Interpersonal violence among women seeking welfare: unraveling lives

Persistence and transience of food insecurity and predictors among residents of two disadvantaged communities in South Carolina

BACKGROUND

Little is known about patterns of household food insecurity (HFI) across more than two time points in adults in the United States, the frequency predictors of different trajectories. The distinctions between persistent and transient food insecurity trajectories may be crucial to developing effective interventions.

OBJECTIVE

To characterize dominant trajectories of food security status over three time points between 2013 and 2016 and identify demographic, socioeconomic and health-related predictors of persistent and transient HFI.

DESIGN

Cohort study in disadvantaged communities in South Carolina.

SETTING

and subjects: 397 middle-aged participants, predominantly female, African American, living in USDA-designated food deserts.

MAIN OUTCOME MEASURE

Household food insecurity over time using the 18-item USDA's Household Food Security Survey Module.

STATISTICAL ANALYSES PERFORMED

Descriptive analyses of food security trajectories and multinomial regression analyses.

RESULTS

At baseline (2013-2014), 61% of households reported HFI during the previous 12 months, which decreased to 54% in 2015 and to 51% in 2016. Only 27% of households were persistently food secure, 36% experienced transient and 37% persistent food insecurity. Female sex (OR 2.7, 95%CI 1.2-5.9), being married or living with a partner (OR 2.4, 95CI% 1.1-5.3) and fair health status (OR 4.4, 95%CI 2.2-8.8) were associated with increased odds of persistent food insecurity. Fair health was also a significant predictor of transient food insecurity.

CONCLUSIONS

These findings suggest that future research should focus on persistent versus transient trajectories separately and that tailored interventions may be needed to make progress on alleviating food insecurity among disadvantaged communities.

Exposição à violência comunitária e familiar e autoavaliação de saúde na população brasileira

RESUMO: Introdução: Os impactos negativos isolados da violência comunitária e da violência familiar na autoavaliação de saúde (AAS) dos indivíduos são conhecidos, mas existe pouca evidência sobre o efeito combinado desses dois tipos de violência interpessoal. Objetivo: Analisar a associação entre a exposição à violência comunitária/por desconhecidos e à violência familiar/por conhecidos e a AAS negativa, distinguindo o tipo de violência sofrido e também considerando sua exposição cumulativa. Métodos: Estudo epidemiológico de corte transversal desenvolvido com os dados da Pesquisa Nacional de Saúde (PNS) 2013. Foram realizados modelos de regressão logística multinominal brutos e ajustados para teste de associação das variáveis. Resultados: Todos os tipos de violência analisados se associaram à AAS negativa. A violência interpessoal comunitária/por desconhecidos isolada esteve associada à AAS como regular (odds ratio - OR=1,38) e ruim (OR = 1,79). A exposição à violência familiar/por conhecidos mostrou-se associada à autoavaliação regular (OR = 1,52) e ruim (OR = 2,70). A exposição concomitante às duas violências mostrou-se associada à avaliação regular (OR = 4,00) e ruim da saúde (OR = 7,81), sendo essa associação de maior magnitude que aquelas para as violências isoladas. Conclusão: O efeito cumulativo da exposição à violência familiar/por conhecido e comunitária/por desconhecido potencializa a avaliação negativa do estado de saúde. Os profissionais de saúde devem estar atentos à polivitimização e ao seu impacto na saúde de vítimas que acessam os serviços de saúde.

Food insecurity, childhood hunger and caregiver life experiences among households with children in South Carolina, USA

OBJECTIVE

We explored how positive and negative life experiences of caregivers are associated with household food insecurity.

DESIGN

The Midlands Family Study (MFS) was a cross-sectional study with three levels of household food security: food secure, food insecure without child hunger and food insecure with child hunger. Ordinal logistic regression analysis was used for analyses of negative and positive life experiences (number, impact, type) associated with food insecurity.

SETTING

An eight-county region in South Carolina, USA, in 2012-2013.

PARTICIPANTS

Caregivers (n 511) in households with children.

RESULTS

Caregivers who reported greater numbers of negative life experiences and greater perceived impact had increased odds of household food insecurity and reporting their children experienced hunger. Each additional negative life experience count of the caregiver was associated with a 16 % greater odds of food insecurity without child hunger and a 28 % greater odds of child hunger. Each one-unit increase in the negative impact score (e.g. a worsening) was associated with 8 % higher odds of food insecurity without child hunger and 12 % higher odds of child hunger. Negative work experiences or financial instability had the strongest association (OR = 1·8; 95 % CI 1·5, 2·2) with child hunger. Positive life experiences were generally not associated with food security status, with one exception: for each unit increase in the number of positive experiences involving family and other relationships, the odds of child hunger decreased by 22 %.

CONCLUSIONS

More research is needed to understand approaches to build resilience against negative life experiences and strengthen positive familial, community and social relationships.

Health of Women Surviving Intimate Partner Violence: Impact of Injury and Fear

This study examined associations between experiencing physical violence and stalking perpetrated by an intimate partner, and the number of health problems women reported. The sample of 2,626 women who survived intimate partner violence (IPV) was extracted from the National Intimate Partner and Sexual Violence Survey 2010. Results showed associations between greater number of health problems and the following seven factors: injury, fear, poor mental health, advanced age, less education, lower income, and marriage; no association was found between number of health problems and number of incidents of physical violence, stalking, or both (in preceding year). The results imply that IPV has long-term adverse impacts on women's physical health.

Trauma-informed Temporary Assistance for Needy Families (TANF): A Randomized Controlled Trial with a Two-Generation Impact

Temporary Assistance for Needy Families (TANF) has limited success in building self-sufficiency, and rarely addresses exposure to trauma as a barrier to employment. The objective of the Building Wealth and Health Network randomized controlled trial was to test effectiveness of financial empowerment combined with trauma-informed peer support against standard TANF programming. Through the method of single-blind randomization we assigned 103 caregivers of children under age six into three groups: control (standard TANF programming), partial (28-weeks financial education), and full (same as partial with simultaneous 28-weeks of trauma-informed peer support). Participants completed baseline and follow-up surveys every 3 months over 15 months. Group response rates were equivalent throughout. With mixed effects analysis we compared post-program outcomes at months 9, 12, and 15 to baseline. We modeled the impact of amount of participation in group classes on participant outcomes. Despite high exposure to trauma and adversity results demonstrate that, compared to the other groups, caregivers in the full intervention reported improved self-efficacy and depressive symptoms, and reduced economic hardship. Unlike the intervention groups, the control group reported increased developmental risk among their children. Although the control group showed higher levels of employment, the full intervention group reported greater earnings. The partial intervention group showed little to no differences compared with the control group. We conclude that financial empowerment education with trauma-informed peer support is more effective than standard TANF programming at improving behavioral health, reducing hardship, and increasing income. Policymakers may consider adapting TANF to include trauma-informed programming.

Family violence in a sample of treatment-seeking gamblers: the effect of having dependent children

This study investigated the effect of problem gambler gender on the relationship between the gambler having dependent children (younger than 18 years) living at home and the gambler perpetrating or being a victim of family violence. The sample comprised 164 help-seeking gamblers (43% female; 37% with dependent child/ren) recruited from three national gambling treatment services in New Zealand. Family violence was measured using a modified version of the HITS scale covering physical, psychological, verbal, emotional and sexual violence. Forty-nine percent of participants reported being a victim of violence and 43% had perpetrated violence. Multivariable logistic regression modelling was conducted, adjusting in sequence for significant socio-demographic, psychosocial and gambling factors. The relationship between having dependent children and being a victim of family violence was gender-related. Female gamblers living with dependent children reported more family violence perpetration and victimisation than male gamblers living with dependent children. Female gamblers with dependent children living at home had greater odds of being a victim of family violence than male gamblers without dependent children living at home. This relationship remained when adjusted for contextual factors of being a victim (ethnicity, income support status, and feelings of inadequacy) in this sample. A similar gender effect of having dependent children living at home on violence perpetration disappeared when known psychosocial contextual factors of violence perpetration (aggression, difficulties in emotion regulation, drug issue in the family, and interpersonal support) were taken into account. These findings suggest the value of coordinated approaches between gambling treatment services and programmes supporting vulnerable families in order to identify vulnerable families and put support mechanisms in place.

The Building Wealth and Health Network: methods and baseline characteristics from a randomized controlled trial for families with young children participating in temporary assistance for needy families (TANF)

BACKGROUND

Families with children under age six participating in the Temporary Assistance for Needy Families Program (TANF) must participate in work-related activities for 20 h per week. However, due to financial hardship, poor health, and exposure to violence and adversity, families may experience great difficulty in reaching self-sufficiency. The purpose of this report is to describe study design and baseline findings of a trauma-informed financial empowerment and peer support intervention meant to mitigate these hardships.

METHODS

We conducted a randomized controlled trial of a 28-week intervention called Building Wealth and Health Network to improve financial security and maternal and child health among caregivers participating in TANF. Participants, recruited from County Assistance offices in Philadelphia, PA, were randomized into two intervention groups (partial and full) and one control group. Participants completed questionnaires at baseline to assess career readiness, economic hardship, health and wellbeing, exposure to adversity and violence, and interaction with criminal justice systems.

RESULTS

Baseline characteristics demonstrate that among 103 participants, there were no significant differences by group. Mean age of participants was 25 years, and youngest child was 30 months. The majority of participants were women (94.2 %), never married (83.5 %), unemployed (94.2 %), and without a bank account (66.0 %). Many reported economic hardship (32.0 % very low household food secure, 65.0 % housing insecure, and 31.1 % severe energy insecure), and depression (57.3 %). Exposure to adversity was prevalent, where 38.8 % reported four or more Adverse Childhood Experiences including abuse, neglect and household dysfunction. In terms of community violence, 64.7 % saw a seriously wounded person after an incident of violence, and 27.2 % had seen someone killed. Finally, 14.6 % spent time in an adult correctional institution, and 48.5 % of the fathers of the youngest child spent time in prison.

CONCLUSIONS

Baseline findings demonstrate that caregivers participating in TANF have suffered significant childhood adversity, adult violence exposure, and poverty-related stressors that can limit workforce success. High prevalence of housing and food insecurity, exposure to adversity, violence and criminal justice systems demands comprehensive programming to support families. Trauma-informed approaches to career readiness such as the Building Wealth and Health Network offer opportunities for potential success in the workforce.

TRIAL REGISTRATION

This study is retrospectively registered with ClinicalTrials.gov. The Identifier is: NCT02577705 The Registration date is October 13, 2015.

Childhood Adversity and Adult Reports of Food Insecurity Among Households With Children

INTRODUCTION

Exposure to childhood adversity, including abuse, neglect, and household dysfunction, is associated with negative long-term health and economic outcomes. Little is known about how adversity exposure in parents' early lives may be related to later food insecurity for parents and their children. This study investigated the association between female caregivers' adverse childhood experiences (ACEs) and household and child food insecurity, taking into account depressive symptoms.

METHODS

This study used cross-sectional data from 1,255 female caregivers of children aged <4 years surveyed in an urban clinical setting from March 2012 through June 2014. Measures included sociodemographic characteristics; caregivers' ACEs, including abuse, neglect, and household dysfunction; depressive symptoms; and household and child food insecurity. Multinomial and logistic regression analyses assessed the relationship among ACEs, depressive symptoms, and household and child food security status.

RESULTS

Caregiver depressive symptoms modified associations between ACEs and food insecurity level. After adjusting for covariates, caregivers reporting both depressive symptoms and four or more ACEs were 12.3 times as likely to report low food security (95% CI=6.2, 24.7); 28.8 times as likely to report very low food security (95% CI=12.8, 64.8); and 17.6 times as likely to report child food insecurity (95% CI=7.3, 42.6) compared with those reporting no depressive symptoms and no ACEs.

CONCLUSIONS

Depressive symptoms and ACEs were independently associated with household and child food insecurity, and depressive symptoms modified the association between ACEs and household and child food insecurity. Comprehensive policy interventions incorporating nutrition assistance and behavioral health may address intergenerational transmission of disadvantage.

Those harmed by others' drinking in the US population are more depressed and distressed

INTRODUCTION AND AIMS

Harms from second-hand smoke were instrumental in enacting tobacco controls. Documenting negative impacts of harms from others' drinking (also called second-hand effects of drinking) is vital to increase political will for optimal alcohol policies. We assessed associations between harms from others' drinking and depression in a national sample of US adults.

DESIGN AND METHODS

Using the landline sample from the 2010 National Alcohol Survey (n = 5388), weighted logistic regression models adjusting for alcohol problems in family of origin, respondent drinking pattern (volume and heaviest drinking), poverty and other demographics were used to analyse associations between experiencing harms from others' drinking in the last 12 months with mild to moderate depression (8-item Center for Epidemiologic Studies Depression scale; alpha = 0.92; using cut point ≥8) and current distress.

RESULTS

Past 12 month family/marital harms, financial troubles, assaults, and vandalised property attributed to others' drinking were each associated with higher depression scores (all P < 0.001). In a combined model, all harms other than assaults remained highly significant. Similar patterns were found for current distress, but with some specific differences because of measurement and analytic approaches chosen also evident.

DISCUSSION

Findings suggest recently experiencing particular harms from others' drinking significantly affects mental health (both depression and distress). This confirms in a US population results recently reported in Australasian samples.

CONCLUSIONS

Studies that quantify the extent to which heavy drinkers victimise others are important for alcohol policy. [Greenfield TK, Karriker-Jaffe KJ, Kerr WC, Ye Y, Kaplan LM. Those harmed by others' drinking in the US population are more depressed and distressed. Drug Alcohol Rev 2015;●●:●●-●●].

The relationship between childhood adversity and food insecurity: 'It's like a bird nesting in your head'

OBJECTIVE

Adverse childhood experiences, including abuse, neglect and household instability, affect lifelong health and economic potential. The present study investigates how adverse childhood experiences are associated with food insecurity by exploring caregivers' perceptions of the impact of their childhood adversity on educational attainment, employment and mental health.

DESIGN

Semi-structured audio-recorded in-person interviews that included (i) quantitative measures of maternal and child health, adverse childhood experiences (range: 0-10) and food security using the US Household Food Security Survey Module; and (ii) qualitative audio-recorded investigations of experiences with abuse, neglect, violence and hunger over participants' lifetimes.

SETTING

Households in Philadelphia, PA, USA.

SUBJECTS

Thirty-one mothers of children <4 years old who reported low or very low household food security.

RESULTS

Twenty-one caregivers (68 %) reported four or more adverse childhood experiences, and this severity was significantly associated with reports of very low food security (Fisher's exact P=0·021). Mothers reporting emotional and physical abuse were more likely to report very low food security (Fisher's exact P=0·032). Qualitatively, participants described the impact of childhood adverse experiences with emotional and physical abuse/neglect, and household substance abuse, on their emotional health, school performance and ability to maintain employment. In turn, these experiences negatively affected their ability to protect their children from food insecurity.

CONCLUSIONS

The associations between mothers' adverse experiences in childhood and reports of current household food security should inspire researchers, advocates and policy makers to comprehensively address family hardship through greater attention to the emotional health of caregivers. Programmes meant to address nutritional deprivation and financial hardship should include trauma-informed approaches that integrate behavioural interventions.

Patterns and Predictors of Service Use Among Women Who Have Separated from an Abusive Partner

Using baseline data from a survey of 309 Canadian women recently separated from an abusive partner, we investigated patterns of access to health, social, legal, and violence-specific services and whether abuse history and social and health variables predict service use. We compared rates of service use to population rates, and used logistic regression to identify determinants of use. Service use rates were substantially higher than population estimates in every category, particularly in general and mental health sectors. Although women were confident in their ability to access services, they reported substantial unmet need, difficulty accessing services, and multiple barriers. The strongest unique predictors of use varied across service type. Health variables (high disability chronic pain, symptoms of depression and PTSD), low income, and mothering were the most consistent predictors. Service providers and policy makers must account for social location, abuse history, and health status of Intimate Violence (IPV) survivors. Strategies to enhance access to primary health care services, and to create a system of more integrated, accessible services, are required.

Domestic Violence and Treatment Seeking: A Longitudinal Study of Low-Income Women and Mental Health/Substance Abuse Care

A study with 591 low-income women examined domestic violence's role in treatment seeking for mental health or substance abuse problems. (The women resided in one of two California counties.) Following Aday's behavioral model of health services utilization, the secondary data analysis considered the women's need, enabling, and predisposing factors. Generalized estimating equations analyzed the women's longitudinal records of treatment seeking. Results showed that those in the sample who were likely to seek treatment had experienced three or more controlling behaviors and only one abusive behavior. Multivariate data analysis showed treatment-seeking women were likely to be white and older; responsible for few dependent children; not graduates of high school; employed; not participating in Medicaid; diagnosed; and perceiving a need for treatment. The implications of these results for services and policies are discussed.

Explaining aboriginal/non-aboriginal inequalities in postseparation violence against Canadian women: application of a structural violence approach

Adopting a structural violence approach, we analyzed 2004 Canadian General Social Survey data to examine Aboriginal/non-Aboriginal inequalities in postseparation intimate partner violence (IPV) against women. Aboriginal women had 4.12 times higher odds of postseparation IPV than non-Aboriginal women (p < .001). Coercive control and age explained most of this inequality. The final model included Aboriginal status, age, a seven-item coercive control index, and stalking, which reduced the odds ratio for Aboriginal status to 1.92 (p = .085) and explained 70.5% of the Aboriginal/non-Aboriginal inequality in postseparation IPV. Research and action are needed that challenge structural violence, especially colonialism and its negative consequences.

Beaten and poor? A study of the long-term economic situation of women victims of severe violence

This 10-year follow-up study based on Swedish national registers compares the economic situation of women victims of violence leading to hospitalization (n = 6,085) to nonexposed women (n = 55,016) in 1992 to 2005. Women exposed to severe violence had a poorer financial situation prior to the assault. Violence seems to heavily reinforce this pattern, indicating a continued need of support from the social work profession. Assaulted women had a worse income development, lower odds for being in employment, and higher odds for having low incomes and means tested social assistance during the 10-year follow-up, independent of having children or not.

Troubled times, troubled relationships: how economic resources, gender beliefs, and neighborhood disadvantage influence intimate partner violence

We evaluate race/ethnicity and nativity-based disparities in three different types of intimate partner violence (IPV) and examine how economic hardship, maternal economic dependency, maternal gender beliefs, and neighborhood disadvantage influence these disparities. Using nationally representative data from urban mothers of young children who are living with their intimate partners (N = 1,886), we estimate a series of unadjusted and adjusted logit models on mothers' reports of physical assault, emotional abuse, and coercion. When their children were age 3, more than one in five mothers were living with a partner who abused them. The prevalence of any IPV was highest among Hispanic (26%) and foreign-born (35%) mothers. Economic hardship, economic dependency on a romantic partner, and traditional gender beliefs each increased women's risk for exposure to one or more types of IPV, whereas neighborhood conditions were not significantly related to IPV in adjusted models. These factors also explained most of the racial/ethnic and nativity disparities in IPV. Policies and programs that reduce economic hardship among women with young children, promote women's economic independence, and foster gender equity in romantic partnerships can potentially reduce multiple forms of IPV.

Intimate partner violence and welfare participation: a longitudinal causal analysis

This longitudinal study examined the temporal-ordered causal relationship between intimate partner violence (IPV), five mental disorders (depression, generalized anxiety disorder, social phobia, panic attack, posttraumatic stress disorder [PTSD]), alcohol abuse/dependence, drug abuse/dependence, treatment seeking (from physician, counselor, and self-help group), employment, child support, and welfare participation. It was a secondary data analysis of records of 571 women; the records were extracted from the study "Violence Against Women and the Role of Welfare Reform" (VAWRWR). Results from generalized estimating equations (GEE) showed that experiencing controlling behaviors reduced likelihood of welfare participation whereas experiencing physical abuse increased it. Significant impact on welfare participation was wielded by panic attack, drug abuse/dependence, and employment; treatment seeking and child support made no significant impact. The study found no significant mediating effect wielded by panic attack, drug abuse/dependence, employment, or child support on welfare participation's relationship to controlling behaviors or physically abusive behaviors experienced. Implications for intervention are discussed.

Reconsidering the effects of poverty and social support on health: a 5-year longitudinal test of the stress-buffering hypothesis

Prior research in the general population has found that social support can buffer the adverse effects of stressors on health. However, both stressors and social support may be qualitatively different for those living in urban poverty. We examined the effects of social support and poverty-specific stressors on self-rated health. We used data from the Welfare Client Longitudinal Survey (WCLS), a 5-year longitudinal study of 718 public aid recipients. We measured received social support and "net social support," defined as the difference between support received and that given to others. We used restricted cubic splines to model the stress-buffering effects of social support on self-rated health as a function of stressful life events and neighborhood disorder. Increased exposure to stressors was associated with poorer self-rated health. Evidence of stress buffering was confined to those with the heaviest exposure to stressors, and its effects decreased across increasing levels of social support. Analyses using net social support had generally more modest effects than those using received social support. Social support does not buffer the effects of stressors on health uniformly for individuals living in conditions of urban poverty. Researchers and policymakers should be cautious in overestimating the beneficial effects that social support may have on health for marginalized populations.

On the declining health status of welfare caseloads: emerging dilemmas for serving the poor

An emerging concern for public policy is welfare reform's potential to inadvertently affect caseload composition by increasing the proportion of recipients with health-related barriers to employment. The authors examine this using data from the Welfare Client Longitudinal Study, an in-depth case study of a large California county. Through quantitative analyses, they examine the extent of change in health-related problems since welfare reform and their potential to progressively impact overall composition of the caseload. They augment this with qualitative data on how local welfare providers are responding to the health-related needs of aid recipients. Results suggest that the burden of health-related problems is growing and that welfare providers may be poorly equipped to respond effectively on their own. The changing composition of welfare caseloads may foster several new policy dilemmas that demand broader attention: states and localities may face difficulties meeting federal workforce participation requirements, may need to restructure welfare-to-work programs to serve a more functionally impaired population, and may need to take steps to better integrate health and welfare services at the local level.

When crises collide: how intimate partner violence and poverty intersect to shape women's mental health and coping?

Until recently, the connection between intimate partner violence (IPV) and persistent poverty had been largely ignored. Recent research indicates, however, that the two phenomena cooccur at high rates; produce parallel effects; and, in each other's presence, constrain coping options. Therefore, both external situational, and internal psychological difficulties are missed when women contending with both poverty and IPV are viewed through the lens of just one or just the other. This article describes mental health consequences for women who contend with both partner violence and poverty. It proposes that the stress, powerlessness, and social isolation at the heart of both phenomena combine to produce posttraumatic stress disorder, depression, and other emotional difficulties. The article also introduces the term ''survival-focused coping'' to describe women's methods of coping with IPV in the context of poverty and highlights the role that domestic violence advocates, mental health providers, and researchers can play in addressing these tightly intertwined phenomena.

The long-term health consequences of relationship violence in adulthood: an examination of low-income women from Boston, Chicago, and San Antonio

OBJECTIVES

We examined the long-term health consequences of relationship violence in adulthood.

METHODS

Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables.

RESULTS

Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health.

CONCLUSIONS

Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women.

"Epidemiological criminology": coming full circle

Members of the public health and criminal justice disciplines often work with marginalized populations: people at high risk of drug use, health problems, incarceration, and other difficulties. As these fields increasingly overlap, distinctions between them are blurred, as numerous research reports and funding trends document. However, explicit theoretical and methodological linkages between the 2 disciplines remain rare. A new paradigm that links methods and statistical models of public health with those of their criminal justice counterparts is needed, as are increased linkages between epidemiological analogies, theories, and models and the corresponding tools of criminology. We outline disciplinary commonalities and distinctions, present policy examples that integrate similarities, and propose "epidemiological criminology" as a bridging framework.

The effects of failing to include hard-to-reach respondents in longitudinal surveys

OBJECTIVES

We sought to determine whether failure to locate hard-to-reach respondents in longitudinal studies causes biased and inaccurate study results.

METHODS

We performed a nonresponse simulation in a survey of 498 low-income women who received cash aid in a California county. Our simulation was based on a previously published analysis that found that women without children who applied for General Assistance experienced more violence than did women with children who applied for Temporary Assistance to Needy Families. We compared hard-to-reach respondents whom we reinterviewed only after extended follow-up effort 12 months after baseline with other respondents. We then removed these hard-to-reach respondents from our analysis.

RESULTS

Other than having a greater prevalence of substance dependence (14% vs 6%), there were no significant differences between hard- and easy-to-reach respondents. However, excluding the hard to reach would have decreased response rates from 89% to 71% and nullified the findings, a result that did not stem primarily from reduced statistical power.

CONCLUSIONS

The effects of failure to retain hard-to-reach respondents are not predicable based on respondent characteristics. Retention of these respondents should be a priority in public health research.

Stress, social support and problem drinking among women in poverty

AIMS

Previous studies have found that stress contributes to problem drinking, while social support can buffer its effects. However, these studies are confined largely to middle-class and general populations. We extend what is known by examining how the unique stressors and forms of social support experienced by women in poverty impact alcohol problems over a 4-year time-period.

DESIGN, SETTING AND PARTICIPANTS

This prospective study used generalized estimating equations (GEE) transition modeling and four annual waves of survey data from 392 American mothers receiving Temporary Assistance for Needy Families (TANF) in a large Northern California county.

MEASUREMENTS

We examined the effects of neighborhood disorder, stressful life events and economic hardship on psychological distress and problem drinking over time, and whether social support moderated these relationships for women in poverty.

FINDINGS

Neighborhood disorder and stressful life events increased significantly the risk for problem drinking, largely through their effect on psychological distress. We found little evidence, however, that social support buffers poor women from the effects of these stressors.

CONCLUSIONS

Women in poverty are exposed to severe, chronic stressors within their communities and immediate social networks which increase vulnerability to psychological distress and problem drinking. The finding that social support does not buffer stress among these women may reflect their high level of exposure to stressors, as well as the hardships and scarce resources within their networks. If the 'private safety net' of the social network fails to provide a strong buffer, more effective environmental interventions that reduce exposure to stressors may be needed to prevent alcohol problems in poor women's lives.

Intimate partner violence in women hospitalized on an internal medicine service: prevalence and relationship to responses to the review of systems

BACKGROUND

Although intimate partner violence is common, the prevalence in patients hospitalized on internal medicine services and whether it is associated with numerous positive responses to the review of systems are not known.

OBJECTIVE

The objective of this study was to assess the prevalence of intimate partner violence in women hospitalized on an internal medicine service and to determine whether it is associated with the number or types of positive responses to the review of systems.

DESIGN

This was a prospective, cross-sectional survey.

SETTING

The setting was a university-affiliated public hospital.

PATIENTS

The patients were women, 18 to 60 years old, hospitalized on an internal medicine service.

MEASUREMENTS

The measurements were responses to screens for intimate partner violence and a review-of-systems questionnaire.

RESULTS

Of the 78 women asked to participate, 72 agreed (92%). The prevalences of experiencing intimate partner violence at any time in the patient's life or within the year prior to presentation were 61% and 22%, respectively. Women with a history of intimate partner violence and women without a history of intimate partner violence had 11 +/- 4 (mean +/- standard deviation) and 8 +/- 5 positive responses to the review of systems, respectively (P < 0.01). Women with 10 or more positive responses were more likely to have a history of intimate partner violence than those with 9 or fewer (odds ratio = 4.82, confidence interval = 1.63-14.23).

CONCLUSIONS

Intimate partner violence is common in women hospitalized in an internal medicine service of a university-affiliated public hospital. Although numerous somatic complaints are associated with a history of intimate partner violence, the high prevalence of this problem warrants screening of all women admitted to internal medical services.

Reconceptualizing and operationalizing context in survey research on intimate partner violence

Survey research in the field of intimate partner violence is notably lacking in its attention to contextual factors. Early measures of intimate partner violence focused on simple counts of behaviors, yet attention to broader contextual factors remains limited. Contextual factors not only shape what behaviors are defined as intimate partner violence but also influence the ways women respond to victimization, the resources available to them, and the environments in which they cope with abuse. This article advances methods for reconceptualizing and operationalizing contextual factors salient to the measurement of intimate partner violence. The analytic focus of the discussion is on five dimensions of the social context: the situational context, the social construction of meaning by the survivor, cultural and historical contexts, and the context of systemic oppression. The authors consider how each dimension matters in the measurement of intimate partner violence and offer recommendations for systematically assessing these contextual factors in future research.

Welfare receipt and substance-abuse treatment among low-income mothers: the impact of welfare reform

OBJECTIVES

We explored changing relations between substance use, welfare receipt, and substance-abuse treatment among low-income mothers before and after welfare reform.

METHODS

We examined annual data from mothers aged 18 to 49 years in the 1990-2001 National Household Survey of Drug Abuse and the 2002 National Survey of Drug Use and Health. Logistic regression was used to examine determinants of treatment receipt.

RESULTS

Among low-income, substance-using mothers, the proportion receiving cash assistance declined from 54% in 1996 to 38% in 2001. The decline was much smaller (37% to 31%) among low-income mothers who did not use illicit substances. Low-income, substance-using mothers who received cash assistance were much more likely than other low-income, substance-using mothers to receive treatment services. Among 2002 National Survey of Drug Use and Health respondents deemed "in need" of substance-abuse treatment, welfare recipients were significantly more likely than nonrecipients to receive such services (adjusted odds ratio=2.31; P<.05). Controlling for other factors, welfare receipt was associated with higher prevalence of illicit drug use. Such use declined among both welfare recipients and other mothers between 1990 and 2001.

CONCLUSIONS

Welfare is a major access point to identify and serve low-income mothers with substance-use disorders, but it reaches a smaller proportion of illicit drug users than it did prereform. Declining welfare receipt among low-income mothers with substance abuse disorders poses a new challenge in serving this population.