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 IPATotal 621/1545=40%

B’more 179/488=37%USVI 442/1059=42%

Past 2-year IPVTotal 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

2217

29

2016

1318 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: OverallOf 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. Croix*

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