Partner violence and medical encounters: African-American women's perspectives

Exploring Primary Care Non-Attendance: A Study of Low-Income Patients

INTRODUCTION

While evidence has been established on the impact of medical appointment non-attendance on the healthcare system and patient health, previous research has not focused on how poverty and rurality may influence patient experiences with non-attendance. This paper explores patient perceptions of non-attendance among those experiencing poverty in a rural U.S county to better inform providers to the context in which their patients make attendance-related decisions.

METHODS

Using a grounded theory approach, we conducted semi-structured interviews with 32 U.S. low-income adults in the rural Western U.S. who recurrently missed primary care appointments. We also used a questionnaire to assess individual characteristics related to health, resiliency, personal mastery, medical mistrust, life chaos, and adverse childhood experiences.

RESULTS

Participants identified 3 barriers to attending appointments: appointment disinterest, competing demands, and insufficient systems. Appointment disinterest stemmed from physical and mental health issues, misalignment between needs and treatment, and comfort with the provider. Competing demands included family responsibilities, employment, and relationships. Finally, participants reported that current scheduling and transportation systems were helpful but insufficient. To provide further context, participants also reported low overall health, moderate levels of medical mistrust, life chaos, and mastery, moderate to low resilience, and very a high number of adverse childhood experiences.

CONCLUSIONS

Results point to the need for modified structures that allow low-income patients more control over their personal health and highlight opportunities for clinics to address patients' lack of interest and fear in the medical encounter.

Childhood Trauma and the Inability to Access Hospital Care Among People who Inject Drugs

Childhood traumatic experiences can disrupt attachment, influence personality development, and precipitate chronic disease. Although the repercussions of these experiences may also pose a barrier to healthcare, few studies have examined the association between childhood trauma and access to healthcare. Therefore, we sought to investigate whether a history of childhood trauma is associated with self-reported inability to access hospital care among persons who inject drugs (PWID). Data were derived from two prospective cohorts of PWID in Vancouver, Canada. We used multivariable generalized estimating equations to examine associations between five types of childhood trauma and self-reported inability to access hospital care, both overall and specifically due to perceived mistreatment by hospital staff. In total, 300 participants (18.3%) reported having tried but being unable to access hospital care in the previous 6 months at some point during the study period; the primary reason was perceived mistreatment by hospital staff (32.1%). In multivariable analyses, childhood emotional abuse was independently associated with self-reported inability to access hospital care, adjusted odds ratio (AOR) = 1.51, 95% CI [1.03, 2.20]. Childhood physical neglect was also independently associated with inability to access care due to perceived mistreatment by hospital staff, AOR = 1.80, 95% CI [1.11, 2.93]. This suggests potentially damaging consequences of early trauma in adult PWID populations. Further, this study emphasizes the need for trauma-informed models of care as well as the need to improve therapeutic alliances with survivors of childhood trauma in the PWID population.

African American HMO Enrollees

Intimate partner violence has been demonstrated to be a significant public health problem among African American women. This study provided an opportunity to examine prevalence of intimate partner violence and health consequences among a group of primarily middle-class, employed African American women enrolled in a privately insured HMO (n = 109 abused and 97 never-abused women). Significantly more abused African American women were divorced or widowed and had incomes less than $50,000 a year. Abused women had more health problems (central nervous system, gynecological, STDs, gastrointestinal), more health problems per medical visits, and more emergency room visits (p < .05) compared to never-abused women. The health consequences of abuse and its association with health disparities are discussed.

Barriers to HIV Medication Adherence: Examining Distinct Anxiety and Depression Symptoms among Women Living with HIV Who Experienced Childhood Sexual Abuse

Experiencing sexual violence in childhood or adolescence is highly prevalent among some women living with HIV, often resulting in anxiety and depression symptoms in adulthood. Anxiety and depression have been associated with HIV medication nonadherence, yet little research has assessed distinct components of anxiety and depression as risk factors of HIV medication nonadherence. The current study examined distinct symptom components of anxiety and depression as predictors of HIV medication non-adherence among women living with HIV and childhood sexual abuse enrolled in a coping intervention. This secondary analysis included a sample of 85 women living with HIV and childhood sexual abuse and being prescribed antiretroviral medication who completed measures on anxiety, depression, and medication adherence. Results from a logistic regression analysis suggest that distinct components of anxiety may be related to medication nonadherence among this population. Targeted mental health interventions for this population may increase adherence to antiretroviral medication.

Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders

Trauma and posttraumatic stress disorder disproportionally affect HIV-positive women. Studies increasingly demonstrate that both conditions may predict poor HIV-related health outcomes and transmission-risk behaviors. This study analyzed data from a prevention-with-positives program to understand if socio-economic, behavioral, and health-related factors are associated with antiretroviral failure and HIV transmission-risk behaviors among 113 HIV-positive biological and transgender women. An affirmative answer to a simple screening question for recent trauma was significantly associated with both outcomes. Compared to participants without recent trauma, participants reporting recent trauma had over four-times the odds of antiretroviral failure (AOR 4.3; 95% CI 1.1-16.6; p = 0.04), and over three-times the odds of reporting sex with an HIV-negative or unknown serostatus partner (AOR 3.9; 95% CI 1.3-11.9; p = 0.02) and <100% condom use with these partners (AOR 4.5; 95% CI 1.5-13.3; p = 0.007). Screening for recent trauma in HIV-positive biological and transgender women identifies patients at high risk for poor health outcomes and HIV transmission-risk behavior.

A model of sexually and physically victimized women's process of attaining effective formal help over time: the role of social location, context, and intervention

As empirical evidence has demonstrated the pervasiveness of sexual assault and intimate partner violence in the lives of women, and the links to poor mental health outcomes, attention has turned to examining how women seek and access formal help. We present a conceptual model that addresses prior limitations and makes three key contributions: It foregrounds the influence of social location and multiple contextual factors; emphasizes the importance of the attainment of effective formal help that meets women's needs and leads to positive mental health outcomes; and highlights the role of interventions in facilitating help attainment. We conclude with research and practice implications.

Attachment and health care relationships in low-income women with trauma histories: a qualitative study

Few studies have examined the relationship between low-income, traumatized women and their health care providers. In this study we interviewed 23 women from primary care and social service settings for the underserved about trauma, attachment, psychiatric symptoms, and reports of their interactions with primary care providers. Nearly all reported trauma exposure, and 17% had current posttraumatic stress disorder. About half were categorized as Unresolved with regard to attachment state of mind. Analyses of a health experiences interview showed that women with Unresolved attachment reported significantly more negative interactions with providers. Attachment may play a role in the relationship between trauma and health care interactions with providers, indicating the need for further study of this relationship and suggesting intervention strategies to help both parties contribute to a more collaborative process.

Military sexual trauma and patient perceptions of Veteran Health Administration health care quality

BACKGROUND

Although sexual trauma is associated with poorer patient perceptions of health care quality, few studies have investigated this relationship in settings with comprehensive policies surrounding detection and treatment of sexual trauma, such as the Veterans Health Administration (VHA). We examined the association of military sexual trauma (MST) with patient satisfaction with VHA outpatient care among men and women.

METHODS

This is a cross-sectional study of a national representative sample of 164,632 VHA outpatients (5,758 women and 158,884 men) from fiscal year 2007. Measures included MST status, patients' ratings of overall satisfaction with VHA care in the last 2 months, and nine other dimensions of patient satisfaction. We assessed bivariate and multivariate associations between MST and overall satisfaction and each dimension of patient satisfaction. Multivariate models were adjusted for demographic characteristics, health status, and medical utilization. All analyses were stratified by gender.

FINDINGS

The proportion of patients reporting very good or excellent overall satisfaction was 78.5% for men and 72.3% for women. Findings showed that, once confounding was controlled, men and women veterans' MST status was not associated with satisfaction ratings of VHA health care overall. However, women veterans with a history of MST rated the dimensions of overall coordination and education and information less favorably than women veterans without an MST history. Post hoc analysis of individual items in these domains suggested that areas of improvement might include greater attention to provider-patient communication, including communication across multiple providers. There was no association between men's MST status and subdomains of health care satisfaction.

CONCLUSION

Patient ratings of overall satisfaction of VHA care are high. Opportunities exist, however, to educate providers on the special coordination needs of female veterans with histories of MST. These female veterans might benefit from care coordination. When investigating satisfaction in patients with histories of sexual trauma, our findings suggest the importance of adjusting analyses for important patient characteristics.

Challenges and successes in linking HIV-infected women to care in the United States

Women currently account for 27% of new human immunodeficiency virus (HIV) infections in the United States, the majority of which are acquired through heterosexual transmission. In the United States, black and Latino persons are disproportionately affected by the HIV epidemic, a disparity that is most dramatically present among HIV-infected women. Many of these women face significant discrimination as a result of race or ethnicity and sex, and they suffer disproportionately from poverty, low health literacy, and lack of access to high-quality HIV care. As a consequence, despite the availability of highly active antiretroviral therapy (HAART), women with HIV often have delayed entry into care and experience poor outcomes. This article reviews risk factors for HIV infection in women, barriers to engagement in care, and strategies to improve linkage to HIV-related medical and social care.

Intimate partner violence among HIV-positive persons in an urban clinic

While the intersection of HIV/AIDS and intimate partner violence (IPV) has gained increased attention, little focus has been given to the relationship among minority men and men who have sex with men (MSM). This pilot study, conducted at an urban clinic, explores the IPV experiences of HIV-positive persons involved in both heterosexual and homosexual relationships. Fifty-six HIV-positive individuals were interviewed to assess for verbal, physical, and sexual IPV, and for HIV-related abuse and attitudes regarding routine IPV screening. Approximately three quarters (73%) of the sample reported lifetime IPV and 20% reported current abuse. Physical IPV (85%) was cited the most by abused participants. IPV rates were highest among African-Americans and MSM. More than one-fourth (29%) of those abused felt the abuse was related to their HIV status. A majority of participants favored IPV screening by providers, but felt it might increase risk of IPV. IPV and its association to HIV are significant issues among this sample. Findings support the need for developing new programs that address these epidemics simultaneously.

Childhood abuse and initial presentation for HIV care: an opportunity for early intervention

An alarmingly high prevalence of childhood sexual and physical abuse has been observed in HIV-infected men and women, with rates several times higher than observed in the general population. Childhood abuse history has been associated with worse antiretroviral adherence and negative health behaviours in HIV-infected patients. This study evaluates the relationship between childhood abuse and the timing of presentation for HIV care. Participants in a multi-center prospective cohort study, who established initial HIV care after January 1996 and had a CD4 count available within six months of initial presentation, were included in this analysis. Bivariate contingency tables and multivariate logistic regression were used to evaluate the association of childhood abuse with early presentation for HIV care (initial CD4 count > or =200/mm3). Among the 186 subjects included in this analysis, 33% had childhood abuse histories and 58% had an initial CD4 count > or =200/mm3. Participants with a history of childhood abuse were more likely to present early for HIV care (AOR=2.12; p=0.03), perhaps because survivors of abuse tend to have higher utilization of health services. Because HIV-infected patients with childhood abuse histories have worse antiretroviral medication adherence and are more likely to engage in high-risk sexual and injection drug use behaviours, early presentation affords clinicians the opportunity for timely institution of interventions that may improve patient outcomes and prevent secondary HIV infections.

Community response and needs of African American female survivors of domestic violence

Relatively few studies have looked specifically at the experiences and needs of African American women who are survivors of domestic violence. This study sought to find out from African American survivors (a) what their experience was with various community entities and (b) how they feel race may have affected these experiences. Results indicate a great deal of dissatisfaction with the services received as they attempt to escape and/or stay away from their abusive partners. This dissatisfaction was in large measure due to lack of cultural competence. Implications for service and suggestions for community entities are presented.

Interactions between victims of intimate partner violence against women and the health care system: policy and practice implications

Intimate partner violence (IPV) affects the use of health care by increasing the risk of poor health outcomes. IPV victims seek health services as often as others but are less likely to receive needed services, more likely to overuse services, and more likely to have a poor relationship with their health care provider. This stems from patient and provider barriers to care that are exacerbated by the lack of a clear and consistent health care system response to IPV. Most health care systems are not equipped to assist either victims or providers seeking to help victims. There are a few models of system-wide interventions, but these are not the current standard. A strong health policy framework is needed, but the decision of the U.S. Preventative Task Force not to recommend universal screening is a setback. Overall, there is limited progress in moving the health care system toward assisting IPV victims.

Health disparities and violence against women: why and how cultural and societal influences matter

This article encourages readers to consider the cultural and societal influences that impact health and health disparities among women survivors of intimate partner violence (IPV). Health consequences caused by IPV are widely documented and broadly discussed. Connections between health disparities and IPV are also discussed as related to women of color. Cultural factors and societal influences are identified to provide the reader with greater awareness of how these issues intersect with and impact IPV. Finally, the implications for scientific research and practice are discussed to include considerations for stronger assessment tools, greater collaboration and community participation, determination of best practices, requirement of cultural competence, mandated accountability, encouragement of mentorship, increased funding for research, increased advocacy, and increased culturally competent media and health promotion campaigns.

Nurse case management for pregnant women experiencing or at risk for abuse

OBJECTIVE

To determine whether individualized nursing case management can decrease stress among pregnant women at risk for or in abusive relationships.

DESIGN

A multisite randomized controlled trial.

SETTING

Two prenatal clinics in the Pacific Northwest and rural Midwest.

PARTICIPANTS

1,000 women who spoke English and were 13 to 23 weeks pregnant at time of recruitment.

INTERVENTION

All intervention group women (N = 499) were offered an abuse video and had access to a nurse case manager 24/7. Additionally, participants at risk for or in abusive relationships received individualized nursing care management throughout the pregnancy.

RESULTS

The most frequent nursing care management activities were providing support (38%) and assessing needs (32%). The nursing care management group received an average of 22 contacts, most (80%) by telephone and had a significant reduction in stress scores as measured by the Prenatal Psychosocial Profile. Compared to the control group, the differences were in the predicted direction, but not statistically different. A major finding was the choice by abused women to focus on basic needs and their pregnancies rather than the abuse, although all received safety planning.

CONCLUSIONS

Pregnant women at risk for or in abusive relationships experience very stressful and complex lives. Nurses need to focus on the needs they identify, which may not be the abusive relationship.

Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events

Among HIV-infected persons, high-level adherence to antiretroviral medications (>90%-95%) is associated with improved immunologic, virologic, and clinical outcomes, and is necessary to prevent the emergence of viral resistance. This study examines whether lifetime traumatic events including physical and sexual abuse, are associated with antiretroviral nonadherence. We present a cross-sectional analysis of the Coping with HIV/AIDS in the Southeast (CHASE) Study, analyzing data from the enrollment interview and medical records of study subjects. The CHASE Study is a prospective cohort study of consecutively sampled HIV-infected subjects from infectious diseases clinics in five southern states; Alabama, Georgia, Louisiana, North Carolina, and South Carolina. Four hundred seventy-four (78%) of the 611 CHASE study subjects reported being treated with antiretroviral medications at enrollment and are included in this analysis. Nonadherence was defined as the patient's self-report of missing any doses of their antiretroviral medications over the previous 7 days. Among study subjects, 54% reported a history of physical and/or sexual abuse, 91% reported at least one lifetime traumatic event, and 24% reported nonadherence with their antiretrovirals. In multivariable logistic regression analysis, the number of categories of lifetime traumatic events (p = 0.03), the Addiction Severity Index (ASI) alcohol score (p = 0.02), and being uninsured (p = 0.04) were associated with antiretroviral nonadherence. The finding that lifetime traumatic events are associated with antiretroviral nonadherence, particularly among those who have been traumatized in multiple ways, highlights the complex and often persisting manifestations of such trauma and calls for further investigation.

Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature

For more than a decade, professional medical and nursing associations have recommended universal screening for intimate partner abuse (IPA). This review of 44 studies examines IPA screening during this period. The purposes of the review are to (a) identify mutable influences on IPA screening, (b) summarize what is known about altering these influences, and (c) outline an agenda for improving IPA screening. Evidence to date indicates that screening is not universal. Promising approaches to improvement start with provider training and relatively simple environmental adjustments. Unanswered empirical questions include "What are the essential components of effective training? Which health care providers are best positioned to screen under which circumstances? Which of the untested mutable influences will further improve IPA screening practice?" The review leads to the following practice recommendations: (a) Interventions should focus on clinicians in training (e.g., medical residents), and (b) screening approaches must be tailored to various practice settings.

Moving beyond disclosure: women's perspectives on barriers and motivators to seeking assistance for intimate partner violence

To investigate women's perceptions of motivators and barriers to seeking help or accessing intimate partner violence (IPV), services six focus groups were conducted in rural and urban settings in North Carolina between June and August of 2002. Coding and theme analysis were used to summarize themes among the 67 focus group participants. The majority of participants were African-American (87%). Participants reported three main categories of motivators: gaining knowledge; reaching an emotional or physical breaking point; and growing concern about children's safety. Participants reported six main categories of barriers: pressure not to talk about, or address IPV; failure to recognize events as IPV, or that IPV was wrong; self-doubt and low self-esteem; fear of losses; fear of perpetrator; or desire to protect the perpetrator. This study documents the difficulties that women face accessing or using services related to IPV. We need to address perceived barriers and better use the opportunity when women experience motivation to seek help and access services.

South Asian Victims of Intimate Partner Violence More Likely than Non-Victims to Report Sexual Health Concerns

To assess relationships between intimate partner violence (IPV) and sexual health among South Asian women in Boston. Surveys assessed demographics, IPV and sexual and reproductive health outcomes of women in relationships with men (N=208). In-depth interviews explored these issues with women with a history of IPV (N=23). Subjects were majority Indian, non-U.S. citizens, and highly educated. Quantitative data were assessed by logistic regression, qualitative data by a grounded theory approach. About 21.2% of the survey sample reported IPV in the current relationship. These women are 2.6 times as likely to report discolored vaginal discharge in the past year (95% CI=1.27-6.50), 3.1 times as likely to report burning during urination in the past year (95% CI=1.52-6.31) and 3.4 times as likely to report unwanted pregnancy in the current relationship (95% CI=1.33-8.66). Interviewed women described how abuse reduces sexual autonomy, increasing risk for unwanted pregnancy and multiple abortions. Study findings demonstrate the need for increased gynecologic health outreach to abused South Asian women in the U.S.

Abused Pregnant Women’s Interactions With Health Care Providers During the Childbearing Year

OBJECTIVE

To explore how intimate partner abuse during pregnancy influences women's decisions about seeking care and disclosing abuse and their preferences for health care professionals' responses.

DESIGN

A qualitative, grounded theory approach using dimensional analysis. Data were collected via 21 interviews.

SETTING

Participants were interviewed in their homes, at their prenatal clinic, at a hospital, and at the investigator's office.

PARTICIPANTS

A convenience sample of 12 English-speaking women abused during pregnancy. Five participants were recruited from two prenatal clinics in the Pacific Northwest; 7 were recruited via snowball sampling.

RESULTS

The grounded theory "living two lives: women's experiences of intimate partner abuse during pregnancy" emerged from the investigation. Abused pregnant women engaged in a process of guarding and revealing their public and private lives. This process affects how women seek and attend prenatal care, their perceptions of health care providers' interventions, and abuse disclosure.

CONCLUSIONS

Intimate partner abuse profoundly affects women's pregnancies and pregnancy-related decisions. Embarrassment, shame, and fear are common emotions. Pregnant, abused women want health care providers to treat them respectfully and empathetically, to recognize the conflict between their public and private lives, to support their decisions, and to be available to help them. They do not expect or want health care providers to fix their situation.

Intimate partner violence and physical health consequences: policy and practice implications

Extensive research indicates that intimate partner violence (IPV) poses a significant risk to the physical health of women. IPV is associated with increased mortality, injury and disability, worse general health, chronic pain, substance abuse, reproductive disorders, and poorer pregnancy outcomes. IPV is also associated with an overuse of health services and unmet need for services, as well as strained relationships with providers. The body of IPV research has several critical gaps. There are almost no longitudinal studies of IPV and health. Most studies are clustered into a few specialties, with almost no research in the areas of allied health, dentistry, or management. A common definition of IPV is still not used. Finally, with some notable exceptions, there has been little success in moving the health care system to routinely screen women for IPV.

Ethnic Differences in Battered Women's Formal Help-Seeking Strategies: A Focus on Health, Mental Health, and Spirituality

The primary goal of this study was to identify ethnic differences in battered women's use of health, mental health, and spiritual coping strategies, as well as differences in the perceived helpfulness of each strategy. The authors recruited a sample of 376 African American and Caucasian victims of interpersonal violence from various sites. In comparison with Caucasian women in the sample, African American women were significantly more likely to report using prayer as a coping strategy and significantly less likely to seek help from mental health counselors. The 2 groups did not significantly differ in terms of the extent to which they sought help from clergy or medical professionals. African American women found prayer to be more helpful than did Caucasian women.

Medically eligible women who do not use HAART: the importance of abuse, drug use, and race

OBJECTIVES

We investigated the prevalence and characteristics of HIV-positive women who do not report highly active antiretroviral therapy (HAART) use.

METHODS

We analyzed HAART use among 1165 HIV-positive participants in the Women's Interagency HIV Study.

RESULTS

Between October 1, 2000, and March 31, 2001, 254 women with clinical indications for HAART reported not using it, 635 reported HAART use, and 276 had no clinical indications. In multivariate analysis, using crack/cocaine/heroin and a history of abuse decreased the likelihood of using HAART, whereas being White increased it.

CONCLUSIONS

One of 4 women for whom HAART was indicated reported not using HAART. Childhood sexual abuse prevention, more intensive abuse treatment, and continuing drug treatment may enhance HIV disease treatment of women.

An integrative review of separation in the context of victimization: consequences and implications for women

Given the number of divorces that occur each year as well as the high rates of intimate partner violence, it is critical that divorce/separation and victimization be considered in research and in clinical practice with women. However, the separation/divorce research and victimization research has often been conducted independently, with limited attention to integration. The integration of these two domains is critically important in facilitating the understanding of these issues for women. This article has 5 main purposes: (a) to review the research on the general consequences of separation; (b) to review the research on the consequences of separation when children are involved; (c) to review the research on the consequences of victimization; (d) to integrate the separation and victimization research to examine separation in the context of victimization; and (e) to discuss the implications of separation in the context of victimization for practice and research.

Evaluating intimate partner violence

PURPOSE

To describe the incidence, assessment, and management of intimate partner violence (IPV) from a cultural perspective emphasizing the values, strengths, and health care needs of African-American women.

DATA SOURCES

Review of the published scientific literature, U.S. Bureau of Justice Statistics and the National Crime Victimization Survey (NCVS) supplemented with hypothetical cases.

CONCLUSIONS

Violence is a social and public health emergency affecting over 10% of the population during their lives and 22% of women who are physically assaulted by an intimate. Roughly 3 million to 4.4 million women report being battered annually, although this is a low estimate. Neither gender nor age nor sexual orientation protects one from IPV. Violent crime causes 2.2 million known injuries with a huge cost in hospital days and other expenses.

IMPLICATIONS FOR PRACTICE

Women often hesitate to report violence; health care professionals detect as few as 5% of battered women. Women suffer for months and years before accurate diagnosis. Clinicians need to be vigilant in case finding, education, prevention, and treatment. Cultural differences in values and beliefs, and behavioral norms influence evaluation, treatment, and referral.