (1.5%)
χ2(4) =264.0**
Social support mean score (SD)
Missing N (%)
3.8 (1.1)
100 (1.2%)
3.7 (1.1)
2571 (48.9%)
F(1,11042)=43.3**
Optimism/resilience mean score (SD)
Missing N (%)
15.9 (3.9)
77 (0.9%)
14.9 (4.2)
2577 (48.9%)
F(1,11059)=102.7**
25
Outcomesb
SF-36 PCS, mean score (SD)
Missing N (%)
49.4 (10.1)
127 (1.5%)
47.6 (10.9)
3750 (71.2%)
F(1,9836)=41.6**
SF-36 Mental Health score, N (%)
≤ 52 (poor mental health)
≥ 53 (good mental health)
Missing N (%)
897 (10.6%)
7541 (89.2%)
15 (0.2%)
285 (5.4%)
1265 (24.0%)
3712 (70.5%)
χ2(1) =75.5**
CESD-10 score, N (%)
>10 (depressive symptoms)
≤ 10 (no depressive symptoms)
Missing N (%)
1438 (17.0%)
6795 (80.4%)
220 (2.6%)
383 (7.3%)
1103 (20.9%)
3776 (71.8%)
χ2(1) =57.1**
Perceived stress, N (%)
Not stressed
Stressed
Missing N (%)
7560 (89.8%)
857 (10.2%)
36 (0.4%)
1320 (85.4%)
225 (14.6%)
3717 (70.6%)
χ2(1) =25.9**
IPV = Intimate partner violence; SF-36 PCS = Short Form-36 physical component summary
score; SF-36 MH = Short Form-36 mental health subscale; CESD-10 = Centre for
Epidemiological Studies Depression scale – 10-item; a covariates measured at survey 1 except
for social support and optimism/resilience which were measured at Survey 3; b all outcomes
measured at Survey 6; c χ2 chi-square analyses; ** p≤0.001.
26
Table 2. Descriptive physical health, stress and mental health scores at baseline and survey 6 for women by intimate partner violence status and
caregiving exposure (N=8453)
Outcome variables: Scores at
baseline and Survey 6
Exposure
IPV, caring IPV, no caring No IPV, caring No IPV, no caring
SF-36 Mental Health, n (%)
Baseline
≤52 (poor mental health)
≥53 (good mental health)
78 (20.7%)
298 (79.3%)
139 (19.2%)
584 (80.8%)
264 (11.4%)
2047 (88.6%)
531 (10.7%)
4435 (89.3%)
χ2(3) =71.3**
Survey 6
≤52 (poor mental health)
≥53 (good mental health)
66 (17.5%)
312 (82.5%)
118 (16.3%)
607 (83.7%)
237 (10.2%)
2083 (89.8%)
469 (9.4%)
4518 (90.6%)
χ2(3) =51.4**
CESD-10, n (%)
Baseline
>10 (depressive symptoms)
130 (35.7%)
239 (34.7%)
478 (21.4%)
882 (18.3%)
χ2 (3) =144.6**
27
≤10 (no depressive symptoms) 234 (64.3%) 450 (65.3%) 1750 (78.5%) 3939 (81.7%)
Survey 6
>10 (depressive symptoms)
≤10 (no depressive symptoms)
127 (34.2%)
244 (65.7%)
195 (27.4%)
517 (72.6%)
404 (17.9%)
1859 (82.1%)
704 (14.5%)
4159 (85.5%)
χ2 (3) =151.6**
SF-36 PCS, mean (95% CI)
Baseline
49.7 (48.8, 50.5)
50.1 (49.5, 50.7)
52.7 (52.3, 52.9)
53.3 (53.1, 53.6)
F(3,8015)=49.9**
Survey 6 44.6 (43.5, 45.6) 46.3 (45.6, 47.0) 49.3 (48.9, 49.7) 50.3 (50.0, 50.6) F(3,8295)=65.8**
Perceived stress, N (%)
Baseline
Not stressed
Stressed
240 (63.3%)
139 (36.7%)
491 (67.6%)
235 (32.4%)
1902 (82.2%)
413 (17.8%)
4269 (85.8%)
708 (14.2%)
χ2 (3) =241.0**
Survey 6
Not stressed
Stressed
286 (75.9%)
91 (24.1%)
599 (83.1%)
122 (16.9%)
2046 (88.3%)
271 (11.7%)
4607 (92.6%)
368 (7.4%)
χ2 (3) =164.5**
CESD-10 = Centre for Epidemiological Studies Depression scale – 10-item; SF-36 PCS = SF-36 Short Form-36 physical component summary
score; ** p≤0.001.