Qualitative study: Understanding Mexican American women's experience in intimate partner violence

The purpose of this qualitative study was to gain an understanding of the experiences of Mexican American women living with intimate partner abuse relevant to the process of disclosure of abuse. Limited research exists on the experiences of women who are of Mexican descent living with intimate partner abuse and their disclosure of abuse. Factors that influence disclosure for other populations are well articulated in the literature however, these factors have not been adequately verified in persons of Mexican descent. Data are reported from in-depth interviews with 26 clients at a shelter and an outreach agency in a south Texas-Mexico border community. Semi-structured interview guide was used to elicit information over an 11 month period. A grounded theory ethnography approach was used to analyze data. Verification strategies and constant comparison techniques (e.g. investigator responsiveness, methodological coherence, sampling adequacy, an active analytic stance, and saturation) enhanced rigor of analysis. Nineteen Mexican immigrant women and seven Mexican American women participated in the study. Several themes were discerned related to women's experiences in abuse: painful living, questioning endurance, and confronting reality. In almost every participant's account there was a description of repeated victimization by her intimate partner or partners, and again, by others within and outside her network. The participants discussed several cultural factors (e.g. embarrassment, concerns for family, avoidance of causing pain to family, protection of partner, avoidance of being judged) that hindered their decisions whether or not to disclose. Participants noted that healthcare workers rarely asked probing questions regarding abuse. The timing and process of disclosure took many turns for women in this study. Some of the factors hindering women from disclosing were found to be influenced by cultural practices. The consequences of disclosure for many of the women led them to re-victimization. Implications for practice to avoid missed opportunities with women living in abuse are to: ask questions routinely to encourage disclosure of abuse and offer community resource information for women living in abuse or both.^

A global perspective on intimate partner violence during pregnancy: An analysis of twelve developing countries

Violence against women has been recognized as a significant worldwide human rights issue and public health problem. Women of reproductive age may be particularly at risk, and pregnancy may trigger or escalate violence. Using data available from Demographic and Health Surveys on 271,103 women of reproductive age (15-49) from Bolivia, Cameroon, Colombia, Dominican Republic, Egypt, Haiti, India, Kenya, Nicaragua, Peru, South Africa, and Zambia, this study examined the nature of domestic violence during pregnancy in developing countries, including prevalence, demographic and risk factors, maternal and child health outcomes, perpetrators of violence, help-seeking behavior, and social support. In the majority of countries analyzed, violence during pregnancy consistently occurred at approximately one-third the rate at which domestic violence occurred overall. Younger women and women with more children were particularly at risk. Abuse during pregnancy was significantly associated with history of a terminated pregnancy and under-5 child mortality in most countries, and with neonatal and post-neonatal mortality in most Latin American countries. Women who were abused during pregnancy were most often abused by their current or former husband or boyfriend and most never attempted to seek help. In most countries that examined social support, women abused during pregnancy had significantly less contact with family and friends. Implications for practice and research are discussed. ^

Pregnancy intention, intimate partner violence, and the use of prenatal care in Jordan

Previous research has suggested an association between intimate partner violence and pregnancy intention status, and pregnancy intention status and the use of prenatal care services, however much of these studies have been conducted in high income countries (HIC) rather than low and middle income countries (LMIC). The objectives of this study were to examine the relationship between pregnancy intention status and intimate partner violence, and pregnancy intention status and the use of prenatal care among ever-married women in Jordan.^ Data were collected from a nationally representative sample of women interviewed in the 2007 Jordan Demographic and Health Survey. The sample was restricted to ever-married women, 15–49 years of age, who had a live birth within the five years preceding the survey. Multivariate logistic regression analyses was used to determine the relationship between intimate partner violence and pregnancy intention status, and pregnancy intention status and the use of prenatal care services.^ Women who reported a mistimed pregnancy (PORadj 1.96, 95% CI: 1.31–2.95), as well as an unwanted pregnancy (PORadj 1.32, 95% CI: 0.80–2.18) had a higher odds of experiencing lifetime physical and/or sexual abuse compared with women reporting a wanted pregnancy. Women not initiating prenatal care by the end of the first trimester had statistically significant higher odds of reporting both a mistimed (PORadj 2.07, 95% CI: 1.55–2.77) and unwanted pregnancy (PORadj 2.36, 95% CI: 1.68–3.31), compared with women initiating care in the first trimester. Additionally, women not receiving the adequate number of prenatal care visits for their last pregnancy had a higher odds of reporting an unwanted pregnancy (PORadj 2.11, 95% CI: 1.35–3.29) and mistimed pregnancy (POR adj 1.41, 95% CI: 0.96–2.07).^ Reducing intimate partner violence may decrease the prevalence of mistimed or unwanted pregnancies, and reducing both unwanted and mistimed pregnancies may decrease the prevalence of women not receiving timely and adequate prenatal care among women in this population. Further research, particularly in LMIC, is needed regarding the determinants of unintended pregnancy and its association with intimate partner violence as well as with the use of prenatal care services. ^

PTSD, Depression, and Substance Abuse Symptoms in Women Exposed to Intimate Partner Abuse

The present study explores relationships among several established correlates of trauma in women exposed to intimate partner abuse (IPA), including PTSD, depression, and dissociation symptoms as well as alcohol use as well as other trauma-related variables, such as social support and violence exposure. Two analysis methods were utilized: variable-oriented methods, which examine relationships between variables, and person-oriented analysis methods, which examine groupings of participants within a larger sample (N = 233). Results of the variable-oriented analyses indicated positive links among depression, PTSD, dissociation, and alcohol use in women exposed to IPA, as well as positive links between the aforementioned psychological symptoms and exposure to violence. Social support was related to decreased psychological symptoms. Person-oriented analyses indicated the presence of four unique profiles of women within the larger study sample: Profile 1 (n = 21), which was labeled High Dissociation, Low Depression/PTSD; Profile 2 (n = 150), which was labeled Low Symptoms, High Social Support, Profile 3 (n = 41); which was labeled Low Dissociation, High Depression/PTSD; and Profile 4 (n = 22), which was labeled High Symptoms, Low Social Support. This research supports previous findings about the relationships among several variables related to IPA as well as suggests the need for careful consideration of differences among women within the larger context of research, advocacy, and clinical interventions related to IPA.

Attentional processes associated with victimization history and posttraumatic symptomatology in women exposed to intimate partner violence

Exposure to intimate partner violence (IPV) puts women at risk for severe and chronic physical and mental health consequences, including elevations in IPV-related psychopathology and increased risk for future victimization. Previous research has examined attention as one of the key information processing mechanisms associated with elevated psychopathology and risk for victimization; however, the nature of attentional processing in response to IPV-related information in women exposed to IPV is poorly understood. Therefore, the current study aimed to further understanding of associations between attentional processing, IPV exposure, and related distress using measures of eye movement and subjective interpretations of IPV-related information. A sample of women exposed to IPV (n = 57) viewed sets of negative, positive, and neutral relationship images for 15 s each while having their eye movements monitored and later provided subjective ratings and interpretations of levels of risk and safety in those images. We examined associations of outcome measures with proximal victimization experiences and IPV-related psychopathology (i.e., depression, posttraumatic stress disorder (PTSD), anxiety, and dissociation). Results indicated a bias to attend to negative relationship images relative to positive and neutral images, though this attention bias fluctuated over time and varied as a function of symptomatology such that depression corresponded with increases in attention to negative images over time and PTSD corresponded with decreases in attention to negative images. The general attention bias for negative images appeared to be explained by rumination on and/or difficulty disengaging from negative images, which was related to general elevations in psychopathology as well as exposure to revictimization by different perpetrators. Subjective interpretations and perception of danger cues were related to victimization history and level and type of IPV-related distress. We replicated these procedures with a sample of undergraduate students without IPV histories or related symptomatology (n = 33) and found that the overall attention bias for negative images was not replicated, despite general similarities in patterns of attention over time. Results therefore indicated associations between attentional processing and IPV exposure and related symptomatology. Implications for models of IPV-related psychopathology and attentional processing as well as directions for future study and interventions are discussed.

Social determinants and health effects of low and high severity intimate partner violence

PURPOSE: We sought to analyze whether the sociodemographic profile of battered women varies according to the level of severity of intimate partner violence (IPV), and to identify possible associations between IPV and different health problems taking into account the severity of these acts. METHODS: A cross-sectional study of 8,974 women (18-70 years) attending primary healthcare centers in Spain (2006-2007) was performed. A compound index was calculated based on frequency, types (physical, psychological, or both), and duration of IPV. Descriptive and multivariate procedures using logistic regression models were fitted. RESULTS: Women affected by low severity IPV and those affected by high severity IPV were found to have a similar sociodemographic profile. However, divorced women (odds ratio [OR], 8.1; 95% confidence interval [CI], 3.2-20.3), those without tangible support (OR, 6.6; 95% CI, 3.3-13.2), and retired women (OR, 2.7; 95% CI, 1.2-6.0) were more likely to report high severity IPV. Women experiencing high severity IPV were also more likely to suffer from poor health than were those who experienced low severity IPV. CONCLUSIONS: The distribution of low and high severity IPV seems to be influenced by the social characteristics of the women involved and may be an important indicator for estimating health effects. This evidence may contribute to the design of more effective interventions.

Identifying sociodemographic differences in Intimate Partner Violence among immigrant and native women in Spain: a cross-sectional study

Objectives: To analyze whether sociodemographics and social support have a different or similar effect on the likelihood of Intimate Partner Violence in immigrants and natives, and to estimate prevalences and associations between different types of IPV depending on women's birthplace. Methods: Cross-sectional study of 10,048 women (18–70 years) attending primary healthcare in Spain (2006–2007). Outcome: Current Intimate Partner Violence (psychological, physical and both). Sociodemographics and social support were considered first as explicative and later as control variables. Results: Similar Intimate Partner Violence sociodemographic and social support factors were observed among immigrants and natives. However, these associations were stronger among immigrants, except in the case of poor social support (adjusted odds ratio natives 4.36 and adjusted odds ratio immigrants 4.09). When these two groups were compared, immigrants showed a higher likelihood of IPV than natives (adjusted odds ratios 1.58). Conclusion: Immigrant women are in a disadvantaged Intimate Partner Violence situation. It is necessary that interventions take these inequalities into account.

How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol

Background: Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues—such as IPV management—get integrated into health systems, and that focuses on healthcare teams’ learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services. Methods: This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management. Discussion: Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.

Intimate partner violence in older women in Spain: prevalence, health consequences, and service utilization

The purpose of this study is to estimate the prevalence of lifetime intimate partner violence (IPV) in older women and to analyze its effect on women's health and Healthcare Services utilization. Women aged 55 years and over (1,676) randomly sampled from Primary Healthcare Services around Spain were included. Lifetime IPV prevalence, types, and duration were calculated. Descriptive and multivariate procedures using logistic and multiple lineal regression models were used. Of the women studied, 29.4% experienced IPV with an average duration of 21 years. Regardless of the type of IPV experienced, abused women showed significantly poorer health and higher healthcare services utilization compared to women who had never been abused. The high prevalence detected long standing duration, negative health impact, and high healthcare services utilization, calling attention to a need for increased efforts aimed at addressing IPV in older women.

Mapping and exploring health systems' response to intimate partner violence in Spain

Background: For a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system. Methods: Information was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain’s 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain. Results: In 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere. Conclusions: Within the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.

Social and immigration factors in intimate partner violence among Ecuadorians, Moroccans and Romanians living in Spain

Background: Intimate partner violence (IPV) against women occurs in all countries, all cultures and at every level of society; however, some populations may be at greater risk than others. The aim of this study was to explore IPV prevalence among Ecuadorian, Moroccan and Romanian immigrant women living in Spain and its possible association with their personal, family, social support and immigration status characteristics. Methods: Cross-sectional study of 1607 adult immigrant women residing in Barcelona, Madrid and Valencia (2011). Prevalence rates and adjusted odds ratios (AORs) were calculated, with current IPV being the outcome. Different women’s personal (demographic), family, social support and immigration status characteristics were considered as explicative and control variables. All analyses were separated by women’s country of origin. Results: Current IPV prevalence was 15.57% in Ecuadorians, 10.91% in Moroccans and 8.58% in Romanians. Some common IPV factors were found, such as being separated and/or divorced. In Romanians, IPV was also associated with lack of social support [AOR 5.96 (1.39–25.62)] and low religious involvement [AOR 2.17 (1.06–4.43)]. The likelihood of current IPV was lower among women without children or other dependants in this subgroup [AOR 0.29 (0.093–0.92)]. Conclusion: The IPV prevalence rates obtained for Moroccan, Romanian and Ecuadorian women residing in Spain were similar. Whereas the likelihood of IPV appeared to be relatively evenly distributed among Moroccan and Ecuadorian women, it was higher among Romanian women in socially vulnerable situations related to family responsibilities and the lack of support networks. The importance of intervention in the process of separation and divorce was common to all women.

Economic crisis, immigrant women and changing availability of intimate partner violence services: a qualitative study of professionals' perceptions in Spain

Introduction: Since 2008, Spain has been in the throes of an economic crisis. This recession particularly affects the living conditions of vulnerable populations, and has also led to a reversal in social policies and a reduction in resources. In this context, the aim of this study was to explore intimate partner violence (IPV) service providers’ perceptions of the impact of the current economic crisis on these resources in Spain and on their capacity to respond to immigrant women’s needs experiencing IPV. Methods: A qualitative study was performed based on 43 semi-structured in-depth interviews to social workers, psychologists, intercultural mediators, judges, lawyers, police officers and health professionals from different services dealing with IPV (both, public and NGO’s) and cities in Spain (Barcelona, Madrid, Valencia and Alicante) in 2011. Transcripts were imported into qualitative analysis software (Atlas.ti), and analysed using qualitative content analysis. Results: We identified four categories related to the perceived impact of the current economic crisis: a) “Immigrant women have it harder now”, b) “IPV and immigration resources are the first in line for cuts”, c) “ Fewer staff means a less effective service” and d) “Equality and IPV policies are no longer a government priority”. A cross-cutting theme emerged from these categories: immigrant women are triply affected; by IPV, by the crisis, and by structural violence. Conclusion: The professionals interviewed felt that present resources in Spain are insufficient to meet the needs of immigrant women, and that the situation might worsen in the future.

Children Exposed to Intimate Partner Violence Against Women in Spain. A Quantitative Analysis

A growing number of authors have been suggesting the necessary incorporation of children in the analysis of gender violence and, specifically, in the analysis of intimate partner violence against women (IPV). Such incorporation would be relevant not only for reducing children's invisibility and vulnerability, but also for achieving a better understanding of the characteristics and dynamics of IPV. Based on these considerations, we present in this paper the results of a secondary analysis applied to the data obtained in the last Spanish Survey on Violence Against Women. The available information allows us to analyze: 1) the presence of children exposed to IPV, 2) the relationship between this presence and the probability of reporting the violence, and 3) women's perception about the parental role of the aggressors.

Barriers and facilitators to effective coverage of Intimate Partner Violence services for immigrant women in Spain

Objective: To explore service providers’ perceptions in order to identify barriers and facilitators to effective coverage of Intimate Partner Violence (IPV) services for immigrant women in Spain, according to the different categories proposed in Tanahashi's model of effective coverage. Methods: A qualitative study based on 29 in-depth personal interviews and four group interviews with a total of 43 professionals working in public services (social and health-care services, women's refuges, the police force, the judiciary) and NGOs in Barcelona, Madrid, Valencia and Alicante (Spain) in 2011. Findings: Current IPV services in Spain partially fail in their coverage of abused immigrant women due to barriers of (i) availability, such as the inexistence of culturally appropriate services; (ii) accessibility, as having a residence permit is a prerequisite for women's access to different services and rights; (iii) acceptability, such as women's lack of confidence in the effectiveness of services; and (iv) effectiveness, for example, lack of specific training among professionals on the issues of IPV and immigration. However, interviewees also identified facilitators, such as the enabling environment promoted by the Spanish Law on Gender-Based Violence (1/2004), and the impetus it has provided for the development of other specific legislative tools to address IPV in immigrant populations in Spain (availability, accessibility and effectiveness). Conclusion: Whilst not dismissing cultural barriers, aspects related to service structure are identified by providers as the main barriers and facilitators to immigrant women use of IPV services. Despite noteworthy achievements, improvements are still required in terms of mainstreaming assistance tailored to immigrant women's needs in IPV policies and services.

How Does Intimate Partner Violence Differ Depending on Level of Rurality of Residential Area in Spain?

Intimate partner violence (IPV) is recognized as a worldwide public health problem. Most theories ascribe IPV to individual, family, or cultural factors. Authors analyzed different residential areas in Spain in terms of IPV frequency as well as its impact on health and the use of services. A standardized self-administered cross-sectional survey was administered to ever-partnered adult women ages 18 to 70 years receiving care at primary health care centers (N = 10,322). Logistic regression analyzed the association between the level of rurality and health indicators, IPV, and use of services. The lowest frequency of IPV among women is reflected in higher rurality. Women of medium and low rurality presented a poorer self-perceived health and more physical health problems. Women from medium and low rurality areas declared seeking health services more frequently. These results show the importance of the environment in health and indicate the need for research on urban–rural differences in health problems to develop specific public health programs for each country.