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 IPV

Baltimore St. Thomas St. CroixAge 0.97

(0.94-0.99)Children <18 years in household

2.14(1.34-3.43)

1.65(1.08-2.52)

1.94(1.19-3.16)

Born in US/USVI (vs foreign born)

2.02(1.32-3.09)

Having a current partner 0.34 (0.22-0.54)

Variables Significantly Associated with Lifetime IPV in Multivariate Analyses,Stratified by Site (Adjusted Odds Ratios, 95% Confidence Intervals)

No significant increased odds in any sites for L-IPV attributed to education level, employment status, insurance status, pregnancy status at time of survey.

Sociodemographics & Recent IPV

Baltimore St. Thomas St. CroixAge 0.97

(0.94-0.99)Children <18 years in household

2.45(1.43-4.18)

1.72(1.00-2.96)

Born in US/USVI (vs foreign born)

1.96(1.21-3.20)

Having a current partner 0.55(0.32-0.94)

0.35(0.20-0.61)

Variables Significantly Associated with Recent IPV in Multivariate Analyses,Stratified by Site (Adjusted Odds Ratios, 95% Confidence Intervals)

No significant increased odds in any sites for R-IPV attributed to 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.

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)

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

Prevalence DiscussionInfluential sociodemographics vary by site

Some (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 women are at increased risk for recent IPV importance of screening and early interventions with young people

regarding health relationships

Further exploration required into “protective” nature of current partnerships in Baltimore and St. Croix

Prevalence DiscussionPhysical health consequences

Findings for AA and AC women mirror those in broader populations

Clearly in contact with health care system—need to utilize opportunities to screen and address.

Community and personal attitudes towards IPAMain 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 for NursingReaffirms that IPA can be a significant contributing factor

to women’s physical health outcomes.

Nursing care in emergency and other health settings needs to include assessment for abuse

Nursing research must focus on developing and implementing culturally tailored and rigorously tested interventions for abused women of all ages, including young women