African Caribbean & African American Women’s StudySymposium Presenters:
Jacquelyn C. Campbell, PhD, RN, FAANGloria Callwood, PhD
Marguerite B. Lucea, PhD, MPH, RNMary Paterno, PhD(c), MSN, CNM, RN
Acknowledgements
Research supported by a subcontract with the Caribbean Exploratory NIMHD Research Center of Excellence (CERC), University of the Virgin Islands, Grant # P20MD002286, National Institutes of Health, PI Gloria Callwood, PhD, RN, FAAN
Team MembersUnited StatesJacquelyn Campbell, PhD, RN, FAAN - PIPhyllis Sharps PhD, RN, FAAN – Co-IRichelle Bolyard, MHSJamila Stockman, PhD, MPHMarguerite B. Lucea, PhD, MSN, MPH, RNBushra Sabri, PhD, LMSW, ACSWAkosoa McFadgion, MS, MSW, PhD studentKaitlan Gibbons, PsyD(c) Mary Paterno, MSN, CNM, RN, PhD studentSharon O’Brien, PhDSachi Mana-ay, BSN studentJessica Draughon, MSN, RN, PhD studentCharmayne M. Dunlop-Thomas, MSCallie Simkoff, BSN, RNGyasi Moscou-Jackson, MHS, BSN, RNChris KunselmanAyanna Johnson, MPHAshley Chappell, BSN, RNLucine Francis, BSN, RNNaa Ayele Amponsah, MPHHossein Yarandi, PhD
US Virgin IslandsDoris Campbell, PhD, ARNP, FAAN – Co-PIGloria Callwood, PhD, RN, FAAN – Co-I, PI of CERC Desiree Bertrand, MSN, RNLorna Sutton, MPATyra DeCastroAlexandria Bradley, RNSally Browne, RNEdris Evans, RNYvonne Francis, RNNaomi Joseph, BSN studentJennifer King, RNSuzette Lettsome, MSPHN, RNJulie Matthew, RNKenice Pemberton, ASN studentJ'Nique Smith, BSN studentJaslene Williams, MSW
Outline of SymposiumOverview of study, settings and methodsPrevalence of lifetime IPA and past 2 year IPVMental health outcomesRelationship between substance abuse, IPV, and HIV risk
behaviorIPA and Reproductive OutcomesTraumatic Brain Injury and IPASummary
Overarching Study BackgroundHealth disparities among African American and African
Caribbean populations have been documented in national and territorial reports
Intimate Partner Abuse (IPA) is related to health disparities for women of color in the US
IPA is a risk factor for a variety of physical and mental health problems in US based studies
(NCHS, 2000; CDC, 2000; Government of the USVI Department of Health, 2003; Campbell, 2002; Campbell et all, 2002; Coker, 2004)
Overarching Study BackgroundPrevalence of IPV
Affects 13 – 62% of women globally; lifetime prevalence most often estimated around 30% (Garcia-Moreno, 2006)
In US, 32.9% of women experience lifetime physical IPV, 18.6% rape and 44.6% other sexual violence, with 9.4% of women reporting lifetime partner rape (Black et al, 2011)
Using BRFSS data, 22.5% of women in the US Virgin Islands report lifetime IPV vs. 26.4% overall (18 states) (Breiding, Black & Ryan,2008)
Gap: No data on prevalence of IPA in US Virgin Islands among women in health care settings compared to mainland US No prevalence analysis specific to the USIV No study of health consequences of IPA in USVI
Specific Aims of ACAAWSTo determine and compare the prevalence of IPA,
including emotional, sexual and physical abuse, in a sample of women from health care settings in the USVI and Baltimore, MD.
To determine to what extent a history of IPA is a risk factor for other medical conditions and symptoms, including: a) mental health; b) STD's/HIV and associated risk behaviors c) reproductive outcomes; and d) traumatic brain injury (TBI)
Setting: USVIUnincorporated territory of the
U.S. made up of 3 main islands (St. Thomas, St. Croix, St. John) and smaller islands
Population (2011 est.) 109,57476% Black, 13% White, 11% otherMedian household income:
$41,8344.8 immigrants/1,000 pop
Most of population US citizensOfficial language: English
Setting: Baltimore, MD
Population: 619,493 (2011)64% Black, 32% White, 4% otherMedian household income: $23,333Persons per household: 2.52Foreign born: 7%
Study Design & MethodsComparative case-control study (randomly selected controls)
Study period 2009-2011Eligibility criteria
Women aged 18-55 years Self-identify as African Caribbean or African American Report intimate partner in the past two years
Women recruited from primary care, prenatal or family planning clinics
Questionnaire administered on a touch screen computer with optional headphones
For women who were Spanish speaking (in USVI) and of low literacy (all sites)For sensitive informationAlerts interviewer if high score on DA or suicidality
CASES = Intimate Partner Abuse (IPA) Intimate Partner Violence (IPV - physical/sexual abuse) &
psychological abuse (threats/emotional abuse/controlling behavior ) IPV assessed using the Abuse Assessment Screen (AAS, McFarlane & Helton -
www.nnvawi.org) Pushed, slapped, hit, kicked, or physically hurt &/OR Forced sex
Psychological abuse: <19 on WEB (Women’s Experiences of Battering – Hall-Smith) Controlled, in fear of current/former intimate partner
Any of the above by current or former intimate partner
Past 2 Year and Lifetime IPV (Physical/Sexual)—subgroups within cases Exclusive of emotional/controlling abuse Reported as Lifetime and Past-two-year
Study Definitions: Cases (IPA/IPV)
CONTROLS = Women never abused by anyone in their lifetime
Not eligible (if meeting age, race, and language requirements) Women experiencing abuse only from someone other than
an intimate partner or ex-partner. Women reporting no partner within 2 years prior to survey
Study Definitions: Controls & Not Eligible
Selection of Sample from Study Population
Final Participants(n=901)
1579 screened from both sites
n=486 n=1059
169controls
159cases
189 controls
n=553
n=461 n=963
384cases
US Virgin IslandsBaltimore City, MD
n=348
34 ineligible race; duplicates
No partner past 2 yrs= 96
No partner past 2 yrs= 25
Didn’t meet case /control criteria = 70
Didn’t meet case /control criteria= 39
Non-selected control =329
Non-selected control = 74
Screened as case; no full survey=11
Lifetime IPA
Total 621/1545=40%B’more 179/488=37%USVI 442/1059=42%
Past 2-year IPV
Total 382/1424= 27%B’more 119/461= 26%
USVI 263/963= 26%
1315 fully eligible women
Education of Participants
Total Baltimore St. Thomas St. Croix0
5
10
15
20
25
30
35
40
45
50
20
27
1519
4244
3842
22
17
29
2016
13
18 18
< High schoolHS GradCollegePost College
(N=901)
Education Levels by Site, χ2 = 38.81, p<0.01
Per
cent
Marital Status of Participants
Marital Status by Site, χ2 = 49.21, p<0.01
Total Baltimore St. Thomas St. Croix0
10
20
30
40
50
60
70
48
59
3844
31
22
42
28
1512
17 18
6 73
9
Single
Partnered, Not Married
Married
Divorced/other
(N=901)
Per
cent
Employed & Insured Participants
Employed Insured0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
TotalBaltimoreSt. ThomasSt. Croix
χ2 = 26.14 p<0.01
Per
cent
χ2 = 124.10 p <0.01
(N=901)
Screening-based prevalence of abuse experiences
Among sample of population in healthcare setting, not limited to participants who meet restricted study definition of cases or “never-abused” controls.*Difference between sites significantly different (Chi-square p<0.01)
0%
10%
20%
30%
40%
50%
40%
32%
27%
8%
37%
30%26%
7%
45%
38%
32%
10%
38%
28%
22%
8%
TotalB'moreSTTSTX
IPA (Lifetime)* (n=1545)
IPV (lifetime)* (n=1545)
Physical/sexual IPV (past 2 yr)* (n=1424)
Forced/coerced sex (past 2 yr)
(n=1424)
Lifetime IPA (cases)
Physical
Psychological
170 (31%)
89 (17%)
Sexual
163 (30%)
26 (5%)
72(13%)
(n=543)
5 (1%)
18 (3%)
Physical
Psychological
Recent (past 2 Year) IPV
Sexual
98 (26%)
9 (2%)
79 (21%)
196 (51%)
(n=382)
Type of abuse among cases
*Difference between sites significantly different (Chi-square p<0.01)
0%
10%
20%
30%
40%
50%
60%
70%
80%
67%
9%
21% 22%
71%
9%
19% 18%
73%
10%15%
26%
57%
9%
28%
20%
Total (n=543)B'more (n=159)STT (n=207)STX (n=177)
Recent IPV (past 2 yr)*
Distant IPV only (not in past 2 yr)
Psychological/ Controlling only
(lifetime)*
Past 2 yr Forced/ Coerced Sex
(subset of recent IPV)
Sociodemographics & Lifetime IPA
Baltimore St. Thomas St. CroixChildren <18 years in household
X (risk) X (risk)
Born in US/USVI (vs foreign born)
X (risk)
Partner born in US/USVI (vs foreign born
X (risk)
Having a current partner X (protective)
Variables Significantly Associated with Lifetime IPA in Bivariate Analyses,Stratified by Site (p<0.05)
No significant associations in any sites between L-IPA and age, education level, employment status, insurance status, pregnancy status at time of survey.
Sociodemographics & Lifetime IPV
Baltimore St. Thomas St. CroixChildren <18 years in household
X (risk) X (risk) X (risk)
Born in US/USVI (vs foreign born)
X (risk)
Partner born in US/USVI (vs foreign born
X (risk)
Having a current partner X (protective)
Variables Significantly Associated with Lifetime IPV in Bivariate Analyses,Stratified by Site (p<0.05)
No significant associations in any sites between L-IPV and age, education level, employment status, insurance status, pregnancy status at time of survey.
Sociodemographics & Recent IPV
Baltimore St. Thomas St. CroixAge X (younger
>risk)X (younger
>risk)Children <18 years in household
X (risk)
Born in US/USVI (vs foreign born)
X (risk)
Partner born in US/USVI (vs foreign born
X (risk) X (risk)
Having a current partner X (protective)
Variables Significantly Associated with Lifetime IPV in Bivariate Analyses,Stratified by Site (p<0.05)
No significant associations in any sites between R-IPV and education level, employment status, insurance status, pregnancy status at time of survey.
Lifetime IPA and Physical HealthCompared to non-abused women, women reporting
lifetime IPA were at higher odds for Being hospitalized (AdjOR 1.37, 95% CI 1.08 – 1.73)Having had surgery (AdjOR 1.58, 95% CI 1.08 – 2.32)Having broken bones (AdjOR 2.34, 95% CI 1.24 – 4.40)Having facial injuries (AdjOR 3.51, 95% CI 2.16 – 5.71)Having eye injuries (AdjOR 2.65, 95% CI 1.60 – 4.38)Having a broken jaw (AdjOR 4.27, 95% CI 1.32 – 13.80)
When controlling for age, marital status, education, employment status, pregnancy status, and having children under 18 years of age in the household.
Exchange Sex – Risk of HIV – Variables in Analysis
Outcome: Exchange Sex Have you had exchange male sex partners, that is, men you have
sex with in exchange for food, money, shelter or drugs? (yes/no)Abuse history*
Recency: No abuse, Lifetime IPA, Past 2 year IPV Based on responses to AAS, WEB, SVAWS, Danger Assessment
Past Year Drug UseHow often in the past year have you used drugs (street drugs, drugs
that weren’t prescribed to you or were taken in a non-recommended way)? (yes if at all; no if never)
PTSD (PC-PTSD) (Prins et al, 2003)
Depressive symptoms(CESD-10) (Andresen et al., 1994)
Results: Overall
Of the total sample completing the full survey (n=901), 892 women (99%) reported their participation, or not, in exchange sex and illicit drug use. 357 controls; 473 cases
Of these women, 7% (n = 61) had engaged in exchange sex.
3% of controls; 10% of cases (χ2 15.23, p<0.001)
9.3% (n=83) reported using illicit drugs 6% of controls; 12% of cases (χ2 8.26, p<0.01)
Results: χ2 AnalysesSignificant associations (χ2 p<.05 with exchange sex)
Site, receipt of government aid, having children in household
Recency of Abuse Drug Use, Alcohol Use, PTSD, Depressive Symptoms
Non-significant associations (χ2 p>.10 with exchange sex):Age, Education level, Employment status, Current
relationship status, Monthly incomeThese variables were not retained for further analysis
Results: Predictors of Exchange SexUnadjusted OR (95% CI) Adjusted OR (95% CI)
Site Baltimore St. Thomas St. Croix
(ref)0.77 (0.43 – 1.38)0.41(0.20 – 0.85)
(ref)0.70 (0.36 – 1.34)0.34 (0.15 – 0.76)
No Government Aid 0.44 (0.21 – 0.90) 0.63 (0.28 – 1.42)
Children <18 2.07 (1.03 – 4.15) 1.39 (0.65 – 2.99)
Recency of Abuse None (control) Lifetime IPA Past 2 year IPV
(ref)2.03 (0.81-5.09)4.42 (2.18-8.95)
(ref)2.03 (0.75 – 5.47)2.95 (1.32 – 6.62)
Drug Use 9.26 (5.20 – 16.46) 5.50 (2.86 – 10.59)
Alcohol Use 1.22 (1.10 – 1.37) 1.04 (0.92 – 1.19)
PTSD 3.27 (1.83 – 5.84) 1.89 (0.94– 3.80)
Depressive symptoms 2.69 (1.58 – 4.58) 1.25 (0.67 – 2.35)
OR = Odds Ratio, CI = Confidence Interval
Discussion of FindingsWomen in St. Croix were significantly less likely
to engage in exchange sex than women in Baltimore (& women on St. Thomas somewhat less likely)
Rates of drug use comparable to previous literature findings—significantly higher among those experiencing IPV than those non-abused womenHowever relatively few in USVI – especially in St. Croix
Few of the socio-demographics were independently related to exchange sex
Recent IPV and past year drug use were both independently associated with exchange sex, a behavior linked to HIV risk.Results support influence of SAVA syndemic
Strategies for Early ID and InterventionImportant to acknowledge risk for and assess for
violence when working with women with a history of substance abuse, and vice versa
When working with HIV+ or women at risk for HIV, discussion of HIV risk behaviors should encompass exchange sex it may be a substantial risk factor, compounded by
substance abuse and IPV.However for most abused women – pathway to HIV is
through having unprotected sex with abusive partner – b/c sex is forced or b/c she fears his abuse if she tries to “negotiate” safe sex
Baltimore*
St. Thomas*
St. Cro
ix*0%
5%
10%
15%
20%
25%
30%
35%
4%
10% 10%
18%
30%
20%
ControlsCases
Balti-more*
St. Thomas
*
St. Croix0%
5%
10%
15%
20%
25%
30%
4%2%
7%
11%
28%
14%ControlsCases
Prevalence of IPA AttitudesCommunity acceptance of IPA Personal acceptance of IPA
* Differences between cases and controls significant (p<0.05)
Influence of Community Attitudes on Lifetime IPA
Women in Baltimore who feel their community is accepting of IPA are more than 4 times as likely to experience IPA than those in communities seen as not accepting of IPA (AOR 4.34, 95% CI 1.85 – 10.24)
Women in St. Thomas who feel their community is accepting of IPA are nearly 3 times as likely to experience IPA than those in communities seen as not accepting of IPA (AOR 2.89, 95% CI 1.26 – 6.63)
Elevated, but not significant, risk in St. Croix
Influence of Personal Attitudes on Lifetime IPA
Women in Baltimore who personally were more accepting of IPA are more than 3 times as likely to experience IPA than those not accepting of IPA (AOR 3.06, 95% CI 1.15 – 7.48)
Women in St. Thomas who personally were more accepting of IPA are nearly 13 times as likely to experience IPA than those not accepting of IPA (AOR 12.77, 95% CI 3.00 – 54.47)
Elevated, but not significant, risk in St. Croix
Prevalence DiscussionLimited number of women demonstrate a long-term separation
from violence (distant IPA)Targeted interventions required to help women break the cycle of violent
relationships (within the same relationship or engaging in sequential violent relationships)
Influential sociodemographics vary by site- community contextSome (e.g. US/USVI born partners) difficult to address
indicate need for increased efforts to encourage social norms changeOthers (e.g. children <18 in household) could benefit from multi-pronged
approach to protect women from repeated violence and to prevent multi-generational transmission of violence
Younger age associated with recent IPV importance of screening and early interventions with young people regarding health
relationships
Prevalence DiscussionPhysical health consequences
Findings for AA and AC women support findings for broader populations
Type of IPABe sure to include psychological/controlling behaviors (in
addition to physical/sexual violence) Indicated by the high rates of psychological abuse/controlling
behavior in St. Croix vs. other sites Community and personal attitudes towards IPA
Main drivers in elevated risk for IPA in relationshipsIndividual based + community/societal interventions
To shape attitudes about use of violence in relationship and To promote healthy relationships
Conclusions Reaffirms that IPA can be a significant contributing factor
to women’s physical health outcomes.New Affordable Health Care Well Women’s Preventive
Health care provisions – reimbursable routine screening and brief counseling for IPV in primary care – need to be implemented throughout USA including USVI
Nursing & medical care in emergency and other health settings including family planning and primary care needs to include assessment for abuse
Research must focus on developing and implementing culturally tailored and rigorously tested interventions for abused women of all ages
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