Health-seeking behaviour during times of illness among urban poor women: a cross-sectional study

BACKGROUND

Urban poor women face dual challenges regarding gender inequalities and urban poverty, which make them more likely to have health problems and affect their health-seeking behaviour. This study aimed to determine the prevalence of health-seeking behaviour during times of illness and predictors of sought care among urban poor women in Kuala Lumpur, Malaysia.

METHODS

This cross-sectional study was performed among 340 randomly selected women residents from April to May 2023. Data was collected using a validated and reliable self-administered questionnaire and analysed using SPSS version 28.0 software. The dependent variable in this study was health-seeking behaviour during times of illness, while the independent variables were sociodemographic characteristics, socioeconomic characteristics, medical conditions, women's autonomy in decision-making, social support, perceived stigma, and attitude towards health. Multiple logistic regression was used to identify the predictors of sought care during times of illness.

RESULTS

Study response rate was 100%, where 72.4% sought care during times of illness. Being non-Malay (AOR = 4.33, 95% CI: 1.847, 10.161), having healthcare coverage (AOR = 2.60, 95% CI: 1.466, 4.612), rating their health as good (AOR = 1.87, 95% CI: 1.119, 3.118), and having pre-existing chronic diseases (AOR = 1.92, 95% CI: 1.130, 3.271) were identified as predictors of sought care during times of illness.

CONCLUSION

The present study showed that health-seeking behaviour during times of illness among the participants was appropriate. Health promotion and education, with a focus on educating and raising awareness about the importance of seeking timely healthcare, are crucial to improving health-seeking behaviour among urban poor women. Collaboration with relevant stakeholders is needed to develop comprehensive strategies to improve access to healthcare facilities for these women.

Trauma-specific mindfulness-based cognitive therapy for women with post-traumatic stress disorder and a history of domestic abuse: intervention refinement and a randomised feasibility trial (coMforT study)

BACKGROUND

Women who have experienced domestic violence and abuse (DVA) are at increased risk of developing post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD). In 2014-2015, we developed a prototype trauma-specific mindfulness-based cognitive therapy curriculum (TS-MBCT) for the treatment of PTSD in a DVA population. This study aimed to refine the prototype TS-MBCT and evaluate the feasibility of conducting a randomised controlled trial (RCT) testing its effectiveness and cost-effectiveness.

METHODS

Intervention refinement phase was informed by evidence synthesis from a literature review, qualitative interviews with professionals and DVA survivors, and a consensus exercise with experts in trauma and mindfulness. We tested the refined TS-MBCT intervention in an individually randomised parallel group feasibility trial with pre-specified progression criteria, a traffic light system, and embedded process and health economics evaluations.

RESULTS

The TS-MBCT intervention consisted of eight group sessions and home practice. We screened 109 women in a DVA agency and recruited 20 (15 TS-MBCT, 5 self-referral to National Health Service (NHS) psychological treatment), with 80% follow-up at 6 months. Our TS-MBCT intervention had 73% uptake, 100% retention, and high acceptability. Participants suggested recruitment via multiple agencies, and additional safety measures. Randomisation into the NHS control arm did not work due to long waiting lists and previous negative experiences. Three self-administered PTSD/CPTSD questionnaires produced differing outcomes thus a clinician administered measure might work better. We met six out of nine feasibility progression criteria at green and three at amber targets demonstrating that it is possible to conduct a full-size RCT of the TS-MBCT intervention after making minor amendments to recruitment and randomisation procedures, the control intervention, primary outcomes measures, and intervention content. At 6 months, none of the PTSD/CPTSD outcomes ruled out a clinically important difference between trial arms indicating that it is reasonable to proceed to a full-size RCT to estimate these outcomes with greater precision.

CONCLUSIONS

A future RCT of the coMforT TS-MBCT intervention should have an internal pilot, recruit from multiple DVA agencies, NHS and non-NHS settings, have an active control psychological treatment, use robust randomisation and safety procedures, and clinician-administered measures for PTSD/CPTSD.

TRIAL REGISTRATION

ISRCTN64458065 11/01/2019.

When Child Welfare Caseworkers Intervene, Do Women Surviving IPV Obtain Recommended Services?

This study looked at 991 women surviving intimate partner violence (IPV), exploring several factors in their receipt of IPV services through the child welfare system. A secondary data analysis, the research used longitudinal data from the National Survey of Child and Adolescent Well-Being II, was conducted to evaluate the relationship between receiving IPV services and child welfare intervention and between such receipt and demographic characteristics. Women in the sample had been substantiated for maltreatment and had lifetime experience of IPV; 15% of these women had received IPV services. Generalized estimation equation results showed likelihood of receiving services increased when the case plan specified needed IPV services. Biological/adoptive mothers retaining custody of children were relatively unlikely to receive IPV services, as were lower income women. Receipt of services was relatively unlikely at the third-wave interview compared with the first-wave interview, but no difference in likelihood of receiving services was found between first- and second-wave interviews. In addition, likelihood of receiving services was not associated here with the number of recent IPV episodes, IPV maltreatment, mother's perceived engagement with caseworker, and mother's race/ethnicity, employment, and education. Some implications for practice are discussed.

Is Perceived Need for Action Among Women in Violent Relationships Nonlinear and, If So, Why?

Despite the prevalence and impact of partner violence, we understand little about women's action taking except that it seems an unpredictable, nonlinear process. This article determines the degree of nonlinearity in perceived need for help, legal action, or leaving among women in violent relationships. The participants included 143 women who experienced violence in the previous month, enrolled from six primary care clinics. Baseline surveys assessed background characteristics and factors which may affect perceived need for action. Multiple times series assessments of violence and need for action were collected daily for 8 weeks via telephone Interactive Voice Response. Measures of nonlinearity of violence, perceived need for help, legal action, and leaving were computed. Repeated measures ANOVA assessed differences across measures of nonlinearity. To identify factors contributing to nonlinearity, staged multiple regression assessed the relationship between nonlinearity measures and outcomes. Ninety-three women completed sufficient time series for nonlinearity assessment. Measures of nonlinearity were lower for need for legal action compared with needs for help and leaving. Regression analysis suggested that isolation, social networks, and lack of awareness contribute to nonlinearity. Women's perceived need for legal action and its level of nonlinearity were lowest compared with those of help seeking and leaving. Although its relative linearity suggests that the need for legal action may be the most predictable, its lower mean rating suggests that legal action is a low priority. Although need for help and leaving are of higher priorities, their nonlinearity suggests that intervention will not yield predictable results.

The coMforT study of a trauma-informed mindfulness intervention for women who have experienced domestic violence and abuse: a protocol for an intervention refinement and individually randomized parallel feasibility trial

Background

Domestic violence and abuse (DVA) is common and destructive to health. Post-traumatic stress disorder (PTSD) is a major mental health consequence of DVA. People who have experienced DVA have specific needs, arising from the repeated and complex nature of the trauma. The National Institute for Health and Care Excellence recommends more research on the effectiveness of psychological interventions for people who have experienced DVA. There is growing evidence that mindfulness-based interventions may help trauma symptoms.

Methods

Intervention refinement and randomized controlled feasibility trial. A prototype trauma-informed mindfulness-based cognitive therapy (TI-MBCT) intervention will be co-produced following qualitative interviews and consensus exercise with stakeholders. Participants in the feasibility trial will be recruited from DVA agencies in two geographical regions and randomized to receive either TI-MBCT or usual care (self-referral to the Improving Access to Psychological Therapies (IAPT) service). TI-MBCT will be delivered as a group-based eight-week program. It will not be possible to blind the participants or the assessors to the study allocation. The following factors will inform the feasibility of progressing to a fully powered trial: recruitment, retention, intervention fidelity, and the acceptability of the intervention and trial design to participants. We will also test the feasibility of measuring the following participant outcomes before and 6 months post-randomization: PTSD, dissociative symptoms, depression, anxiety, DVA re-victimization, self-compassion, and mother-reported child health. Process evaluation and economic analysis will be embedded within the feasibility trial.

Discussion

This study will lead to the development of a TI-MBCT intervention for DVA survivors with PTSD and inform the feasibility and design of a fully powered randomized controlled trial (RCT). The full trial will aim to determine the effectiveness and cost-effectiveness of a TI-MBCT intervention in improving the clinically important symptoms of PTSD in DVA survivors.

Trial registration

ISRCTN, ISRCTN64458065, Registered 11 January 2019.

Factors that Affect Choice of Mental Health Provider and Receipt of Outpatient Mental Health Treatment

According to the US Department of Health and Human Services, 91 million adults live in mental health professional shortage areas and 10 million individuals have serious mental illness (SMI). This study examines how the supply of psychiatrists, severity of mental illness, out-of-pocket costs, and health insurance type influence patients' decisions to receive treatment and the type of provider chosen. Analyses using 2012-2013 MarketScan Commercial Claims data showed that patients residing in an area with few psychiatrists per capita had a higher predicted probability of not receiving follow-up care (46.4%) compared with patients residing in an area with more psychiatrists per capita (42.5%), and those in low-psychiatrist-supply areas had a higher predicted probability of receiving prescription medication only (10.2 vs 7.6%). Patients with SMI were more likely than those without SMI to obtain treatment. A $25 increase in out-of-pocket costs had marginal impact on patients' treatment choices.

The impact of intimate partner violence, depressive symptoms, alcohol dependence, and perceived stress on 30-year cardiovascular disease risk among young adult women: A multiple mediation analysis

Intimate partner violence (IPV), the physical, sexual, psychological abuse or control by a former or current intimate partner, affects almost one-third of women in the United States. IPV exposure can result in many negative outcomes including physical injury, increased stress, and depression. Currently, there is a small, but, growing body of literature examining the link between IPV victimization and increased cardiovascular disease (CVD) risk among young adult women. To better prevent this negative outcome, it is imperative to understand what factors associated with IPV victimization may be increasing this risk. A secondary analysis of Wave IV of the Add Health study was conducted to examine possible factors mediating past year IPV exposure and 30-year CVD risk score including perceived stress, depressive symptoms, and alcohol dependence among a representative sample of young adult women in the United States. Multiple mediation analyses were run to examine the possible mediating factors in the relationship between IPV and CVD risk. In a multiple mediation model, the indirect effect of perceived stress became insignificant when depressive symptoms were introduced. The findings of this study reveal that 30-year CVD risk in the context of IPV victimization should continue to be examined among this population. The mediation models suggested the importance of stress and depression in the context of IPV and heart health. Screening for depression among women exposed to IPV should be considered as an important intervention point, not only to mitigate mental health issues, but to also help prevent the development of cardiovascular disease.

Racial Disparities in Intimate Partner Violence Examined Through the Multiple Disadvantage Model

This research adopted the perspective of the multiple disadvantage model to explore racial disparities in intimate partner violence (IPV) against women and IPV's links to social structural factors, social relationships, substance use, and health/mental health and access to related services. The study used data from 6,588 women who completed the National Violence Against Women Survey; linear regression was conducted separately for four ethnic groups. Results consistently showed physical assaults to increase with posttraumatic stress disorder symptoms. For African Americans, increases in assaults were linked to injury, disclosing IPV to friends/family as well as medical professionals, Medicaid use, and drug use; decreases, in turn, were linked to past assault by ex-partners. For Latinas, increases in assaults were associated with eight factors: being married, number of ex-partners, depression, disclosing IPV to friends/family and disclosing to mental-health professionals, drug use, alcohol abstinence, and partner's frequent alcohol use. For European Americans, increases in assaults were linked to number of ex-partners, injury, low income, Medicaid use, disclosing IPV to friends/family as well as mental-health professionals, and alcohol abstinence; decreases were associated with age and with other health insurance coverages. For women of other ethnicity, increases were linked to number of ex-partners, disclosing IPV to mental-health professionals, Medicaid use, drug use, and woman's own as well as partner's alcohol abstinence; decreases in this ethnicity category were linked to past assault by ex-partners. Intervention and policy implications are discussed.

Racial Disparities in Intimate Partner Violence and in Seeking Help With Mental Health

Applying Aday and Andersen's health services utilization model, this examination of racial disparities in women's experience of intimate partner violence also looked at racial disparities in mental disorders and in use of mental health professionals' help. We conducted a secondary data analysis of 6,589 women completing the National Violence Against Women Survey. Per our linear regression results, minority women, versus White, tended proportionally to seek less help from mental health professionals. Help seeking by African American women was less likely if they were using illegal drugs; among Hispanic women, additional threats from partner curtailed help seeking from mental health professionals. "Other ethnic minority" women's help seeking decreased with their use of stimulants. Implications for intervention are discussed.