Trajectories of Depression, Post-Traumatic Stress, and Chronic Pain Among Women Who Have Separated From an Abusive Partner: A Longitudinal Analysis

Gendered Worlds of Pain: Women, Marginalization, and Chronic Pain

The importance of gender is undertheorized in chronic pain research, meaning extant research cannot sufficiently shed light on how chronic pain experience and treatment are connected to institutions and societal structures. Much literature on gender and pain is not critical in orientation, making it difficult to translate data into recommendations for improved treatment and care. Our study takes a critical approach informed by social theory to understand chronic pain among women who experience socioeconomic marginalization. Drawing on a gender-based subanalysis of interview data collected in Canada as part of an institutional ethnography of chronic pain among people who are socioeconomically marginalized, from women's narratives, we identified 4 themes that speak to gender, chronic pain, and marginalization. These are 1) gendered minimization of women's health concerns, 2) managing intergenerational poverty, 3) living with violence and trauma, and 4) gendered organization of family care. Together, these themes highlight how women's experiences of chronic pain and marginalization amplify gendered vulnerabilities in health care, social services, and society in general. Our findings depict a deeply gendered experience of chronic pain that is inseparable from the daily struggle of managing one's life with pain with heavy responsibilities, the baggage of past trauma, and responsibility for others with few resources. We emphasize the importance of chronic pain care and health and social services that are both gender- and trauma-informed. PERSPECTIVE: This article draws on an institutional ethnography (a holistic qualitative methodology) of chronic pain and socioeconomic marginalization to demonstrate the importance of chronic pain care and health and social services that are both gender- and trauma-informed.

The association between violence against women and chronic pain: a systematic review and meta-analysis

Violence against women is a phenomenon that involves at least 35% of women worldwide. Violence can be sexual, physical, and/or psychological, perpetrated by the partner, another family member, or a stranger. Violence is a public health problem because its consequences include higher morbidity, higher mortality, and short and long-term physical and psychological health diseases. Most studies prove an association between any type of violence and some chronic pain diagnoses but no one has done a complete collection of this evidence. This systematic review and meta-analysis aimed to evaluate whether this association is statistically significant, including the largest number of studies. Through the inclusion of 37 articles, the association has been demonstrated. Compared with no history of violence, women who did experience violence showed 2 times greater odds of developing chronic pain. The impact of violence was significant also on fibromyalgia separately, but not on pelvic pain.PROSPERO registrationPROSPERO CRD42023425477.

Understanding what shapes the priorities of women who are mothering in the context of intimate partner violence: A qualitative study

AIM

To explore the priorities of women mothering children in the context of intimate partner violence and to understand what shapes those priorities.

DESIGN

A qualitative study using interpretive description, informed by Feminist Intersectionality adhering to the COREQ guidelines.

METHODS

Thematic analysis was used to analyse the data.

DATA SOURCES

Dialogic, semi-structured interviews were conducted with a community sample of 20 adult Canadian women who were mothering dependent children (under 18 years) in the context of recent intimate partner violence from a current or former partner.

RESULTS

Women's main priorities focused on their own and their children's well-being and creating stability related to housing and finances. Three themes identified: it's all about the kids; my safety…totally disregarded; and I have to take care of him. Multiple external factors (coercive control, structural inequities, assumptions about mothering) shape priorities and the tensions arising from competing priorities women felt compelled to address simultaneously.

CONCLUSION

Priorities of women mothering in the context of intimate partner violence are complex, shaped not only by what they want but by the limited options available to them given constraints such as income, employment, housing and service responses. Coercive control, structural inequities and assumptions about mothering are important factors influencing mothers' priorities and experiences. Better understanding mothers' priorities can support better tailored policies, services and nursing practice.

IMPLICATIONS FOR NURSING

Structural inequities that negatively impact health and well-being by limiting access to resources and the supports needed to enhance health can be better recognized and addressed through a trauma and violence informed care approach.

IMPACT

This study addressed understanding the priorities of women mothering in the context of intimate partner violence. This research will impact women mothering in the context of intimate partner violence who receive care from nurses and other providers as well as those who provide care.

REPORTING METHOD

This study adhered to relevant EQUATOR guidelines (the COREQ checklist).

NO PATIENT OR PUBLIC CONTRIBUTION

The women who took part in the interviews for this study did not participate in the study design, analysis or manuscript preparation.

Longitudinal effectiveness of a woman-led, nurse delivered health promotion intervention for women who have experienced intimate partner violence: iHEAL randomized controlled trial

BACKGROUND

Intimate partner violence (IPV) threatens the safety, health and quality of life of women worldwide. Comprehensive IPV interventions that are tailored, take a long-term view of women's needs, including health concerns, and maximize choice and control, have the potential to effectively address heath and safety concerns. Few such interventions have been tested, including in the Canadian context.

METHODS

A parallel randomized controlled trial of adult (age 19 + years), English-speaking, Canadian women with histories of IPV randomized either to iHEAL, a tailored health promotion intervention delivered by Registered Nurses over 6-7 months, or to community service information (usual care control). Primary (Quality of Life, PTSD symptoms) and secondary outcomes (Depression, Confidence in Managing Daily Life, Chronic Pain, IPV Severity) were measured at baseline and 6, 12 and 18 months post-intervention via an online survey. Generalized estimating equations were used to test for differences by study arm in intention-to-treat (full sample) and per protocol (1 + iHEAL visit) analyses focussing on short-term (immediately post-intervention) and longer-term (1 year post-intervention) effects. Selected process evaluation data were summarized using descriptive statistics.

RESULTS

Of 331 women enrolled, 175 were randomized to iHEAL (135 who engaged in 1 + visits) and 156 to control. Women who received iHEAL showed significantly greater short-term improvement in Quality of Life compared to the control group, with these effects maintained 1 year later. Changes in PTSD Symptoms also differed significantly by group, with weaker initial effects that were stronger 1 year post-intervention. Significant moderate, short- and longer-term group effects were also observed for Depression and Confidence in Managing Daily Life. IPV Severity decreased for both groups, with significant immediate effects in favour of the intervention group that grew stronger 1 year post-intervention. There were no changes in Chronic Pain.

CONCLUSION

iHEAL is an effective, acceptable and safe intervention for diverse groups of women with histories of IPV. Trial results provide a foundation for implementation and ongoing evaluation in health care settings and systems. Delayed effects noted for PTSD Symptoms and IPV Severity suggest that longer-term assessment of these outcomes may be needed in trials of IPV interventions.

TRIAL REGISTRATION

Clinicaltrials.gov ID NCT03573778 (Registered on June 29, 2018).

Providing Gender Sensitive and Responsive Trauma-Informed Psychiatric Nursing Care. How Hard Can It Be?

This paper addresses the challenge of providing gender sensitive and responsive trauma-informed care (TIC) in psychiatric nursing practice. Gender identity, gender subordination, and gender-related trauma history are examined as three key individual-level factors that affect nurses' capacity to engage therapeutically to provide gender sensitive and responsive TIC. Using Peplau's Interpersonal Theory and building on a shared trauma and resilience model, gender-sensitive and responsive TIC is situated within interpersonal science and the ability of the psychiatric nurse to attune to her own and her patient's gender ideologies. Strategies for transforming practice including self-reflection, self-compassion, and peer and supervisor support are reviewed. Noting the import of the practice environment, several observations of changes needed at the level of the unit, organization, and society to effect gender equitable policies that enable the implementation of gender-sensitive and responsive TIC are made.

Cultural collectivism, intimate partner violence, and women's mental health: An analysis of data from 151 countries

Culture, defined as the distinctive, learned beliefs and patterns of behavior that are particular to a given group or community, is a key determinant of mental health. The cultural dimension of individualism-collectivism, which measures the extent to which a given society accords importance to individuals as opposed to larger groups, has been associated with cross-national variations in mental health outcomes such as depression and suicide. However, this cultural dimension is also associated with variations in the frequency of intimate partner violence (IPV), which has a significant and sustained adverse impact on women's mental health. This study examines the relationships between individualism-collectivism, the frequency of IPV, and rates of depression and suicide in women, based on data from 151 countries. In this data set, IPV was significantly associated with age-standardized rates of depression and suicide in women, even after adjusting for demographic variables. Cultural collectivism was positively correlated with IPV, but this relationship was significantly influenced by national income and women's educational attainment. In multivariate analyses, IPV, but not cultural collectivism, remained significantly associated with depression in women. These results highlight the importance of screening for and addressing IPV in women seeking mental health care, particularly in low- and middle-income countries where cultural and economic factors may both increase the risk of IPV and delay or impede its reporting.

Post-separation abuse: A literature review connecting tactics to harm

Post-separation abuse is a pervasive societal and public health problem. This literature review aims to critically synthesize the evidence on tactics and consequences of post-separation abuse. We examined 48 published articles in the US and Canada from 2011 through May 2022. Post-separation abuse encompasses a broad range of tactics perpetrated by a former intimate partner including patterns of psychological, legal, economic, and mesosystem abuse as well as weaponizing children. Functional consequences include risk of lethality and deprivation of fundamental human needs. Connecting tactics of post-separation abuse to harms experienced by survivors and their children is crucial for future research, policy, and intervention work to promote long-term safety, health, and well-being of children and adult survivors.

Long-Term Recovery from Intimate Partner Violence: Recovery and Hope

Recovery is a preferred outcome for assessing intervention effectiveness in the context of intimate partner violence (IPV), but measurement tools are in nascent form. It is therefore unclear what the recovery potential of survivors may be. A national online survey explored the self-rated recovery progress of Australian women (n = 1116), using visual analog scales (VAS) for recovery, hope, and other demographic variables. Findings show that many women rated themselves as completely recovered (14% of the eligible sample and 22% of the women who had left their partner > 10 years previously). However, most women experienced recovery as an ongoing process of healing (81%) and some women made little recovery progress (5%). Nevertheless, 77% of women who had separated >10 years ago rated their recovery as significant (scores of >70/100). Surprisingly, hope and recovery scores were only moderately correlated. This requires further investigation to determine what impacts on hope in long-term recovery, and how subjective and objective measures of hope and recovery vary in the context of IPV. The VAS was an efficient unidimensional measure for an online survey and is proposed for use in clinical and service contexts requiring subjective measures.

Structural and construct validity of the Quality of Life Scale among Canadian women with histories of intimate partner violence

OBJECTIVES

To evaluate the structural and construct validity, and internal consistency of the Quality of Life Scale among Canadian women with histories of intimate partner violence.

METHODS

Consistent with COSMIN Guidelines, a secondary analysis was conducted using data from a community sample of 250 adult (over 18 years) Canadian women with histories of partner violence and who participated in Wave 5 of the longitudinal Women's Health Effects Study. Data were collected 4 years after baseline using structured interviews that included the Quality of Life Scale and two mental symptom scales (Center for Epidemiological Depression Scale and Davidson Trauma Scale) used to assess construct validity of the Quality of Life Scale.

RESULTS

Confirmatory factor analysis in MPLUS 8 with maximum likelihood estimation supported the hypothesized unidimensional structure of the 9-item Quality of Life Scale based on acceptable fit indices. Internal consistency, estimated using Cronbach's alpha and composite reliability, were .91 and .92, respectively, with item-total correlations ranging from .46 to .84. Inter-item correlation coefficients (range = .30-.79), suggesting that all items contribute to the total score. As hypothesized, the quality of life total score was negatively related to the total scores on both the Center for Epidemiologic Studies-Depression (r = -.739) and Davidson Trauma Scale (r = -.537), providing evidence of construct validity of the Quality of Life Scale.

CONCLUSION

The Quality of Life Scale is a brief, reliable, valid, unidimensional self-report measure appropriate for use with women who have experienced partner violence. By addressing an important measurement gap, results of this study have potential to advance research on women's quality of life in the context of partner violence, including improving the evaluation of a growing body of advocacy and health interventions designed to support women's healing and well-being.