Examining Intimate Partner Violence and Health Factors Among Rural Appalachian Pregnant Women.

579508 research-article2015

JIVXXX10.1177/0886260515579508Journal of Interpersonal ViolenceShannon et al.

Article

Examining Intimate Partner Violence and Health Factors Among Rural Appalachian Pregnant Women

Journal of Interpersonal Violence 1–19 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886260515579508 jiv.sagepub.com

Lisa Shannon, PhD, MSW,1 Shondrah Nash, PhD,1 and Afton Jackson, MPH1

Abstract Among pregnant women, intimate partner violence (IPV) is recognized as a critical risk factor in adverse health outcomes for the mother and newborn alike. This pilot study examined IPV and health for rural Appalachian pregnant women, a particularly vulnerable high-risk and high-needs group. Participants were 77 rural, Appalachian pregnant women entering a hospitalbased inpatient detoxification unit primarily for Opiate Dependence. Study participants gave informed consent to a face-to-face interview and secondary data abstraction from hospital medical records. IPV was measured via questions from the National Violence Against Women Survey, the Revised Conflict Tactics Scale (CTS2), and the Psychological Maltreatment of Women Inventory (PMWI). The majority of the sample reported lifetime psychological (89.6%) and physical (64.9%) violence. A little over three fourths (75.3%) experienced IPV in the past year. Furthermore, over one third (39.0%) experienced stalking, physical, or sexual violence in the past year. Most participants (71.4%) experienced psychological abuse in the past year. IPV experiences, in conjunction with pervasive substance use, mental and physical health problems, and poverty present in rural Appalachia, 1Morehead

State University, KY, USA

Corresponding Author: Lisa Shannon, Social Work, and Criminology, Morehead State University, 318 Rader Hall, Morehead, KY 40351, USA. Email: [email protected]

Downloaded from jiv.sagepub.com at Monash University on November 15, 2015

2

Journal of Interpersonal Violence

culminate in a particularly high-risk and high-needs group of pregnant women. These women present unique opportunities and challenges for prevention, intervention, and treatment. Keywords rural Appalachia, intimate partner violence, pregnancy Male-to-female psychological, physical, and/or sexual abuse in intimate partner relationships is neither infrequent nor inconsequential. Recent national estimates purport that approximately one in three women (35.6%) have experienced lifetime intimate partner violence (IPV; Black et al., 2011). Thirty percent of these individuals associate a negative consequence with the experience, including symptoms of post-traumatic stress disorder (PTSD), need for health care, and/or lost productivity (i.e., missed school and/or work; Black et al., 2011). Worldwide estimates from the World Health Organization (WHO; 2011) show that IPV during pregnancy is between 1% and 28%, with the majority of reporting countries ranging between 4% and 12%. Consistently, IPV is recognized as a principal risk factor in adverse health outcomes for the mother and newborn alike (Devries et al., 2010), including: substance use (i.e., tobacco/alcohol), delayed prenatal care, poorer reproductive health (i.e., low-birth weight, pre-term labor, and obstetrical complications), and mental/ physical health problems (i.e., depression, injury; WHO, 2011). Recent victimization appears to be common among pregnant substancedependent women (Haller & Miles, 2003; Kissin, Svikis, Morgan, & Haug, 2001; Sweeney, Schwartz, Mattis, & Vohr, 2000; Velez et al., 2006). For example, Kissin et al. (2001) suggested that almost one quarter of pregnant women (N = 240) admitted to a comprehensive hospital-based treatment program reported psychological abuse from an intimate partner within the previous 30 days. Furthermore, approximately 8% experienced physical abuse and 1% experienced sexual abuse in the 30-day period prior to treatment (Kissin et al., 2001). Similarly, Velez et al. (2006) reported that of the 715 pregnant study participants, approximately 41% reported emotional abuse, 20% reported physical abuse, and 7% reported sexual abuse from intimate partners during their pregnancies. Haller and Miles (2003) also suggested that a high proportion, a little less than three fourths (71%), of the pregnant or postpartum women in substance abuse treatment experienced some type of victimization within the 30 days prior to treatment. Research suggests that IPV, when combined with certain factors, may add to the risk of negative health outcomes experienced by pregnant women;


3

Shannon et al.

substance abuse is one such factor (Amaro, Fried, Cabral, & Zuckerman, 1990; Connelly, Hazen, Baker-Ericzén, Landsverk, & Horwitz, 2013). Women who have experienced IPV generally show a greater risk of using heavier quantities of alcohol and prescription/non-prescription drugs than women who have not experienced IPV (Amaro et al., 1990). Pregnant women who have experienced IPV also have shown an increased incidence of substance use and psychosocial stress, in addition to reports of less support from partners, less support from others, and lower self-esteem (Curry, 1998). In addition to substance abuse, the negative effects of socio-economic disparities in rural areas and the physical isolation of rural communities can further complicate pregnant women’s victimization and availability to utilize healthbenefiting behaviors. Extended distances from needed services pose a distinct challenge for women experiencing IPV in rural cultures and their health care providers, and it is not uncommon for an abuser to exploit a woman’s geographic isolation by withholding transportation (Adler, 1996). As a group, rural pregnant women lack the resources typically enjoyed by their urban counterparts, including: public transportation, access to shelters, access to neighbors who live close enough to provide support when needed, and employment opportunities (Bhandari et al., 2008). Taken as a whole, poverty, geographic isolation, and the cumulative potential for stressors associated with chronic disparity and financial hardship comprise a serious consideration for interventionists, researchers, as well as pregnant women experiencing IPV in rural residencies. Rural pregnant women report stress over having to go great distances to reach a hospital when in labor and concern about the possibility of impassable roads during their journey (Bhandari et al., 2008). During interviews with approximately 25 low-income pregnant women from rural communities, Bloom, Bullock, and Parsons (2012) found financial stress a predominant concern, compounded by a lack of employment, transportation, and affordable housing options. Findings from the Bloom and colleagues study exposed both psychological and physical tolls, with reportedly high levels of global perceived stress, violence exposure, and symptoms of depression and PTSD among the sample. Life and limitations associated with rural Appalachian regions in Kentucky, the area and population observed in this research, may pose dramatic implications for substance-dependent pregnant women compromised by IPV. Poverty, for one, is both a serious and chronic consideration in rural, Appalachian Kentucky. The poverty rate in many of Kentucky’s rural Appalachian counties exceeds the national average (Appalachian Regional Commission [ARC], 2012a). Based on 2012 classifications, 41 of Kentucky’s 54 rural, Appalachian counties were categorized as economically distressed


4


based on the 3-year unemployment rate, per capita market income, and the poverty rate (ARC, 2012b). Furthermore, research has shown concerns over the misuse and non-medical use of prescription opiates in Kentucky’s Appalachian regions (Havens, Walker, & Leukefeld, 2007; Hays, 2004; Shannon, Havens, Mateyoke-Scrivner, & Walker, 2009). Compared with the urban areas of Kentucky, rural pregnant women had higher rates of illicit opiate use, illicit sedative/benzodiazepine use, and injection drug use (IDU) in the 30 days prior to substance abuse treatment admission (Shannon, Havens, & Hays, 2010). In view of their socio-economic hardships and the concealment often associated with IPV and substance abuse, women who are pregnant, substance-dependent, and constrained by geographic isolation and a scarcity of resources are situated as an undetected high-risk group. Previous studies have shown high rates of IPV among Appalachian women with 81% of participants reporting some type of IPV during the current pregnancy, 28% reporting physical IPV, and 20% reporting sexual violence (Bailey & Daugherty, 2007). The purpose of this study was to examine IPV and health for rural Appalachian pregnant women entering a hospital-based inpatient detoxification program, thus expanding on previous research by also focusing on a substance-using population. Pregnant women entered the University of Kentucky Chandler Medical Center (UK Chandler Medical Center) to receive methadone-supervised detoxification to (a) be drug-free upon discharge or (b) stabilize/receive longer term methadone maintenance treatment with outpatient follow-up. The decision to participate in methadone-supervised detoxification versus longer term methadone maintenance treatment was related to both the woman’s choice and medical recommendation. This decision was made prior to entering the treatment facility.

Method Participants This study, in its entirety, focused on 114 pregnant women who voluntarily agreed to participate in a pilot research study about pregnant women’s health and well-being. There were three eligibility criteria for study participation: (a) aged 18 and older, (b) pregnant, and (c) undergoing short-term inpatient methadone-supervised detoxification or methadone stabilization at the UK Chandler Medical Center. Data collection began in August 2005 and concluded in October 2007. Due to the scope of this particular article, only rural, Appalachian women (defined below) were the focus (n = 77). All data presented in this article focus solely on the rural Appalachian sample (n = 77). On average, women were 25 years old (M = 24.96, SD = 3.83).


5

Shannon et al.

The vast majority were White (98.7%), unemployed (89.6%), and reported a past year income of less than US$14,999 (87.7%). A significant minority reported an education level of some college or more (40.3%) and marital status as single (41.6%). On average, women had one child (M = 1.17, SD = 0.909) and were at 20 weeks gestation (M = 19.79, SD = 9.68). At the time of the interview, over three fourths (76.6%) reported receiving prenatal care. Please see Table 1 for more social and demographic descriptive information. All participants had a diagnosis of Opiate (91%), Poly-substance (26%), or Benzodiazepine (18%) dependence (data not shown in table).

Measures Demographics. Measures to assess participant demographics, including age, race, education, employment status, income, and marital status, were adapted from the Health Services Research Questionnaire (HSRQ; Chitwood, McBride, Metsch, Comerford, & McCoy, 1998) and the Addiction Severity Index (ASI; McLellan, Luborsky, Woody, & O’Brien, 1980). Geographic area. Participants were asked primary county of residence. Beale 2003 rural–urban continuum codes were utilized to classify participants’ home county (i.e., range = 1-9; 1 = county in a metro area of 1 million or more to 9 = completely rural or less than 2,500 urban population, not adjacent to a metro area; Economic Research Service [ERS], 2004). Rural and urban distinctions followed the guidelines of the ERS (2007) suggesting Beale codes of 3 or less be considered urban. Participants’ county of residence was further coded as Appalachian or non-Appalachian based on classifications provided by the ARC (2012b). Only women with counties classified as rural and Appalachian were retained in the current analyses (n = 77). IPV. IPV was measured with questions from the National Violence Against Women Survey (Tjaden & Thoennes, 1998), the Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996), and the Psychological Maltreatment of Women Inventory (PMWI; Tolman, 1989, 1999). Items for inclusion were selected based on previous work with women who had victimization histories by male intimate partners in rural Appalachian Kentucky (Logan, Walker, Cole, Ratliff, & Leukefeld, 2003). Due to time constraints, the complete battery of items included in the CTS2 and the PMWI were not feasible for inclusion. IPV items were broken down into several subscales based on previous literature (e.g., jealousy/control, symbolic violence/threats; Follingstad & DeHart, 2000; Kasian & Painter, 1992; Logan, Cole, Shannon, & Walker, 2007; Marshall, 1992). There were a total


6


of 16 IPV questions (see Table 2 for subscales). Women were first asked about lifetime IPV experiences (yes/no). If the participant endorsed an item, the same question was asked about past year experiences. Responses to past year questions ranged from 0 = not in past year, 1 = once, 2 = twice, 3 = 3 to 5 times, 4 = 6 to 10 times, 5 = 11 to 20 times, and 6 = more than 20 times in the past year. During data analysis, questions were categorized according to IPV type (i.e., psychological, physical, stalking, sexual, and injury), and past year IPV was dichotomized (0 = no, 1 = yes). Pregnancy status, physical/mental health. Information on pregnancy status (i.e., gestational age, receipt of prenatal care) and physical/mental health was obtained from participant medical records at the UK Chandler Medical Center. Prenatal care included visits to a primary care physician and/or obstetrician, taking prenatal vitamins, and receipt of an ultrasound. Physical and mental health problems were recorded as lifetime occurrences; due to the structure of the medical record, information could not be reliably coded into time frames (i.e., past year). Information on physical/mental health was gathered from a series of questions asked as part of the assessment completed upon entrance into the inpatient detoxification unit. This information was self-reported by the participant and later entered as part of the medical record. Substance use. Participants’ history of substance use and treatment was assessed with measures adapted from the ASI (McLellan et al., 1980). The ASI was used to gather information on lifetime use as well as the number of months the participant had used tobacco, alcohol, and a variety of drugs (e.g., opiates, including heroin and prescription opiates; sedatives; and crack or cocaine) in the past 12 months. The ASI has been shown to have good internal consistency reliability (Leonhard, Mulvey, Gastfriend, & Schwartz, 2000).

Procedure All study procedures were reviewed and approved by the University of Kentucky Medical Institutional Review Board. Pregnant women admitted to the UK Chandler Medical Center for short-term inpatient methadone-supervised detoxification or stabilization were recruited to be part of a study on pregnant women’s health and well-being. Eligible women were provided with a brochure describing the study by the unit social worker, and those who agreed to participate in the study consented to (a) a face-to-face interview and (b) have specific health information extracted from their medical records.


7

Shannon et al.

Separate consent forms were used for the face-to-face interview and secondary data extraction to conform to guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Both consent forms were explained orally at the time of participation with sufficient time for women to ask questions before beginning the interview protocol. The face-to-face interview took approximately 45 minutes and was conducted during women’s inpatient stay at the UK Chandler Medical Center. Interviews were completed on the inpatient unit in a private location and began after informed consent was obtained. Due to the sensitive nature of topics covered in the interview and to further protect the confidentiality of participant’s responses, a Federal Certificate of Confidentiality was obtained. Women received a token of appreciation in the form of small gifts for themselves or their child (approximately US$5.00 monetary value) for participating in the study. Secondary health data were collected from the woman’s medical record after discharge at the UK Chandler Medical Center in a private location. Study recruitment yielded a high participation rate: 94% of the pregnant women approached for the study agreed to participate. Of those agreeing to participate (n = 126), 90% (n = 114) completed the interview protocol. Twelve women who agreed to participate were unable to be scheduled prior to discharge. There was no personal information collected prior to the completion of the interview; thus, there is no way to determine how many, if any, of the women not interviewed were from the rural, Appalachian area. As part of the study protocol, interviews were scheduled at minimum 1 day after women were admitted to allow time for stabilization. On average, interviews were conducted 4 days (M = 4.23, SD = 2.31) into the inpatient stay.

Results These analyses focus on 77 rural, Appalachian pregnant women. As discussed above, Table 1 displays the social and demographic characteristics of the sample. Participants had an extensive intimate partner victimization history (data not shown in table). Ninety-one percent reported lifetime IPV experiences. The majority of participants reported lifetime psychological abuse (89.6%), physical violence (64.9%), and injuries from violence (54.5%). A significant minority experienced lifetime stalking (44.2%) and sexual abuse (32.5%). Participants also had significant histories of childhood victimization (before the age of 14), including emotional abuse (35.6%), sexual abuse (26.0%), and physical abuse (23.4%). Nearly every participant had been in a relationship in the past year (96.1%; data not shown in table). Table 2 presents the participants’ past


8


Table 1. Participant Social and Demographic Characteristics. Rural Appalachian (n = 77) Age Race White (non-Hispanic) Black Appalachian Education Less than high school GED or high school diploma Some college or more Employment status Unemployed Employed part-time Employed full-time Past year income Less than US$14,999 Marital status Single Married Separated Divorced Number of children Pregnancy status Gestational age (weeks) First trimester (1-12 weeks) Second trimester (13-27 weeks) Third trimester (28-42 weeks) Received prenatal care

24.96 (SD = 3.83) 98.7% 1.3% 100% 33.8% 26.0% 40.3% 89.6% 5.2% 5.2% 87.7% 41.6% 22.1% 13.0% 23.4% 1.17 (SD = .909) 19.79 (SD = 9.68) 31.2% 45.5% 23.4% 76.6%

year IPV experiences. A little over three fourths (75.3%) experienced IPV in the past year. More specifically, over one third (39.0%) experienced stalking, physical, or sexual violence in the past year. On average, participants experienced about three IPV tactics in the past year. Most participants (71.4%) experienced psychological abuse in the past year. For this, perpetrators utilized a variety of tactics (see Table 2), the most common being insulted, swore, shouted, or yelled (52.6%); degraded, treated you as inferior (33.8%); monitored time (33.8%); and destroyed belongings or threatened harm (33.8%). Other past year IPV experiences included physical violence (32.5%), injuries from violence (23.4%), stalking (14.3%), and sexual abuse (14.3%). Downloaded from jiv.sagepub.com at Monash University on November 15, 2015

9

Shannon et al. Table 2. Participant Past Year Intimate Partner Victimization Experiences.

Rural Appalachian (n = 77) Experienced intimate partner violence (past year) Experienced stalking, physical, or sexual violence Average number of tactics experienced Psychological Insulted, swore, shouted, or yelled Degraded, treated as inferior Monitored time Destroyed belongings, threats to harm Financial monitoring (i.e., denied access to money) Threatened to take children Threatened to harm or kill you Threatened to harm your children/someone close Stalking Physical violence Pushed, shoved, grabbed, slapped Punched, kicked, or beat you up Threatened/used a weapon Sexual abuse Sexual insistence Forced sex/rape Injured from violence Sprained, bruised, or left a small cut Medical intervention

75.3% 39.0% 3.38 (SD = 3.75) 71.4% 52.6% 33.8% 33.8% 33.8% 27.3% 20.8% 15.6% 6.5% 14.3% 32.5% 32.9% 15.6% 6.5% 14.3% 14.3% 1.3% 23.4% 23.4% 6.5%

Table 3 presents the participants’ mental and physical health status. Nearly half (48.1%) of the women had a mental health issue other than substance use. The most common mental health issues noted were suicidal thinking/attempts (22.1%), anxiety (22.1%), and depression (18.2%). Less than one fifth of participants (16.9%) were previously hospitalized for psychiatric issues. The majority of women had a physical health problem (94.8%). The most common physical health problems reported were liver/ kidney problems (36.4%), pregnancy problems (31.2%), female problems (27.3%), heart/blood/circulatory problems (22.1%), and respiratory problems (20.8%). Participants’ lifetime and past year substance use is presented in Table 4. As expected given the study sample, participants had an extensive lifetime substance use history. Almost all participants reported lifetime use of illegal/ illicit opiates (98.7%), alcohol (97.4%), marijuana (97.4%), cigarettes


10


Table 3. Mental and Physical Health. Rural Appalachian (n = 77) Mental health and substance use Has a mental health disorder other than substance use Suicidal thinking/attempts Anxiety Depression Mood disorder Bipolar Borderline Previous psychiatric hospitalizations Physical health Has a physical health problem Liver/kidney problems Pregnancy problems Female problems Heart/blood/circulatory problems Respiratory problems Muscle/bone problems Other health problems Neurological problems (i.e., seizures) Stomach/digestive problems Chronic pain Head injury Sexually transmitted infections Dental problems Appendix problems Eye/ear/nose/throat problems Thyroid/endocrine problems

48.1% 22.1% 22.1% 18.2% 7.8% 3.9% 3.9% 16.9% 94.8% 36.4% 31.2% 27.3% 22.1% 20.8% 18.2% 15.6% 13.0% 12.5% 11.7% 11.7% 10.4% 6.5% 5.2% 2.6% 1.3%

(96.1%), and legal (prescribed) opiates (92.2%). Over three fourths reported lifetime use of illegal/illicit benzodiazepines (87.0%) and cocaine/crack cocaine (85.7%). Over half reported lifetime injection drug use (53.2%). Past year substance use was also extensive. Most reported using illegal/illicit opiates (98.7%), cigarettes (92.2%), illegal/illicit benzodiazepines (67.5%), marijuana (54.5%), and legal (prescribed) opiates (54.5%). A little less than one half reported past year alcohol use (49.4%). Over one third (41.6%) injected drugs and 81.8% used multiple substances.


11

Shannon et al. Table 4. Lifetime and Past Year Substance Use.

Rural Appalachian (n = 77) Lifetime Cigarettes Alcohol Marijuana Illegal/illicit opiates Legal opiates Illegal/illicit benzodiazepines Legal benzodiazepines Cocaine or crack cocaine Injected drugs Past year Cigarettes Alcohol Marijuana Illegal/illicit opiates Legal opiates Illegal/illicit benzodiazepines Legal benzodiazepines Cocaine/crack cocaine Injected drugs Poly-substance user

96.1% 97.4% 97.4% 98.7% 92.2% 87.0% 36.4% 85.7% 53.2% 92.2% 49.4% 54.5% 98.7% 54.5% 67.5% 22.1% 36.8% 41.6% 81.8%

Chi-square tests for independence were used to examine associations between past year IPV and mental health, physical health, and substance use. Tests revealed only one significant association between IPV and past year marijuana use (Pearson χ2 = 5.336, df = 1, p = .021).

Discussion IPV was prevalent among this sample of pregnant, substance-using women. Psychological and physical abuse were prevailing types of IPV in the women’s lifetime and past year experiences; psychological abuse was the most recurring form. Well over half of the sample reported lifetime psychological and physical violence. These lifetime rates are much higher than those determined in extant analyses of IPV prevalence among multiple relevant samples, including the general population (i.e., the National Violence Against Women Survey—nationally representative data on men and women aged 18-65 years; Coker et al., 2002), pregnant women (WHO, 2011), and rural Appalachian women (Bailey & Daugherty, 2007). Downloaded from jiv.sagepub.com at Monash University on November 15, 2015

12


Study findings are extremely important, given this was not a sample recruited because of IPV experiences. Rather, this sample represents a group of women from rural Appalachia with substance use histories and who are currently pregnant that are at extremely high risk of victimization. These data have critical implications for women and potentially fetal health as psychological abuse may have a variety of profound effects on women. In a study conducted by Sackett and Saunders (1999) examining four forms of psychological abuse (i.e., jealous control, ignore, ridicule traits, and criticize behavior), ridiculing of traits was strongly related to fear and ignoring was strongly correlated with low self-esteem. Although the present study did not assess how various types of abuse affected the women, results indicate that the sample experienced a pervasive history of similar psychological IPV tactics. As will be further discussed, the relationship between physical IPV and negative effects on women’s health has been well documented (Campbell, 2002; Coker et al., 2002). However, emerging research suggests psychological violence tactics warrant attention from practitioners related to potential health implications. It was not surprising that adverse physical health problems were somewhat common among the sample, given the pervasive poverty in the rural Appalachian region, as well as the history of substance use (including high rates of tobacco use) and victimization among the women. IPV among women has been linked to several negative physical health outcomes such as chronic irritable bowel syndrome, eating disorders, vaginal bleeding/infection, hypertension, sexually transmitted diseases (STDs), chest pains, chronic pelvic pain, and injuries (Campbell, 2002; Coker et al., 2002). In addition to physical health complications, nearly half of the sample had mental health issues other than substance use. This finding is consistent with other studies suggesting an association between IPV and adverse mental health outcomes such as depression, PTSD, social dysfunction, and anxiety (Campbell, 2002). The rate of mental health issues is higher than general population estimates (depression, anxiety, and somatic complaints); the WHO (2014) estimates that approximately 33% of individuals in the community have these issues and is reported predominantly by women. National estimates have suggested comparable rates of lifetime depression symptoms among women (21.3%) compared with the current population (Kessler et al., 1994). As discussed, these findings are not unexpected given the life experiences (i.e., IPV and substance use) of these women; however, adding these findings to the fact that these women live in an under-privileged and under-served area (i.e., rural Appalachia), they are a particularly high-risk and high-needs population. There are several characteristics of this sample which may make them of particular concern for targeting assessment, education, and services. First, the


13

Shannon et al.

sample is rural Appalachian. Previous research indicates more severe IPV experiences among women residing in rural, Appalachian Kentucky (Logan et al., 2007). In addition, research has suggested that compared with the urban areas of Kentucky, rural pregnant women have shown higher rates of illicit opiate use, illicit sedative/benzodiazepine use, and injection drug use in the 30 days prior to substance abuse treatment admission (Shannon et al., 2010). Furthermore, rural women also experience many barriers to substance abuse treatment (Jackson & Shannon, 2012). Being in a treatment setting, away from the abuser, family, or friends, may trigger feelings of safety and allow the woman to disclose abuse. In fact, “healthcare providers are often the first professionals to offer care to women who are abused” (American College of Obstetricians and Gynecologists, 2012, p. 414). Unfortunately, a lack of health care providers is common in rural areas (Rural Assistance Center, 2012). Second, nearly half of the sample was single and of relatively low socio-economic status (i.e., a large majority reported annual earnings of less than US$14,999). Marriage and high socio-economic status are associated with reduced risk of IPV (Abramsky et al., 2011). Rural poverty relates to IPV in that it reduces the victim’s chances of escaping the abuse and adds to family or relationship stress (Rural Assistance Center, 2012). Rural poverty may also cause women to feel stuck in harmful relationships due to limited options for gaining financial freedom, thereby potentially increasing the risk of domestic violence (Rural Assistance Center, 2012). Furthermore, it can be hard to find affordable legal assistance in rural areas (Rural Assistance Center, 2012).

Implications for Treatment and Prevention As victimized women seek treatment for themselves (i.e., for any physical and/or mental health issues) or their children, methods to assess for IPV should also occur. In fact, the Family Violence Prevention Fund (1999) recommends IPV assessment (i.e., methods of detection/case finding) be used for women in primary care, emergency rooms, inpatient, mental health, pediatrics, family planning, and obstetrics/gynecology. The American College of Obstetricians and Gynecologists (2012) suggests health care providers periodically assess all women at yearly visits or new patient visits. Obstetricians should include IPV questions in the comprehensive assessment at the first prenatal visit, once per trimester, and again at the postpartum appointment (American College of Obstetricians and Gynecologists, 2012). Health care providers should be on the lookout for certain signs or behaviors that may indicate the potential presence of IPV such as depressive symptoms, mental illness, substance abuse symptoms, recurrent pregnancies albeit the patient


14


does not want to be pregnant, frequent occurrence of STDs, requests for an STD test, or fearful of discussing condom usage with a partner (American College of Obstetricians and Gynecologists, 2012). Despite methods of detection, in general, treatment services for domestic violence offenders are limited in rural areas (Rural Assistance Center, 2012). Furthermore, rural relationships are closely knit (Rural Assistance Center, 2012). Therefore, victims may be reluctant to disclose abuse to health care or law enforcement personnel and/or familiarity with an abuser may not result in a full investigation of allegations (Rural Assistance Center, 2012). Moreover, a lack of public transportation and irregular cell phone reception, which are characteristic of rural areas, may serve as hindrances to victims receiving help (Pennsylvania Coalition Against Domestic Violence, 2014). Furthermore, poverty, isolation, lack of social support, and associated stress, which are also characteristic of rural areas, can present challenges to victims (Renzetti, Edleson, & Bergen, 2011). IPV can be prevented; however, “the solutions are just as complex as the problem” (Centers for Disease Control and Prevention [CDC], 2013). Education is one method for IPV prevention. Existing literature on rural women and children suggests that a lack of education influences rates of domestic and family violence (Rural Assistance Center, 2012). Education can be in the form of pamphlets or booklets on IPV. These can be distributed in local health care settings, high schools, or even churches. Free IPV seminars could be offered at a local library. One way rural communities promote domestic violence awareness is through a coordinated community response (CCR). A CCR consists of several professionals/organizations (e.g., health care providers, law enforcement agencies, advocates, social service agencies, and local businesses) all working together to “protect victims, hold batterers accountable, and engage the entire community in efforts to change the social norms and attitudes that contribute to domestic violence” (The Advocates for Human Rights, 2006, third paragraph). Prevention approaches should strive to decrease common IPV risk factors and encourage building healthy relationships (CDC, 2013). Several primary prevention strategies, such as early childhood and family-based approaches, school-based approaches, interventions to reduce alcohol and substance abuse, and structural and policy approaches, are other methods to consider for IPV prevention (Harvey, Garcia-Moreno, & Butchart, 2007). IPV prevention requires a multifaceted approach, particularly when working with rural Appalachian women who live in closed communities with pervasive norms which allow the continued perpetuation of violence against women (Websdale, 1997). Websdale’s (1997) work suggests that rural patriarchy lies at the root of socially patterned battering of women in these communities, creating a good ol’ boy’s network


15

Shannon et al.

and local politics which sustain and reproduce subordinate, vulnerable, and isolated positions for many rural women. In these communities, traditional patterns of intervention, such as home visitors, are often considered unacceptable and can often put women in isolated communities at further risk. While this study contributes to the small but growing literature on IPV and pregnancy among rural Appalachian women, there are several noteworthy study limitations. First, while self-report has been identified as a valid method for gathering data, participants may under-report such behaviors in an interview setting. This may be particularly applicable given the target population of pregnant, substance-using women and the associated social stigma. In addition, it is possible due to heavy drug and/or alcohol use responses may be biased by limited memory or ability to recall information. Second, the faceto-face interview was limited to approximately 45 minutes due to the structure and routines on the inpatient psychiatric unit (e.g., medication time, psychotherapy, visiting hours). As a result of time constraints, information gathered in the face-to-face interview was limited; areas of potential importance such as other types of childhood maltreatment and other health problems (not collected in the medical record; that is, obesity) could not be thoroughly explored. Third, this is a sample of pregnant women seeking inpatient detoxification and is thus a non-probability, purposive sample which limits the generalizability of findings. Furthermore, this sample of pregnant women was recruited at various points during the pregnancy; this might influence the experience and reporting of mental health and substance use problems. Finally, the rural area in this study primarily represents the southeastern, Appalachian area of Kentucky. Due to the heterogeneity associated with rural areas, these findings may not be generalizable to other rural areas. In conclusion, this sample of rural pregnant, substance-using women experienced a widespread history of IPV which was a combination of psychological, threatening, and physical in nature. Past research has established that IPV has detrimental effects on the mother and fetus (Devries et al., 2010). Of note among the sample were reports of considerable psychological abuse in the past year, including but not limited to insults and degradation, destruction of property, and tactics of control. Despite its non-battering and sometimes imperceptible nature, psychological abuse by an intimate partner has significant mental and physical health consequences that cannot be taken lightly (Sackett & Saunders, 1999). The pervasiveness of psychological maltreatment and substance use found in this study, in addition to physical and sexual violence, underscores the need for a coordinated, multi-agency approach involving assessment and treatment initiatives for multiple forms of abuse. Furthermore, health care providers who serve this group should not only consider the social and economic milieus of Appalachian life but also


16


their potential to impede effective solutions and women’s empowerment. Integrating help initiatives that directly address abused, pregnant, and substance-using Appalachian women’s chronic impoverishment, absence of resources, vulnerability to stress, and seclusion from services is important and strongly advised. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References Abramsky, T., Watts, C. H., Moreno, C., Devries, K., Kiss, L., Ellsberg, M., . . . Heise, L. (2011). What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health, 11, 109-125. Adler, C. (1996). Unheard and unseen: Rural women and domestic violence. Journal of Nurse-Midwifery, 41, 463-466. The Advocates for Human Rights. (2006). Coordinated community response. Retrieved from http://www.stopvaw.org/coordinated_community_response Amaro, H., Fried, L., Cabral, H., & Zuckerman, B. (1990). Violence during pregnancy and substance use. American Journal of Public Health, 80, 575-579. American College of Obstetricians and Gynecologists. (2012). Committee Opinion No. 518: Intimate partner violence. Obstetrics and Gynecology, 119, 412-417. Appalachian Regional Commission. (2012a). County economic status and number of distressed areas in Appalachian Kentucky, Fiscal Year 2012. Retrieved from http:// www.arc.gov/images/appregion/economic_statusFY2012/CountyEconomic StatusandDistressAreasFY2012Kentucky.pdf Appalachian Regional Commission. (2012b). History of Appalachian Regional Commission. Retrieved from http://www.arc.gov/about/ARCHistory.asp Bailey, B., & Daugherty, R. (2007). Intimate partner violence during pregnancy: Incidence and associated health behaviors in a rural population. Maternal and Child Health Journal, 11, 495-503. Bhandari, A. H., Levitch, K. K., Ellis, K. B., Kevin, E., Elizabeth, G., & Bullock, L. (2008). Comparative analyses of stressors experienced by rural low-income pregnant women experiencing intimate partner violence and those who are not. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37, 492-501. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., . . . Stevens, M. R. (2011). The National Intimate Partner and Sexual Violence


17

Shannon et al.

Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Bloom, T., Bullock, L., & Parsons, L. (2012). Rural pregnant women’s stressors and priorities for stress reduction. Issues in Mental Health Nursing, 33, 813-819. Campbell, J. C. (2002). Health consequences of intimate partner violence. The Lancet, 359, 1331-1336. Centers for Disease Control and Prevention. (2013). Intimate partner violence: Prevention strategies. Retrieved from http://www.cdc.gov/violenceprevention/ intimatepartnerviolence/prevention.html Chitwood, D., McBride, D., Metsch, L., Comerford, M., & McCoy, C. (1998). A comparison of the need for health care and use of health care by injection-drug users, other chronic drug users and non-drug users. American Behavioral Scientist, 41, 1107-1122. Coker, A. L., Davis, K. E., Arias, I., Desai, S., Sanderson, M., Brandt, H. M., & Smith, P. H. (2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23, 260-268. Connelly, C. D., Hazen, A., Baker-Ericzén, M., Landsverk, J., & Horwitz, S. M. (2013). Is screening for depression in the perinatal period enough? The co-occurrence of depression, substance abuse, and intimate partner violence in culturally diverse pregnant women. Journal of Women’s Health, 22, 844-852. Curry, M. (1998). The interrelationships between abuse, substance use, and psychosocial stress during pregnancy. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 27, 692-699. Devries, K. M, Kishor, S., Johnson, H., Stöckl, H., Bacchuse, L. J., Garcia-Moreno, C., & Watts, C. (2010). Intimate partner violence during pregnancy: Prevalence data from 19 countries. Reproductive Health Matters, 18, 158-170. Economic Research Service. (2004). Measuring rurality: Rural-urban continuum codes. Retrieved from http://www.ers.usda.gov/data-products/rural-urbancontinuum-codes/.aspx Economic Research Service. (2007). Measuring rurality: What is rural? Retrieved from http://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/ what-is-rural.aspx Family Violence Prevention Fund. (1999). Preventing domestic violence: Clinical guidelines on routine screening. Retrieved from www.vawnet.org/Assoc_Files_ VAWnet/screpol.pdf Follingstad, D., & DeHart, D. (2000). Defining psychological abuse of husbands towards wives: Contexts, behaviors, and typologies. Journal of Interpersonal Violence, 15, 891-920. Haller, D. L., & Miles, D. R. (2003). Victimization and perpetration among perinatal substance abusers. Journal of Interpersonal Violence, 18, 760-780. Harvey, A., Garcia-Moreno, C., & Butchart, A. (2007). Primary prevention of intimate-partner violence and sexual violence: Background paper for WHO expert meeting May 2-3, 2007. Retrieved from http://www.who.int/violence_injury_ prevention/publications/violence/IPV-SV.pdf


18


Havens, J. R., Walker, R., & Leukefeld, C. G. (2007). Prevalence of opioid analgesic injection among rural nonmedical opioid analgesic users. Drug Alcohol Dependence, 87, 98-102. Hays, L. (2004). A profile of OxyContin addiction. Journal of Addictive Disorders, 23, 1-9. Jackson, A., & Shannon, L. (2012). Barriers to receiving substance abuse treatment among rural pregnant women in Kentucky. Maternal and Child Health, 16, 1762-1770. Kasian, M., & Painter, S. (1992). Frequency and severity of psychological abuse in a dating population. Journal of Interpersonal Violence, 7, 350-364. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., . . . Kendler, K. S. (1994). Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19. Kissin, W. B., Svikis, D. S., Morgan, G. D., & Haug, N. A. (2001). Characterizing pregnant drug-dependent women in treatment and their children. Journal of Substance Abuse Treatment, 21, 27-34. Leonhard, C., Mulvey, K., Gastfriend, D., & Schwartz, M. (2000). The Addiction Severity Index: A field study of internal consistency and validity. Journal of Substance Abuse Treatment, 18, 129-135. Logan, T. K., Cole, J., Shannon, L., & Walker, R. (2007). Relationship status and protective orders among a diverse sample of women. Journal of Family Violence, 22, 237-246. Logan, T. K., Walker, R., Cole, J., Ratliff, S., & Leukefeld, C. (2003). Qualitative differences among rural and urban intimate violence victimization experiences and consequences: A pilot study. Journal of Family Violence, 18, 83-92. Marshall, L. (1992). Development of the severity of violence against women scales. Journal of Family Violence, 7, 103-120. McLellan, A., Luborsky, L., Woody, G., & O’Brien, C. (1980). An improved diagnostic evaluation instrument for substance abuse patients. Journal of Nervous and Mental Disorders, 168, 26-33. Pennsylvania Coalition Against Domestic Violence. (2014). Rural communities. Retrieved from http://www.pcadv.org/Learn-More/Domestic-Violence-Topics/ Rural-Communities/ Renzetti, C. M., Edleson, J. L., & Bergen, R. K. (2011). Sourcebook on violence against women (2nd ed.). Thousand Oaks, CA: SAGE. Rural Assistance Center. (2012). Domestic violence frequently asked questions. Retrieved from http://www.raconline.org/topics/domestic-violence/faqs#ruraldv Sackett, L. A., & Saunders, D. G. (1999). The impact of different forms of psychological abuse on battered women. Violence and Victims, 14, 1-13. Shannon, L., Havens, J. R., & Hays, L. (2010). Examining differences in substance use among rural and urban pregnant women. The American Journal on Addictions, 19, 467-473. Shannon, L., Havens, J. R., Mateyoke-Scrivner, A., & Walker, R. (2009). Contextual differences in substance use for rural Appalachian treatment-seeking women. The American Journal of Drug and Alcohol Abuse, 35, 59-62.


19

Shannon et al.

Straus, M., Hamby, S., Boney-McCoy, S., & Sugarman, D. (1996). The revised conflict tactic scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283-316. Sweeney, P. J., Schwartz, R. M., Mattis, N. G., & Vohr, B. (2000). The effect of integrating substance abuse treatment with prenatal care on birth outcomes. Journal of Perinatology, 4, 219-224. Tjaden, P., & Thoennes, N. (1998). Stalking in America: Findings from the national violence against women survey (NCJ-1669592). Washington, DC: National Institute of Justice, Centers for Disease Control and Prevention, Bureau of Justice Statistics, U.S. Department of Justice. Tolman, R. (1989).The development of a measure of psychological maltreatment of women by their male partners. Violence and Victims, 4, 159-177. Tolman, R. (1999). The validation of the psychological maltreatment of woman inventory. Violence and Victims, 14, 25-35. Velez, M. L., Montoya, I. D., Jansson, L. M., Walters, V., Svikis, D., Jones, H. E., . . . Campbell, J. (2006). Exposure to violence among substance dependent pregnant women and their children. Journal of Substance Abuse Treatment, 30, 31-38. Websdale, N. (1997). Rural women battering and the justice system: An ethnography. Thousand Oaks, CA: SAGE. World Health Organization. (2011). Intimate partner violence during pregnancy: Information sheet. Retrieved from http://whqlibdoc.who.int/hq/2011/WHO_ RHR_11.35_eng.pdf?ua=1 World Health Organization. (2014). Gender and women’s mental health. Retrieved from http://www.who.int/mental_health/prevention/genderwomen/en/

Author Biographies Lisa Shannon, PhD, MSW, is an assistant professor of social work at Morehead State University. She has published in peer-reviewed journals on topics, including substance use, drug court, and intimate partner violence. She is currently the principal investigator for multiple projects examining outcomes associated with participation in community-based substance abuse treatment. Shondrah Nash, PhD, is an associate professor of sociology at Morehead State University. She has published on the nexus of spousal violence and religious coping, and she has been an active participant in Appalachian Kentucky’s domestic violence prevention and resource communities. Afton Jackson, MPH, is a research assistant with Morehead State University. She has been involved with substance use and mental health research for more than 4 years. She has published in peer-reviewed journals such as Maternal and Child Health. Her research interests include substance use, mental health, and women’s health.


Intimate Partner Violence Among Pregnant Young Women: A Qualitative Inquiry.

Prevalence and risk factors of intimate partner violence among pregnant women in Japan.

Intimate partner violence and suicidal ideation in pregnant women.

Risk factors for severe intimate partner violence and violence-related injuries among women in India.

Multilevel correlates of broadly- and narrowly-defined intimate partner violence among pregnant women in Los Angeles.

Childhood Abuse, Intimate Partner Violence and Risk of Migraine Among Pregnant Women: An Epidemiologic Study.

Employment status and intimate partner violence among Mexican women.

Relations Between Intimate Partner Violence and Forgiveness Among College Women.

Empowerment, intimate partner violence and skilled birth attendance among women in rural Uganda.

Association of childhood physical and sexual abuse with intimate partner violence, poor general health and depressive symptoms among pregnant women.

Intimate partner violence after disclosure of HIV test results among pregnant women in Harare, Zimbabwe.

Intimate partner violence among HIV positive pregnant women in South Africa.

Gender, psychopathy factors, and intimate partner violence.

Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents.

Examining the interface between substance misuse and intimate partner violence.

Relationship Factors and Condom Use Among Women with a History of Intimate Partner Violence.

Sociocultural and Victimization Factors That Impact Attitudes Toward Intimate Partner Violence Among Kenyan Women.

Factors Mediating the Relationship Between Intimate Partner Violence and Cervical Cancer Among Thai Women.

Risk Factors for Recent Intimate Partner Violence among Methamphetamine-Using Men and Women.

Intimate partner violence among rural South African men: alcohol use, sexual decision-making, and partner communication.

Intimate partner violence and mental health.

Intimate partner violence and poor mental health among Thai women residing in Sweden.

Cultural Beliefs, Intimate Partner Violence and Mental Health Functioning among Vietnamese Women.

Factors influencing disclosure among women experiencing intimate partner violence during pregnancy in Moshi Municipality, Tanzania.