Intimate Partner Violence (IPV), Factors Influencing IPV, and Adverse Maternal Health Among

Intimate Partner Violence (IPV), Factors Influencing IPV, and Adverse Maternal Health among

Pregnant Thai Women

Division of Research and Advanced Studies of the University of Cincinnati

In partial fulfillment of the requirements for the degree of

Doctor of Philosophy

College of Nursing

April 2012

Treechada Punsomreung

B.S.N., Boromarajonani College of Nursing Praputhabat, 1993

M.S.N., Chulalongkorn University, 2000

Committee Chair: John Schafer, Ph.D.

ABSTRACT

Background: Intimate partner violence (IPV) is recognized as a human rights violation which has taken away certain rights of women; freedom from fear and want, to move, to be safe, to be healthy, to live. IPV is of pandemic proportions because its prevalence is worldwide. In

Thailand, IPV and the safety of abused women remains a prominent problem. The World Health

Organization (WHO) studied women's health and domestic violence against women in several countries including Thailand. The results revealed that 41% of women in Bangkok and 47% in rural areas experienced physical or sexual violence at least once during their lifetime by an intimate partner. IPV can occur at any time over a woman’s life, including during pregnancy.

IPV can lead to the risk of death for mother and unborn child. Victims of IPV, before or during pregnancy, also face more complications of pregnancy. IPV during pregnancy is associated with posttraumatic stress disorder (PTSD), depression, anxiety, increased use of cigarettes, alcohol, and drugs, as well as later entry into prenatal care. Additionally, IPV impacts health care delivery, economics, social services, the criminal justice system, and law enforcement.

Objective: The purpose of this research was to test a hypothesized model by using path analysis to explain the relationships among IPV, factors influencing IPV, and adverse maternal health.

Methods: The cross-sectional survey research design examined the direct effects of: a) self-esteem; b) exposure to violence; c) acceptance of violence; and d) fear of partner on IPV during pregnancy in pregnant Thai women and to examine the direct effect of IPV on adverse maternal health using path analysis. The study was conducted at the Prenatal Care Unit at

Phraphutthabat Hospital, Saraburi Province, Thailand. Participants were selected by random

iii selection. 304 pregnant women participated. Data were collected between June and September

2011 using one questionnaire composed of six sections. All instruments that were used in the current study were tested for empirical construct validity and reliability. There were some changes in some scales based on psychometric properties. Statistical Package for the Social

Science (SPSS/PC 20.0) and Mplus version 6.12 were used for data management and data analysis.

Results: The fit indices indicated that the hypothesized model was not a good initial fit to the observed data. The model needed to be modified based on theoretical reasonability and modification indices. The fit indices indicated that the final model fit the observed data well (χ²

(7, N = 283) =12.865, p= .076, χ²/df = 1.84, RMSEA = .054, CFI = .980, and TLI = .941

Conclusions: Given the severe consequences and human costs and high economic costs of

IPV during pregnancy, these results suggest that many factors can be used to predict IPV during pregnancy. Also, IPV during pregnancy has a huge direct effect on maternal health. Several of these factors may represent potential targets for intervention. Strategies need to be developed for effective interventions to reduce the incidence and prevalence of IPV and therefore promote maternal health.

Treechada Punsomreung

ACKNOWLEDGEMENTS

I could not have completed my journey without help from many wonderful people.

Without their support, I would not have come this far and completed this journey. First, I would like to express my gratitude to my advisor and chairperson, Dr. John Schafer, for his guidance, ongoing support, intellectual challenge, statistical expertise, encouragement throughout my doctoral program, and belief in me. I also would like to express my sincere thanks to Dr. Donna

Shambley-Ebron for her positive support and attention to detail that she brought to the study.

Many thanks go to Dr. Bonnie Fisher for her insightful suggestions.

Also, I would like to thank to Dr. Carol Deets, Dr. Jan Dyehouse, Dr. Jean Anthony, Dr.

Edith Morris, Dr. Sue Davis, Dr. Yin Xu, and Dr. Susan Elek, my late previous advisor, for teaching and supporting me from the beginning of my journey. Thank you to my cohort in the doctoral program who shared this journey with brilliant discussion, especially to Dr. Kate York and Carolyn Smith. I appreciate and treasure your friendship and support. You made my stay in the U.S. so wonderful.

Also, I would like to take this opportunity to thank Praputthabath Hospital where I collected the data. Special thanks go to the 304 participants, the chief nursing officer, and the staff nurses at this site for their cooperation.

To my close friends, Dr. Kittiya Evans, Dr. Jinjutha Chaisena Dallas, and Sriprapai

Inchaithep, thank you for your assistance with tool development, translation, data analysis, and for the warm support. Many thanks go to my Thai friends in Cincinnati – Dr. Mayom, Ple, Lynn,

Kob, Toy, and Steve. It is hard to list all the names here, but thanks to everyone for being so supportive throughout all my endeavors.

I would like to thank the Royal Thai Government and the University of Cincinnati for financial support throughout these years. I would also like to acknowledge the generous funding for my study from the Deets Dissertation Award and the Graduate Student Governance

Association Award.

Last, many thanks and love go to my parents for their faith, hope, and belief in me. Also, thank you to my sisters, brothers-in-law, and relatives for their support and taking care of Mom and Dad when I am far away. This dissertation is dedicated to them.

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CONTENTS

Abstract …………………………………………………………………………………….. II Acknowledgements…………………………………………………………………………. V List of Tables.………………………………………………………………………………. IX List of Figures ……………………………………………………………………………… X Chapter One: Introduction...... 1 Introduction………………………………………………………………………………… 1 Problem……………………………………………………………………………………… 3 Purpose of the Study...... 7 Significance for Nursing…………………………………………………………………….. 8 Hypothesized Model………………………………………………………………………… 9 Definitions of Terms...... 10 Intimate Partner Violence (IPV)………………………………………………………… 10 Self-Esteem……………………………………………………………………………… 10 Acceptance of Violence………………………………………………………………… 11 Fear of Partner…………………………………………………………………………… 12 Exposure to Violence…………………………………………………………………… 12 Adverse Maternal Health………………………………………………………………… 13 Research Questions and Hypotheses...... 14 Chapter Two: Literature Review…………………………………………………………. 17 Prevalence of IPV in General Population and Pregnant Women…………………………… 17 Worldwide……………………………………………………………………………….. 17 Thailand………………………………………………………………………………….. 17 Thai Culture Influencing IPV……………………………………………………………….. 22 Family……………………………………………………………………………………. 22 Religiosity………………………………………………………………………………... 25 Media…………………………………………………………………………………….. 28 Alcohol…………………………………………………………………………………... 30 Barriers to seeking outside help…………………………………………………………. 32 Relationships between Self-Esteem, Acceptance of Violence, Exposure to Violence, Fear of Partner, and IPV………………………………………………………………………….. 34 Self-esteem and IPV…………………………………………………………………….. 34 Acceptance of Violence and IPV………………………………………………………... 38 Exposure to Violence and IPV…………………………………………………………… 42 Fear of Partner and IPV………………………………………………………………….. 45 Exposure to Violence and Fear of Partner……………………………………………… 48 Fear of Partner Mediating Exposure to Violence and IPV………………………………. 50 Relationships between Self-Esteem, Acceptance of Violence, and Exposure to Violence 51 Self-Esteem and Acceptance of Violence………………………………………………. 51 Self-Esteem and Exposure to Violence……………………………………………… 52 Acceptance of Violence and Exposure to Violence……………………………………… 53 Relationships between IPV and Maternal Health…………………………………………… 55 Pregnancy Complications……………………………………………………………… 56 Physical Health Problems………………………………………………………………... 61 Psychological Health Problems………………………………………………………... 64

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Philosophy Underpinning the Current Study……………………………………………….. 67 Summary…………………………………………………………………………………….. 69 Chapter Three: Methodology……………………………………………………………... 70 Research Design…………………………………………………………………………….. 70 Study Setting...... 70 Sample...... ………. 71 Measurements...... 73 Self-Esteem………………………………………………………………………………. 73 Acceptance of Violence………………………………………………………………….. 75 Exposure to Violence…………………………………………………………………….. 77 Fear of Partner…………………………………………………………………………… 79 IPV……………………………………………………………………………………….. 80 Adverse Maternal Health………………………………………………………………. 82 Demographic Information and Pregnancy History……………………………………… 86 Data Collection……………………………………………………………………………… 86 Data Management and Data Analysis………………………………………………………. 89 Protection of Human Participants…………………………………………………………… 91 Chapter Four: Results……………………………………………………………………... 97 Participants...... 97 Psychometric of Study Instruments…………………………………………………………. 97 Study Variables……………………………………………………………………………… 103 Univariate analysis……………………………………………………………………….. 103 Bivariate analysis………………………………………………………………………… 109 Path analysis……………………………………………………………………………… 111 Summary…………………………………………………………………………………….. 122 Chapter Five: Discussion…………………………………………………………………... 124 Discussion of the Study Findings…………………………………………………………... 124 Research Question One………………………………………………………………….. 124 Research Question Two………………………………………………………………….. 126 Research Question Three…………………………………………………………………. 138 Conclusion...... 139 Implications for Nursing…………………………………………………………………….. 140 Strengths and Limitations of the Study……………………………………………………… 143 Recommendations for Future Research……………………………………………………... 144 Summary…………………………………………………………………………………….. 145 References…………………………………………………………………………………… 146 Appendices…………………………………………………… …………………………….. 191

LIST OF TABLES Table 2.1 Pregnancy Complications in Victims of IPV …………………………………….. 60 Table 2.2 Physical Symptoms and Chronic Diseases in Victims of IPV…………………… 63 Table 4.1 Factor loading for Confirmatory Factor Analysis of the RSS…………………… 98 Table 4.2 Factor loading for Confirmatory Factor Analysis of the TAIPVS……………….. 99 Table 4.3 Factor loading for Confirmatory Factor Analysis of the TIPVFS……………….. 99 Table 4.4 Factor loading for Confirmatory Factor Analysis with Promax of Exposure to Violence Scale………………………………………………………………………………. 100 Table 4.5. Factor Loading for Confirmatory Factor Analysis of the WHO Violence against Women Instrument………………………………………………………………………….. 101 Table 4.6. Factor Loading for Confirmatory Factor Analysis with Promax of Negative Physical and Psychological Heath…………………………………………………………... 102 Table 4.7. Internal Consistency Reliability Estimates of Instruments………………………. 103 Table 4.8. Frequencies of Participants Demographic Characteristics ……………………… 104 Table 4.9. Frequencies of Experience of IPV during Pregnancy and Exposure to Violence. 106 Table 4.10. Test of Normality of Study Variables………………………………………… 108 Table 4.11. Means, Standard Deviation, Range, Skewness, and Kurtosis of Study 108 Variables…………………………………………………………………………………….. Table 4.12 Variances, Covariances, Correlations, Means and Standard Errors of the Means 111 of the Study Variables in the Path Analysis………………………………………………… Table 4.12. Kendall’s Tau Correlation Matrix of Study Variables…………………………. 111

LIST OF FIGURES Figure 1.1 Hypothesized Model of Relationships among IPV, Factors Influencing IPV, and Adverse Maternal Health……………………………………………………………………...... 9 Figure 4.1 Boxplots of the Study Variables…………………………………………………. 107 Figure 4.2 Q-Q Plots of Study Variables……………………………………………………. 109 Figure 4.3 Scatterplot Matrixes (SPLOMs) of the Study Variables………………………… 110 Figure 4.4. Hypothesized Model with Standardized Estimates……………………………... 113 Figure 4.5. Final Model with Standardized Estimates………………………………………. 119

CHAPTER ONE: INTRODUCTION

"Everyone has the right to life, liberty and security of person. No one shall be subjected to torture or to cruel, inhumane or degrading treatment or punishment. Everyone has the right to recognition everywhere as a person before the law. Everyone has the right to an effective remedy by the competent national tribunals for acts violating the fundamental rights granted him by the constitution or by law." (The United Nations: Universal Declarations of Human Rights, 1948)

Introduction

Intimate partner violence (IPV) is recognized as a human rights violation which has taken away certain rights of women; freedom from fear and want, to move, to be safe, to be healthy, and to live (Lerdsrisuntad, 2004; The United Nations as cited in Thomas & Beasley, 1993). IPV is of pandemic proportions because of its prevalence throughout world (Gupta et al., 2008;

Heise, Ellsberg, & Gottemoeller, 1999). The global research findings point out that at least one third of women around the world have been abused by their partners and 15% to 71% of women at 15 sites in 10 countries have been abused by their partners (Heise et al., 1999; World Health

Organization, 2005).

IPV is now being recognized as a major public health problem (Krantz & Garcia-Moreno,

2005; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002) for the following reasons: (a) IPV is common within a population; (b) the consequences of IPV are tremendous and devastate families and societies (M. L. Rosenberg, O'Carroll, & Powell, 1992; Wathen et al., 2007); and (c) costs of

IPV are great and are a fiscal burden, which is not limited to the individual victim (McKenna,

2009). In the U.S., each year approximately 4.8 million women are physically assaulted and/or raped by a partner (Tjaden & Thoennes, 2000). Over 1,500 deaths were caused by IPV in 2005 2

(U.S. Department of Justice, 2005) and spending related to IPV was estimated at more than $8.3 billion in 2003 (Max, 2004).

IPV can occur at any time over a woman’s life, including during pregnancy, affecting both the pregnant woman and her unborn babies (J. C. Campbell, 2002; Krug, Mercy, Dahlberg,

& Zwi, 2002). Women sustaining IPV during pregnancy had a fourfold to 19-fold increased risk of maternal death (Dutton & Nicholls, 2005; El Kady, Gilbert, Xing, & Smith, 2005) and were found to have a twofold increased risk of perinatal and neonatal morbidity (Ahmed, Koenig, &

Stephenson, 2006; A. L. Coker, Sanderson, & Dong, 2004; El Kady et al., 2005). IPV leads to adverse health and the risk of death for both mother and unborn child.

In Thailand, accurate statistics of IPV are difficult to obtain because of women’s silence and underreporting (Han & Resurreccion, 2008). Thai people in general view IPV as a private and family issue and believe that outsiders should not interfere (Foundation of Women, 1993 as cited in Sricumsuk, 2006). Most cases of IPV may not be reported because Thai women are reluctant to declare their human rights and want to preserve the family for their children (Stalker,

2006). Thai women have been taught to keep family problems private. To expose these problems to outsiders will result in loss of face and a certain amount of shame (Costa & Matzner, 2002).

Within Thai culture, the preservation of family well-being and saving family face are regarded as more important than the happiness of an individual (Ho, 1990; Kerley, Xu, Sirisunyaluck, &

Alley, 2010). Abused women who are concerned about violation and threat from their partners and fear the associated social stigma may not disclose their experiences with IPV (Lerdsrisuntad,

2004), therefore the magnitude of the problem may be unknown (Kongsakon,

Bhatanaprabhabhan, & Pocham, 2008).

Creating specific laws to protect women from IPV are necessary since a rights–based approach with IPV is not accepted broadly (Lersdsrisuntad, 2004). In 2007, The Protection of

Victims of Domestic Violence Act was passed for the first time in Thai history. Prior to the Act,

Thailand’s Constitution of 1997 acknowledged the human rights of women by including a specific provision on domestic violence in article 53: “Children, youth, and family members shall have the right to be protected by the State against violence and unfair treatment”

(Lersdsrisuntad, 2004, p. 26). Such changes will need to be fully accepted in the Thai culture for any significant advancement toward alleviating the burden of IPV on women.

Problem

Although reliable country-wide sources and statistics to support the problem of IPV in

Thailand are rare (Grisurapong, 2002; Quicker, 2002) and IPV is underreported, there is evidence that indicates that IPV in Thailand is a prominent problem. The WHO studied women's health and domestic violence against women in several countries including Thailand. The results revealed that 41% of women in Bangkok and 47% in Nakhonsawan experienced physical or sexual violence at least once during their lifetime by an intimate partner (C. Garcia-Moreno,

Jansen, Ellsberg, Heise, & Watts, 2006). In addition, The Reproductive Health Survey in 2006 revealed that 1.044 million married women aged 15- 49 years experienced physical and/or emotional abuse within one month prior to the survey (Office of Women Affairs and Family

Development, 2008).

As previously mentioned, IPV can occur at any stage of a woman’s lifetime and, unfortunately, times of pregnancy are no exception (J. C. Campbell, 2001). In several studies, pregnant women were found to be at even higher risk for IPV (J. C. Campbell et al., 2000; J.

McFarlane, Soeken, & Wiist, 2000; J. Webster, Sweett, & Stolz, 1994). The effects of IPV may

4 lead to poor health of both the mother and unborn child. Morbidity of abused pregnant women is nearly four times higher than for women who had not experienced IPV (El Kady et al., 2005).

Women abused by an intimate partner during pregnancy have more than three times the risk of becoming an attempted/completed femicide victim than women who did not experience IPV

(McDonald & Ho, 2002) and women who were victims of IPV before or during pregnancy face more complications of pregnancy including abortions and miscarriages (Hedin & Janson, 2000;

Morland, Leskin, Rebecca Block, Campbell, & Friedman, 2008), preeclampsia (Sanchez et al.,

2008), high blood pressure or edema, hyperemesis gravidarum, gestational diabetes, premature rupture of membrane (PROM), placenta problems (Silverman, Decker, Reed, & Raj, 2006), antepartum hemorrhage (Janssen, 2003; Silverman et al., 2006), infection, anemia, low weight gain (J. McFarlane, Parker, & Soeken, 1996), uterine rupture, and cesarean delivery (El Kady et al., 2005).

IPV during pregnancy has been associated with posttraumatic stress disorder (PTSD)

(Rodriguez et al., 2008), depression (Jundt et al., 2009; Rodriguez et al., 2008; N. Thananowan

& Heidrich, 2008), anxiety (Jundt et al., 2009), attempted suicide (Amaro, Fried, Cabral, &

Zuckerman, 1990; Martin, Macy, Sullivan, & Magee, 2007), and less happiness about being pregnant (Amaro et al., 1990). Moreover, IPV during pregnancy has been associated with increased rate of cigarette, alcohol, and drug use (Bailey & Daugherty, 2007; Huth-Bocks,

Levendosky, & Bogat, 2002; J. McFarlane et al., 1996; Shurman, Rodriguez, & Shurman, 2006), later entry into prenatal care (Bailey & Daugherty, 2007; Huth-Bocks et al., 2002; J. McFarlane et al., 1996), and less adherence to recommended prenatal clinic visits (Moraes, Arana, &

Reichenheim, 2010). Abused women faced negative social consequences including isolation from social networks (N. El-Bassel, Gilbert, Rajah, Foleno, & Frye, 2001; Hadeed & El-Bassel,

2006), strained relationships with health providers such as physicians and nurse practitioners

(McNutt, van Ryn, Clark, & Fraiser, 2000; Plichta, 2004), and limited access to health care

(Weinbaum et al., 2001).

In pregnancy, IPV may result in fetal stress and fetal death (Dye, Tolliver, Lee, &

Kenney, 1995), preterm delivery (Covington, Hage, Hall, & Mathis, 2002; El Kady et al., 2005;

Huth-Bocks et al., 2002; Silverman et al., 2006), low birth weight (LBW) (Huth-Bocks et al.,

2002; J. McFarlane et al., 1996; Silverman et al., 2006), intrauterine growth retardation (IUGR)

(A. L. Coker et al., 2004), low APGAR score, and extended neonatal intensive care (Covington et al., 2002). IPV may not only result in the adverse health of pregnant women and unborn babies, but also has a negative impact on the health of the children later. Children whose mothers have a history of IPV have higher health care utilization and costs than children whose mothers have no such history (Rivara, Anderson, Fishman, Bonomi, Reid, Carrell, & Thompson, 2007b).

Children who witnessed IPV have increased risk of physical and sexual abuse, being a victim or perpetrator, and adverse behaviors such as depression, anger, and anxiety when compared to children without comparable histories (Hornor, 2005; Johnsona et al., 2002).

In addition to adverse maternal and neonatal health during pregnancy, IPV impacts health care delivery, economics, social services, the criminal justice system, and law enforcement

(Max, Rice, Finkelstein, Bardwell, & Leadbetter, 2004). Abused women used more health care services, including primary care, emergency and urgent care, specialty care, outpatient hospital and laboratory services, and pharmaceuticals than nonabused women (Bonomi, Anderson,

Rivara, & Thompson, 2009; Rivara, Anderson, Fishman, Bonomi, Reid, Carrell, & Thompson,

2007a).

Due to limited data in Thailand, the economic toll of IPV at the individual, local, and national levels is unknown. However, national-level economic cost-estimates of injury from interpersonal violence that was defined as “an act of violence inflicted by another individual or by a small group of individuals” are available and revealed that direct medical costs from interpersonal violence was 1.3 billion baht ($42.5 million USD) and productivity losses for injuries due to interpersonal violence were 14.4 billion baht ($471 million USD) in 2005

(Dhisayathikom et al., 2008). In the U.S., the economic costs of IPV including expenditures for hospitals, physician and other professional services, mental health services, ambulance transport, and the lost productivity were $5.8 billion in 1995 and IPV costs exceeded $8.3 billion in 2003

(Max et al., 2004). Estimates for Australia amounted to 13.6 billion Australian dollars in 2009

(The National Council to Reduce Violence against Women and their Children, 2009), for

Finland, $198 million, in 2001(Heiskanen & Piispa, 2001), for Canada, 4.2 billion Canadian dollars ($4.25 billion USD) in 1995 (Greaves, Hankivsky, & Kingston-Reichers, 1995). In the

U.S., total annual health care costs are 42% higher for physically abused woman and 33% higher for psychologically abused women respectively compared with nonabused women (Bonomi et al., 2009). The costs do not include those that are difficult to evaluate, such as the immense personal toll of pain, grief, distress, and humiliation experienced by abused women (Anderson et al., 2008). The costs also exclude social services such as women’s shelters and counseling clinics, shelter, moral support, financial assistance from IPV victims’ friends and family, the value of time lost from volunteer work, and recreational activities (CDC, 2003).

In response to the severe consequences and high economic and human costs of IPV during pregnancy, factors influencing IPV should be studied. Understanding how these factors influence IPV during pregnancy will provide the basis for developing effective interventions to

7 reduce the incidence and prevalence of IPV. To date, most of the studies on IPV and factors influencing IPV were conducted in the U.S. and other developed countries. Little is known about factors influencing IPV during pregnancy in Thailand. Six studies on IPV during pregnancy were found in the Thai literature, with only two studies related to factors influencing IPV during pregnancy. The factors related to IPV during pregnancy that were investigated in these studies were personal characteristics of abused women, marital relationships, and attitudes toward gender role (N. Thananowan & Heidrich, 2008). Studies on IPV which emphasized pregnancy outcomes are rare (J. Webster, Chandler, & Battistutta, 1996) and the results are inconsistent (N.

Thananowan, 2004) .

Purpose of the Study

The purpose of this research study was to test a hypothesized model explaining the relationship among IPV during pregnancy, factors influencing IPV, and adverse maternal health in Thai women, using path analysis. In the extant literature, most investigators testing the relationships between factors influencing IPV and IPV during pregnancy used correlation or regression analysis. Correlation analysis only addresses a relationship between two variables.

Regression analysis explains possible cause-and-effect relationships among a set of variables on a specific dependent variable, however, a saturated model with no degrees of freedom (df) cannot test goodness of fit (GOF). Path analysis can estimate and test direct and indirect causal effects simultaneously. A saturated model without degrees of freedom can test GOF and look at specific direct effects by using path analysis. Path analysis provides a better method to explain the effects of the multiple factors influencing IPV. The potential factors were: acceptance of violence, self- esteem, exposure to violence, fear of partner, and how IPV during pregnancy

(physical, psychological, and/or sexual abuse and controlling behaviors) affected adverse

8 maternal health. Adverse maternal health was evaluated using both physical and psychological health during pregnancy as well as pregnancy complications.

Significance for Nursing

Nursing has been involved in the effort to overcome the problem of IPV since the 1970s

(Draucker, 2002). The Nursing Network on Violence Against Women International (NNVAWI), which aims to "end violence against women, empower battered women, and change the health care system to be more responsive to the needs of abused women and their children" (Campbell

& Parker, 1999, p. 541), was founded in 1986. On the practice level, nurses have an opportunity to design prevention and intervention programs for IPV that are innovative and culturally specific (Draucker, 2002). Koss and Hoffman (2000) suggested that domestic violence services did not reach desired goals because of a lack of culturally specificity.

If the findings of this research showed the factors influencing IPV and IPV affected maternal health, it would support the need for more culturally specific programs for pregnant

Thai women. The outcome of this study would help to increase understanding of the factors influencing IPV in Thai culture and would raise awareness for personal concern with maternal health during pregnancies affected by IPV. In addition, abused pregnant women would be identified with newly developing culturally sensitive tools and would be assisted with intervention programs that provide care and assistance to victims. The ultimate goal of this study is to provide the basic knowledge for developing an effective and culturally specific intervention program to eliminate IPV and promote maternal health during pregnancy for Thai women.

Research findings from this study can be used to advocate for policy that enhances the redistribution of power in Thai society to promote gender inequity. Public health policy

9 development can use the findings about adverse maternal and infant health for future support of policies that promote maternal health of victims of IPV and fund IPV programs.

Hypothesized model

A hypothesized model was developed based on the research literature. The hypothesized model of relationships among IPV, factors influencing IPV, and adverse maternal health is presented in Figure 1.1. In accordance with the hypothesized model, the relationships among

IPV, factors influencing IPV, and adverse maternal health were addressed by several hypotheses.

These hypotheses were generated to explain three research questions. In the model, acceptance of violence, self-esteem, and exposure to violence were exogenous variables. Fear of partner,

IPV, and adverse maternal health were endogenous variables.

Figure 1.1. Hypothesized Model of Relationships among IPV, Factors Influencing IPV, and

Adverse Maternal Health

Figure 1.1 illustrates the hypotheses of this research. The relationships shown in the model have been identified in Western literature, but no evidence exists to support the findings in pregnant Thai women. The relationship between exposures to violence and IPV has been found in Thai research but not in pregnant women (Kerley et al., 2010). The relationship between

10 acceptance of violence and IPV has been found as a control variable in Thai research, but not in pregnant women (Kerley et al., 2010). Self-esteem as a factor of IPV has been found in Thai research (Srisutham, 2003), but has not been studied in pregnant Thai women. The final factor, fear of partner as it relates to IPV, has not been studied in the Thai culture. The model was used to test only factors influencing IPV even though the literature indicates that some variables can be both causes and effects of IPV.

Definitions of Terms

Intimate Partner Violence (IPV)

Theoretical definition: IPV is defined as any behavior within a relationship that causes physical, psychological, or sexual harm including acts of physical violence, psychological violence, forced intercourse and other forms of sexual coercion. It also includes various controlling behaviors such as isolating a person from family and friends or restricting access to information and assistance (WHO, 2002).

Operational definition: In the current study, IPV was operationally defined as pregnant Thai woman’s experiences of IPV including physical, sexual, and psychological abuse and controlling behavior by an intimate partner including the spouse, ex-spouse, boyfriend, and ex-boyfriend that occurred during their recent pregnancy. The individual score on the WHO Violence against

Women Instrument (Archavanitkul, Kanchanachitra, Im-em, & Lerdsrisuntad, 2005) modified by the investigator was used to measure experiences of IPV. The scores ranged from 0 to 18. A high score indicated more experiences of IPV.

Self-Esteem

Theoretical definition: Self-esteem is defined as “a confidence and satisfaction in oneself”

(Merriam-Webster, 2009). Rosenberg (1965) asserted that self-esteem was composed of a

11 positive and negative attitude to the self. People with high levels of self-esteem feel themselves as worthy and self-respecting. In general, self-esteem means confidence in self-competence and self-worthiness (Foa, Cascardi, Zoellner, & Feeny, 2000). Coopersmith (1967) defined self- esteem as the degree of self-value and self-respect as well as self-competence and ability.

Operational definition:

In the current study, self-esteem was operationally defined as a Thai pregnant woman’s score on the Thai version of the Rosenberg’s Self-Esteem Scale (Rosenberg, 1989) which was translated by Srisaeng (2003). The scores ranged from 9 to 36. A high score indicated high self-esteem.

Acceptance of Violence

Theoretical definition:

Acceptance of violence has been defined as attitudes, justification, or tolerance of violence to oneself (Foshee, Linder, MacDougall, & Bangdiwala, 2001; Kaura & Lohman, 2007; O'Keefe &

Treister, 1998).

Operational definition:

Acceptance of violence was operationally defined as a pregnant Thai woman’s attitudes that physical, psychological, and sexual violence was acceptable, tolerable or justifiable and stereotypical Thai beliefs about IPV that were generally false but were widely and persistently held or accepted by pregnant Thai women. The pregnant Thai woman’s score on the Thai

Acceptance of Intimate Partner Violence Scale (TAIPVS) that was developed by the investigator was used to measure acceptance of IPV. The scores ranged from 16 to 64. A high score indicated high acceptance of IPV.

Fear of Partner

Theoretical definition:

Fear is defined as “a feeling of dread related to the identified source which the person validates”

(Kim & Moritz, 1982). Also, fear is an experience caused by threat (Yokom, 1984 cited in

Taylor-Loughran et al., 1989).

Operational definition:

Fear of partner was operationally defined as a pregnant Thai woman’s feeling of apprehension, fright, dread, or tension toward her partner. The pregnant Thai woman’s score on the Thai

Intimate Partner Violence Fear Scale (TIPVFS) that was developed by the investigator was used to measure fear of a partner. The scores ranged from 10 to 40. A high score indicated a high fear of partner.

Exposure to Violence

Theoretical definition:

Be consistent here with the other definitions. Buka, Stichick, Birdthistle and Earls (2001) suggested that both direct exposure (victimization) and indirect exposure (witnessing) have been considered when studying about exposure to violence. Exposure to violence may include watching, hearing, and experiencing the aftermath through observing maternal depression or seeing bruises, or being directly involved by calling the police or trying to intervene (Fantuzzo &

Mohr, 1999).

Operational definition:

Exposure to violence was operationally defined as experiences of physical or psychological abuse committed by a parent, stepparent, or adult living in the same house as the pregnant Thai woman in her first 18 years of life, experience of sexual abuse committed by an adult, relative,

13 family friend, or stranger who was five or more years older than the Thai pregnant woman in her first 18 years of life. Witnessing interparental violence was operationally defined as experiences of physical or psychological abuse between parents that included watching, hearing, or experiencing aftermath in their first 18 years of life. Ten questions that were translated and adapted from the Conflicted Tactic Scale (Straus, 1979) by Jirapramukpitak (2005) were modified by the investigator and were used to measure experiencing physical and psychological abuse. Four questions from Wyatt (1985) that were adapted and translated into Thai by

Jirapramukpitak (2005) were used to measure experiencing sexual abuse. Six questions that were translated and adapted from the Conflicted Tactic Scale (Straus, 1979) by Jirapramukpitak

(2010) were slightly modified by the investigator and were used to measure witnessing interparental violence.

Adverse Maternal Health

Theoretical definition:

In 1948, the WHO defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Maternal health was defined by the WHO as health of women during pregnancy, childbirth and the postpartum period.

Operational definition:

Adverse maternal health was operationally defined as a pregnant Thai woman’s negative physical and psychological health as well as complications during pregnancy

Negative physical and psychological health was a poor physical functioning and mobility, depression and posttraumatic stress disorder (PTSD) that assessed by using 16 items that compounded with five questions from the physical functioning, role functioning, and bodily pain subdomain of the SF-12 health survey (Ware, Kosinski, & Keller, 1996). The SF- 12 health

14 survey was translated into Thai (Sricumsuk, 2006), eight questions from the Edinburgh Postnatal

Depression Scale (J. Cox, Holden, & Sagovsky, 1987) that were translated into Thai

(Pitanupong, Liabsuetrakul, & Vittayanont, 2007), and three questions of Thai Screening Test for

Posttraumatic Stress Disorder (PTSD) (Arunpongpaisal et al., 2007). The raw scores from each instrument were transformed to Z-scores and then Z-scores of three instruments were combined to evaluate physical and psychological heath. High scores indicated poor health. Pregnancy complications were assessed by 11 items developed by the researcher.

Research Questions and Hypotheses

The target population was pregnant Thai women who were between the ages of 18 and 49 years attending the Prenatal Care Unit of Phraphutthabat Hospital in Saraburi, Thailand.

Specific Aim One.

To determine whether or not the hypothesized model of IPV, potential factors influencing IPV and, maternal health, including low self-esteem, high acceptance of violence, high exposure to violence, and high fear of partner fit the observed data representative of pregnant women in Thailand.

Research question one. Does the hypothesized model fit the observed data?

Hypothesis one. The hypothesized model will fit the observed data as indicated by multiple tests of goodness of fit (GOF) including chi-square statistic tests (desired value greater than .05), the ratio chi-square: degree of freedom (desired value smaller than 2:1), the root-mean- square error of approximation (RMSEA) (desired value smaller than .08), Tucker –Lewis Index

(TLI) (desired value greater than .90), and Comparative Fit Index (CFI) (desired value greater than .95).

Specific Aim Two. To determine the significance of potential factor influencing such as low self-esteem, high acceptance of violence, high exposure to violence and high fear of partner that may influence IPV during pregnancy among a representative sample of pregnant women in

Thailand.

Research question two. What factors influence IPV during pregnancy?

Hypothesis 2a. Pregnant Thai women’s acceptance of violence has a significantly direct positive effect on IPV during pregnancy.

Hypothesis 2b. Pregnant Thai women’s exposure to violence has a significantly direct positive effect on IPV during pregnancy.

Hypothesis 2c. Pregnant Thai women’s exposure to violence has a significantly direct positive effect on pregnant women’s fear of partner.

Hypothesis 2d. Pregnant Thai women’s fear has a significantly direct positive effect on

IPV during pregnancy.

Hypothesis 2e. Pregnant Thai women’s self-esteem has a significantly direct negative effect on IPV during pregnancy.

Hypothesis 2f. Pregnant Thai women’s exposure to violence has a significantly indirect effect on IPV during pregnancy through pregnant women’s fear of her partner.

Hypothesis 2g. There is a significantly positive relationship between exposure to violence and acceptance of violence.

Hypothesis 2h. There is a significantly negative relationship between self-esteem and acceptance of violence.

Hypothesis 2i. There is a significantly negative relationship between exposure to violence and self-esteem.

Specific Aim Three To determine the effect of IPV during pregnancy on adverse maternal health including negative physical and psychological health as well as complications among a representative sample of pregnant women in Thailand.

Research question three. Does the experience of IPV during pregnancy have an effect on adverse maternal health among pregnant women in Thailand?

Hypothesis three. The experience of IPV during pregnancy on Thai women has a significant direct positive effect on adverse maternal health.

CHAPTER TWO: LITERATURE REVIEW

The literature on IPV and factors influencing IPV is reviewed in this chapter. The review is composed of five sections: (1) prevalence of IPV in the general population and in pregnant women; (2) Thai culture influencing IPV; (3) relationships between self-esteem, acceptance of violence, and exposure to violence; (4) relationships between self-esteem, acceptance of violence, exposure to violence, fear, and IPV; and (5) relationships between IPV and maternal health.

Prevalence of IPV in General Population and Pregnant Women

Worldwide

IPV occurs across all populations regardless of social class, economic, religious, or culture groups (Heise & Garcia-Moreno, 2002). According to a United Nation report, IPV was found in all member countries (Quicker, 2002). The report estimates that one third of women worldwide experience IPV (Krug, Mercy et al., 2002). In the U.S., almost 5.3 million women aged 18 and older become victims of IPV each year (CDC, 2003), and more than 1 million women are stalked by their intimate or formal partner each year (Tjaden & Thoennes, 2000). In

Australia, 17% of women reported sexual violence and 11% of women experienced physical violence over their lifetime (Australian Bureau of Statistics, 2005). One study that collected the data using nationally representative sample from nine countries, the results showed that 18-48% of ever-married women reported IPV (Kishor & Johnson, 2004). Also, a recent study by the

World Health Organization (WHO) that included over 24,000 women from 15 sites in 10 countries including Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia and

Montenegro, Thailand, and the United Republic of Tanzania revealed that the lifetime prevalence

18 of physical or sexual partner violence ranged from 15% in Japan to 71% in Ethiopia (C. Garcia-

Moreno et al., 2006).

Prevalence of abuse during pregnancy varies greatly between studies depending upon the definitions, samples, and tools used. Prevalence of IPV during pregnancy in developing countries ranged between 4% and 29% (Nasir & Hyder, 2003). In the WHO study, prevalence of ever- pregnant women physically abused during pregnancy ranged between 1% and 28% (World

Health Organization, 2005) and the multi-country Demographic and Health Surveys (DHS) found a prevalence of 1% to 11% among women who had ever been pregnant who experienced violence during pregnancy by their husbands (Kishor & Johnson , 2004). In industrialized countries outside of United States such as Australia, Sweden, Switzerland, and the U.K., the prevalence of abuse during pregnancy was 3.4% to 11.0% (J. Campbell, Garcia-Moreno, &

Sharps, 2004). Recent studies found a prevalence of IPV during pregnancy between 4% and 44%

(Audi, Segall-Corrêa, Santiago, Andrade, & Pèrez-Escamila, 2008; Chu, Goodwin, & D'Angelo,

2010; Clark, Hill, Jabbar, & Silverman, 2009; Farid, Saleem, Karim, & Hatcher, 2008;

Mohammadhosseini, Sahraean, & Bahrami, 2010; Perales, Cripe, Lam, Sanchez, & Sanchez,

2009). However, prevalence of IPV goes underreported because the collection of accurate statistics “has been hampered by the difficultly of identifying and defining what should be considered” (L. E. Walker, 1999, p. 23). Additionally, reliable statistics on existence of IPV are few (L. E. Walker, 1999). These data surrounding the prevalence rates of IPV confirm that the problems of IPV have proliferated across the world, including Thailand.

Thailand

In Thailand, as in other countries, reliable country-wide sources and statistics to support the problem of IPV are rare (Grisurapong, 2002; Quicker, 2002). Accurate statistics are difficult

19 to obtain because of the cultural norm of women’s silence (Han & Resurreccion, 2008). The reported prevalence of IPV has changed vastly over time. Levinson (1989) conducted an ethnographic study of a village community in central Thailand finding that little or no wife abuse occurred. Similarly, Campbell (1985) used the ethnographic method in several developing countries and found that wife abuse in Thailand, especially in central Thailand, was not present.

These findings were likely due to the culture of silence with Thai women. Conversely, the WHO studied women's health and domestic violence against women in several countries, which showed that 41% of women in Bangkok and 47% in rural Thailand had the experience of physical or sexual violence at least once during their lifetime by an intimate partner (C. Garcia-

Moreno et al., 2006). The Thai Reproductive Health Survey in 2006 found that 1.044 million married women aged 15-49 years experienced physical and emotional abuse within one month of the survey (Office of Women Affairs and Family Development, 2008). The Thai Ministry of

Public Health reported that there were 22,925 cases of women and children seeking help from

“One Stop Crisis Centers,” which were established for helping women and child suffering from violence at 783 public hospitals around the country in 2009 (Bureau of Health Service System

Development, 2009). Women who became the victims of violence elevated from 3,585 cases to

12,921 cases recorded in 2004 and 2008 with more than 50% of abusers being partners (Bureau of Health Service System Development, 2009). These results show a more than 300% increase in

IPV toward women between the years of 2004 and 2008.

Prevalence in Thailand of IPV during pregnancy was found to vary greatly. The WHO multi-country study on women’s health and domestic violence against women found a 4% prevalence of IPV during pregnancy in Bangkok (n = 1,536) and Nakonsawan (n = 1,286)

(Archavanitkul et al., 2005). Six hospital-based studies that conducted about IPV in pregnant

Thai women were found. First, Thananowan and Heidrich (2008) collected data from five hospitals located in Bangkok and found that nearly 15% of 475 pregnant Thai women reported abuse during pregnancy and the percentage of physical, emotional, and sexual abuse during pregnancy was around 10%, 15%, and 5%, respectively. Secondly, Deoisres (2004) conducted a random sampling cross-sectional study with 481 women from 12 public hospitals in four provinces in the eastern part of Thailand and found that 48% of the women reported being abused during their current pregnancy. Among abused women, 33% experienced physical abuse,

93% were emotionally abused, and 8% were sexually abused. Next, Chatchawanwit (2008) reported that 34% of the 300 Pregnant Thai women recruited from antenatal care at Maharat

Nakhonratchasima Hospital reported being abused during pregnancy. Pregnant women reported physical, emotional, and sexual abuse during pregnancy at rates of 5%, 28%, 9%, respectively.

Sangwan (2008) collected data from 360 pregnant women who visited at the antenatal care unit of The Rajvithi Hospital located in Bangkok and the results showed that 84% of pregnant women experienced IPV at some point in their life time or in the past 12 months prior to data collection.

Seventy two percent were psychologically or emotionally abused, nearly 50% were physically abused, and 46% were sexually abused. Another study with 421 participants from two public hospitals in Khon Khen province found that 26% of pregnant women were physically abused, while 54% reported psychological abuse and 19% were sexually abused (Sricamsuk, 2006).

Lastly, a study of 400 pregnant women attending an antenatal clinic in Bangkok found that 12% were physically abused and 22% were mentally abused in the past six months (Thanaudom,

1996). From the above findings, the prevalence of IPV against pregnant women ranged between

4% and 48%. Results were based on a random sample in one study and non-random samples in five studies.

With regard to the prevalence of IPV, the Thai government has become concerned about the IPV situation and has accepted that IPV is a serious social problem, prompting the government to launch many campaigns to decrease the IPV problem over the past several years

(McAuslan, 2006). For example, in 1999 the Thai government designated the month of

November as the campaign of “no violence against women and girls.” Throughout November each year, related public and private organizations have created activities to encourage people to be aware about the problem of violence. The One Stop Crisis Centers were established at public hospitals around Thailand in 1998 to help women and children suffering from violence. Each center provides multidisciplinary team support for health, emotional, and social needs of victims

(Office of Women’s Affairs and Family Development, 2008). The Thai government passed a law to protect victims of violence in 2007. However, research on IPV that was conducted in several settings and populations after the campaigns of the government still showed a high prevalence of

IPV, indicating that IPV is still a significant problem in Thailand.

As mentioned earlier, the prevalence of IPV in Thailand changed vastly over the time, the prevalence was tiny in 1985 and grew to more than 40% in 2005. It can be assumed that many

Thai women experienced IPV, but they did not disclose the problem with outsiders. Thai culture encouraged gender bias, and Confucianism, collectivism, as well as self-reliance have been rooted deeply in Thai society. Hence, victims keep silent to save face for herself and her family.

According to Thailand’s policies on prevention of violence against women, awareness rising is the one strategy that has been used to eliminate violence against women. Her Royal Highness

Princess Bajrakitiyabha Mahidol of Thailand, the Goodwill Ambassador of the United Nations

Development Fund for Women (UNIFEM) in Thailand, launched the UNIFEM campaign in

2009 to ‘Say No to Violence against Women,’ which is to promote public awareness of IPV. The

22 campaign has used all sources of media to raise awareness of violence against women and the main message of the campaign is VAW is not a private issue. After launching this campaign, victims of violence may disclose their situation and seek help.

Thai Culture Influencing IPV

The literature review involving Thai culture influencing IPV included the following aspects: (a) family, (b) religiosity, (c) alcohol, (d) media, and (e) barriers to seeking outside help.

Family

The problem of IPV in Thai culture must be established within the context of family

(Kerley et al., 2010). Thai culture continues to emphasize patriarchal values and reinforces traditional gender roles within the context of family (Hoffman, Demo, & Edwards, 1994).

Furthermore, Confucianism that emphasizes “close family ties, hierarchy and order,” and does not stress “independence and autonomy” (Ho, 1990, p.133) has spread its root deeply in Thai culture (Zhang & Cartwright, 2009). In addition, Thai culture stresses “macho” characteristics in its male population. It is culturally acceptable for Thai men to have sex with women before getting married and for men to have sexual intercourse with women who are not their wives. In contrast, the above-mentioned activities are taboo for Thai woman. Navaboonniyom (2001) found that if the wife had extra-marital sex, there was an enormous stigma attached, while if the husband had extra-marital sex, the wife blamed herself. Premarital or extramarital sex was a clear-cut double standard which still exists among Thai men (Hoffman, Demo, & Edward, 1994).

Traditionally, the model and the ideals that have been instilled in young Thai women about being a “good wife” teaches the responsibility, first and foremost, to take care of their entire family. Preserving family well-being and saving family face are regarded as more important than the happiness of an individual (Ho, 1990). Keeping family harmony and concern

23 about self behind those of their family were highly valued (Ho, 1990; Kerley et al., 2010). On the basis of these values, many Thai women defined IPV as a family and private matter, and admitting IPV to an outsider results in not only loss of face but also a certain amount of shame

(Costa & Matzner, 2002). To maintain family harmony, women abused by their husbands are expected to tolerate their husbands’ behavior. Also, divorce or separation was found to be unacceptable and stigmatizing for women because married life is accepted in Thai culture and women are expected to be married and be mothers rather than have careers and independence

(Hirschman & Teerawichitchainan, 2003; Ruangjiratain & Kendall, 1998; Stalker, 2006). The women who want to divorce their husbands will be questioned by society more than men

(Boonmongkon et al., 2005). The idea and acceptance that a woman must have only one husband; while a man may have many divorces and remarriages was presented in Sricumsuk’s study (2006). One of her participant stated that

In Thai culture, if we are separated, women are always the ones who are blamed and

stigmatized as “Mae Haang” or “Mae Mai” (a widow). This stigma makes us like a bad

person. Also, some people in the community perceive that domestic violence is a husband

and wife matter so they do not bother to help, but at the same time these people say that it

is the women who choose so they cannot help. If women do not choose to leave the

husband, they have to be patient for the sake of family and children (p.132).

Another confirmation that Thai women strongly believe in having one husband only was found in Asssavarak’s study (2007). A participant stated that “To accept violence is better than to divorce” (p.8).

The Thai metaphor that a husband is the forelegs and a wife is hind legs of the elephant is a deeply embedded belief of Thai women. Specifically, the wife as hind legs must follow the

24 course charted by her husband and support her family from the back. The Thai husband is always considered to be the head and master in the family; whereas the ideal wife subordinates her needs and desires without condition in order to serve her husband. In other words, the wife must be obedient to her husband and defer any authority and major decision making to her husband

(Coyle & Kwong, 2000).

Thai women are expected to display submissive and passive characteristics. The wife must take the traditional role responsibility for household chores and child care (Hoffman et al.,

1994). Some Thai women see themselves “actualizing their potential and demonstrating their ability only through marriage and childbearing” (Coyle & Kwong, 2000, p. 497). In the meantime, Thai men are expected to be the stronger sex and exhibit domineering traits and are not expected to engage in household chores and child care (Gray & Punpuing, 1999;

Lertsrisantad, 2004). When the men believe that they are the head of the household and their wives are the caretakers and mothers, they are the dominant partners in the marital relationship.

As a result, some men believe that they can violate their wives who cannot meet their demands and expectations (Sricamsuk, 2006) and can violate their wives as a form of discipline

(Sripichyakan, 1999 as cited in Costa & Matzner, 2002).

In the Ayutthaya period (1351-1767 A.D.), Thai laws gave husbands the right to have many wives; simultaneously, women were allowed only one husband and were criticized and looked down upon if they did not follow this law. If a wife had an affair with another man and her husband found out, he had the legal right to kill her without receiving any punishment. Yet, wives who found their husbands to have an affair with another woman had no legal rights to file for divorce (Kaewfun, 2007). Also, the law allowed a husband to physically abuse his wife. If the husband decided that his wife was guilty of wrongdoing, he had the right to beat her as

25 punishment, after which the wife could not take any action against him (Kaewfun, 2007). Esterik

(2002) presented that feudal law in the Ayutthaya period distinctly defined women as personal property of their husbands or their fathers and husbands and they could sell the women into slavery. The men had the rights over their women until 1867 (Esterik, 2002). In the early

Rattanakosin period (1782-1851 A.D.), The Three Seals Law, which was passed in 1805, still continued the legal rights of husbands to have power over their wives. The wives were private property of their husbands who could manage their wives’ money and land as well as bestow punishment on them, including killing. Later, the above-mentioned laws were canceled, and The

Domestic Violence Act A.D. 2007 was enacted. However, even now, many Thai women are submissive to their husbands and unaware of their rights.

Overall, the idea of the ideal family may be deeply rooted in Thai women’s belief. Thai women who feel that the meaning of life is to play traditional wife and perfect mother roles, and that divorce or separation would be the major stigma of their life, may approve of their subservience without any questions and stay with their abusive partner. Staying with abusive partners leads to the accepting of the unexpected outcome of IPV.

Religiosity

Buddhism is the dominant religion in Thailand and has a deep role in forming attitudes and identity of Thais (Limanonda, 1995). Approximately 95% of Thais are Buddhist

(Assanangkornchai, Conigrave, & Saunders, 2002). Although Buddhism is not the direct cause of IPV, some tenets of Buddhism promote gender inequality that may be a leading factor encouraging IPV in Thailand. Buddhism, like Hinduism, considers women submissive to men

(Niaz, 2003 cited in Boonmongkon et al., 2005). For example, ordination or becoming a monk is an easy way to earn merit and to repay a debt of gratitude to parents and only men can perform

26 an ordination (Limanonda, 1995; Stalker, 2006). Women are not permitted to take part in this important traditional practice in Thailand. Moreover, interpretation of Buddhism's gender hierarchy represents women as inferior citizens to their male counterparts. Buddhism certifies that men are the most important individuals in the family (Boonmongkon et al., 2005).

Thai Buddhists strongly believe in reincarnation, karma, merit, and sin

(Assanangkornchai et al., 2002; Coyle & Kwong, 2000; Davidson, Connor, & Lee, 2005;

Mishra, 2010). The following are definitions of the above words in Buddhism: (a) reincarnation is defined as “rebirth in new bodies or forms of life” (Davidson et al., 2005, p.121); (b) karma means “action “or “doing” in the Sanskrit word, and the law of karma refers to the way of cause and effect that bring about inevitable results in either this current life or a reincarnation; (c) merit means “spiritual credit held to be earned by performance of righteous acts and to ensure future benefits”; and (d) sin is defined as an offense against religious or moral law. In the reincarnation belief, accumulated merit in one’s present life affects the next life (Davidson et al., 2005;

Merriam-Webster, 2009). If a woman wants to earn merit, she must do everything for her man and her children (Coyle & Kwong, 2000). To reproduce, fulfill domestic duties, and encourage a son to become a monk are the ways that they believe they will yield merit (Coyle & Kwong,

2000). Interestingly, Buddhists believe that bad karma causes a person to reincarnate as a woman

(Khuankaew, 2002). Before gaining enlightenment, women must be reborn as men and as a result, a number of women Buddhists accept a poor self-image, lower worth in society, and feel second-class regarding their spiritual being (Loy, 2008).

Law of Karma in Buddhism may help people to change both their attitudes and behaviors to distasteful conditions and to accept challenges (Mikulas, 1983). Abused wives believed that their bad karma resulted from a previous life and they were suffering IPV at the hands of their

27 husbands in their present life as a result (Assavarak, 2007). For example, Assavarak (2007) quoted one of the women who believed in karma as saying, “I accept that it is destiny. It cannot be changed. I have to pay for what I had done in a previous life” (p. 11). Bhuyan, Mell, Senturia

Sullivan, and Shiu-Thornton (2005) found that Buddhist Khmer women were to be patient and endure abuse from their partners according to their karma. Subsequently, abused women may accept violence in their relationship and stay with their abusive partner due to their view of bad karma.

Buddhism dictates principles of responsibility, compassion, and taking care of others

(Hoffman et al., 1994). The principle of Buddhism seeks to encourage family well-being rather than supporting violence and emphasizes that spouses should take care of each other (Coyle &

Kwong, 2000). A married couple can maintain or cherish the family’s harmony by accepting the roles of husband role and wife. The leading role as the master of the family is given to the husband, while the subservient role as caretaker and mother is played by the wife (Hoffman et al., 1994). They also state that a “wife shows respect for her husband in the symbolic way by not suggesting her superiority in either action or speech” (p. 79). The role of Buddhism in family life presented above encourages gender bias and inequality.

Buddhism is not the cause of IPV, but some aspects of Buddhism promote gender inequality, a leading factor in encouraging IPV. Moreover, victims of IPV who accept gender as bad karma may tolerate abusive relationships and stay with abusive partners who may endanger their lives.

Media

That exposure to violence in movies, on television, and in video games increases the risk of violent behavior has been well documented and exposure to media violence affects viewers in

28 the short and long term (Huesmann, 2007). Although media is not a direct contributing factor of

IPV, it is an important factor influencing attitudes on acceptance of IPV. According to Malamuth and Check (1981), male subjects’ acceptance of interpersonal violence significantly increased when exposed to films portraying violent sexuality. Exposure to sexually explicit media violence increased male viewers’ acceptance of rape, shaped unconcerned attitudes toward abused women, and produced desensitization to sexual violence (Allen, Emmers, Gebhardt, & Giery,

1995). With regard to exposure to media violence by women, the results were similar to male participants. Krafka, Linz, Donnerstein, and Penrod (1997) found that exposure to sexually explicit violent stimuli increased desensitization and rated the stimuli as less degrading to women. Women reported more emotional involvement after viewing a date rape film than did men. Wilson, Linz, Donnerstein, & Stipp (1992) stated that women in general would process the movie content carefully and therefore be more affected emotionally. Women were taught by media portrayals and social norms to self- silence and to put the needs of self behind their partners (Flood & Pease, 2009). Leaving an abusive relationship can be difficult for women due to the influence of mass media showing male domination, female submission, and “happy endings” to stories that portrayed IPV (Carden, 1994).

In Thailand, dramas are one of the most popular television genres, most being broadcast during prime time. A survey of violence in television dramas on five free TV channels in 2009 by Media Monitors (under the support of Thai Health Promotion Foundation) found that the prevalence of psychological violence, physical violence, and sexual violence presented in television dramas (N = 113) was 90% (n = 90), 82% (n = 93), and 40% (n = 46), respectively.

This violence, as well as structural violence, was displayed in all of television dramas (Thai

Health Promotion Foundation, 2009). References to violence or sex, or content that was insulting

29 to some group or other, was found in every program aired between 4 p.m. and 10 p.m. throughout August of 2005 (Kanchanachitra, 2009). Furthermore, the expansion of television dramas has promoted the cultural idea of female submissiveness (Keesbury, 2003).

Today, media presenting sexual references and male-centered pornography, which may encourage viewers to have sex, are easily accessible in the form of soap operas, pornographic

VCDs, music videos, cartoons, advertisements, and websites, and can encourage viewers to perform sexually risky behaviors (Kanchanachitra, 2009). According to an Assumption Business

Administration College (ABAC) pollon February 2009, 13% of secondary school students have had sex and 10% of them admitted that pornography and sexually explicit movies on VCDs and on the internet had incited them (Kanchanachitra, 2009). O-Prasertsawat and Petchum (2004) found that 58% of secondary school students in Bangkok use the internet to view pornography and 66% were exposed to sexually explicit content via the internet. As a result, the children can become victims of sexual violence and cause them to act out sexually against other children

(Polpinij, Sibunruang, Paungpronpitag, Chamchong, & Chotthanom, 2009). Even if pornography is free of physical and sexual violence, there remains degrading or dehumanizing acts and verbal psychological abuse considered to be verbal violence (Jarvie, 1991). Additionally, Malamuth,

Addison, & Koss (2000) found an association between sexual violence and pornography in some men. Although the media is not the leading factor to influencing IPV, it is factor encouraging acceptance of IPV. The media can make perpetrators and victims feel indifferent to violence.

Frequent exposure to violence in the media can cause desensitization and make it seem more acceptable in society.

Alcohol

Alcohol can seriously impair an individual’s functioning in many roles including being a spouse, partner, parent, and a contributor to household functioning (World Health Organization,

2004). Many studies show that alcohol consumption is related to IPV and alcohol has been confirmed to be a significant risk factor for IPV (Cunradi, Caetano, & Schafer, 2002; Golding,

1999; Schafer, Caetano, & Cunradi, 2004; M. P. Thompson & Kingree, 2006; Walton-Moss,

Manganello, Frye, & Campbell, 2005). A study in the United States that reported data from 501 men and 1,756 women who had experienced an IPV physical assault revealed that those whose partners had been drinking were significantly more likely to be injured than those whose partners had not been drinking (M. P. Thompson & Kingree, 2006). Alcohol consumption may increase the heated arguments between spouses to levels that are unmanageable, leading to violence (A.

Stickley, Timofeeva, & Sparen, 2008).

With regard to alcohol consumption in Thailand, adult consumption of pure alcohol per capita increased from 0.26 liters per year in 1961 to 8.47 liters per year in 2001(World Health

Organization, 2004). Alcohol is broadly used in Thailand and is an important part of family celebrations and ceremonies including ordination and funerals (Newman, Shell, Li, & Innadda,

2006). In 2010, Thavorncharoensap et al. found that 31% of Thai adults were classified as drinkers. A study conducted in Thailand revealed a strong association between domestic violence and alcohol use (Kongsagon, 2008). The study indicated that families with a drinking member(s) reported nearly four times higher risk for family violence. The first population-based survey conducted in Thailand found that 30% of women in Bangkok who suffered from IPV were abused when their partner was drunk and that alcohol was the leading cause of IPV reported by

31 women in other provinces, where 41% of abused women were beaten when their partners were drunk (Archavanitkul et al., 2005).

Drinkers are often incapable of controlling their emotions and physical behavior; therefore, a loss of control allows men who used alcohol to assault their wives. At that time, abusers feel as if they could excuse their abuse by saying that they were not acting as themselves

(Kaewfun, 2007). The men were more likely to violate their partners when drunk because they feel that most people will forgive them (Kaewfun, 2007). In this way, alcohol may act as a cultural enabler of antisocial behavior (Jewkes, 2002). This situation was supported by the Thai proverb that says “never believe a mad man, never blame a drunk.” This reflects the view of Thai society that the actions of the men who drink should be forgiven or at least accepted as uncharacteristic of them (Kaewfun, 2007). Thai social norms suggest that drunken abusers should not be blamed or punished because they are not conscious of their battering. This is the main reason why wives still live with their partners because they believe that the abusive husband may have a problem with alcohol (Easton et al., 2007 as cited in Assavarak, 2007). The occurrence of IPV when a man is drinking is rationalized through cultural norms for drunken behavior, not by the pharmacological effects of alcohol (Eng, Li, Mulsow, & Fischer, 2010;

Källmén & Gustafson, 1998). At present, IPV continues to be a problem in Thai society, and will continue until drinking men battering their partners is seen as avoidable acts of violence.

Barriers to Seeking Outside Help

IPV is regarded as a private issue and family matter in several countries including

Thailand (Kaewfun, 2007; Rennison & Walchans, 2000; A. Stickley, Kislitsyna, Timofeeva, &

Vågerö, 2008). Moreover, the IPV problem is viewed as a non-serious one (Thajeen, 2002 as cited in Sricamsuk; 2006). Reported examples of people in Thailand who consider IPV as a

32 private and family matter include an abused wife, policemen, health care professionals, social workers, and the village headman, who is the person elected to administer a single village (Saito,

Cooke, Creedy, & Chaboyer, 2009; Wongsuriyasak, 2009). IPV is seen as a personal problem and a non-serious problem and has been supported in a study by Sricamsuk (2006). Results showed that more than 70% of Thai women participants reported the following barriers to violence disclosure: (a) IVP seen as a private issue, (b) IPV seen as a family affair/private issue,

(c) thought IPV not serious enough, (d) felt shame to ask for help, and (e) believed that no one could help (Sricamsuk, 2006). Correspondingly, in research findings of Archavanitkul et al.

(2005), the majority of participants viewed IPV as a private matter and an ordinary matter in a relationship; that couples quarrelling once in a while was normal. Some male participants believed that women must have done something wrong to motivate her husband’s violence and the abused women were blamed.

The culture value of collectivism is the one barrier of seeking help for victims of IPV.

Thai society is characterized as collectivism, which is a cultural value that encourages harmony and obedience within the group. Thus, Thais wish to avoid conflict, fear to lose face, hesitant to engage in direct confrontation with misunderstandings, and tend to use collaborative strategies when facing conflicts (Callister & Wall, 2004; M. R. Yoshioka & Choi, 2005). Thai women experiencing IPV with tight collectivism values always remain silent and do not to seek help due to the shame of telling other people (Sricumsuk, 2006). The research findings that emerge from

Sricomsuk’s study are similar to those found in Shen (2011). Shen found that in the collective of

Chinese culture, victims of IPV keep silent and forego seeking help because of personal and family shame.

Women who lack of a support system is hard for her to seek help. In a study in the United

States by Felson, Messner, Hoskin, and Deane (2002), abused women were found to be less likely to call the police because of their fear of reprisal, their desire to protect abusive partners, and their privacy concerns. The abused women reported battering situations to the police, but the police did not arrest or charge abusive partners. The police tended to help couples reconcile instead of prosecuting their abusers. Officers’ misunderstandings about the legal rights of victims and officers’ own viewpoints regarding IPV as a family matter and a personal problem influences this behavior. In a study in Thailand by Kaewfun (2007), many women who reported

IPV to police return the following day to request that the police do not arrest their abusive husbands. For example, when a participant reported her IPV to the police, they did not help her because it was “. . . a private problem and sooner or later the participant and her partner would be good to each other” (Saito et al., 2009). Ekachai (2003), Assavarak (2007), and Han and

Resurreccion (2008) stated that participants in their studies reported that police did not do anything when victims reported their abuse situation. Assavarak (2007) presented the following situation, “Once, I called the police, but they did nothing. So my friend took me to the hospital.

My arm was broken and my eye was green” (p. 9). Han and Resurreccion (2008) quoted a victim as saying, “I went to the police once to ask for help. They said they couldn’t intervene in family affairs. They told me that if I couldn’t fight him, I should run and hide, and wait for him to cool down. They did not help me at all” (p.1). Because the police did nothing in the above examples, abused wives were forced to go back to abusive relationships. Victims reporting their husbands to police can lead them to be angry and more violent (Assavarak, 2007).

In Thailand, specific laws have been passed to protect women from IPV, yet there are many difficulties in implementing them. This includes The Domestic Violence Act B.E. 2550

34 within the National Police Bureau. Narongsak (2009) reported that there were problems with the implementation, including (a) definition and interpretations of the Act, (b) the officers hold negative attitude and were lacking in expertise, (c) female law enforcement officers were rare,

(d) all of victims were not informed about the Act, (e) victims refused to give some information to male officers, and (f) the public did not understand the value of the Act. Recommendations were made for the agencies to improve the effective applicability of the Act, educate the public on the value of the Act, and improve the knowledge and awareness of human rights for women protected under the Act.

Wife abuse manifested as IPV is viewed as a personal issue and family matter and victims and officers who are involved with IPV consider this as a non-serious problem. Most of the perpetrators’ behaviors were found to be condoned by their wives and were not punished by legal officers. This dire situation of IPV in Thailand may continue and escalate unless cultural changes are enacted.

Relationships between Self-Esteem, Acceptance of Violence, Exposure to Violence, Fear,

and IPV

Self-Esteem and IPV

It is not entirely clear whether low self-esteem causes IPV or low self-esteem is a negative consequence in a battering relationship. However, the relationship between self-esteem and IPV is well established (Aguilar & Nightingale, 1994; Cascardi & O'Leary, 1992; Foa et al.,

2000; Hotaling & Sugarman, 1986). Self-esteem has been shown to be associated with adverse psychological outcomes, such as depression, in IPV survivors (Cascardi & O'Leary, 1992).

Furthermore, women with poor self-esteem may be more likely to be victims of IPV because they feel they deserve such violent behaviors (Stets, 1991). Women with low self-esteem may

35 experience tolerance for abusive relationships and low self-esteem may contribute to the difficulty for victims of IPV to leave an abusive partner or to terminate a battering relationship

(Aguilar & Nightingale, 1994; S. F. Lewis & Fremouw, 2001).

In regard to the association between self-esteem and IPV, there are several studies to support that self-esteem may have caused and predicted IPV (Burke, Stets, & Pirog-Good, 1988;

Hotaling & Sugarman, 1986; O'Keefe & Treister, 1998; Stets, 1991). O’Keefe and Treister

(1998) conducted a cross-sectional study to explore the predictors of victimization for boys and girls within dating relationships. The participants were 385 boys and 554 girls who studied at a public school in the Los Angeles area. The results showed that self-esteem (β = .08, p = .03), ethnic identification (β = -.11, p = .005), justification of violence (β = .12, p = .000), number of partners (β = .12, p = .002), relationship conflict (β = -.12, p = .01), seriousness of relationship (β

= .09, p = .03), interpersonal control (β = -.11, p = .005), community violence (β = .12, p = .006), and perpetration of dating violence (β = .54, p = .000) were the predictors of female victimization. Further support for direct effects of self-esteem on IPV was provided by Burke et al. (1988). They conducted a cross-sectional study to explore the roles of gender identity and self-esteem in physical and sexual violence in dating relationships. The participants included 298 women and 207 men and were selected by random sampling from 56 upper-level classes at a large Midwestern university. The results for self-esteem revealed that it directly affected sustained sexual abuse (β = -.18, p < .001), but did not affect physical violence toward women.

Similarly, Stets (1991) found that low self-esteem affected sustained psychological violence

(Tobit coefficient = -.241, p < .05) after controlling for interpersonal control.

Regarding the relationship between IPV and self-esteem, Jezl, Molidor, and Wright

(1996) examined the rates of victimization by physical, psychological, and sexual abuse in

36 adolescents dating relationships with 114 male subjects and 118 female subjects. The researchers found that self-esteem and psychological maltreatment in dating relationships had a significant association for women (r = -.28, p = .002).

Hotaling and Sugarman (1986) reviewed 97 risk factors of IPV by using 52 case- comparison studies as data. Risk factors were categorized into four groups including (a) consistent risk, (b) inconsistent risk, (c) consistent nonrisk, and (d) risk markers with insufficient data. For classification of risk markers, those that were measured in at least three studies and were able to predict direction of IPV in at least 70% of studies were identified as consistent risk,

31% to 69% in the predicted direction in at least three studies were identified as inconsistent risk, less than 30% in the predicted direction in at least three studies were identified as consistent nonrisk. Self-esteem was determined as an inconsistent risk for predictive IPV. Of five studies, three showed a significant negative relationship between self-esteem and IPV (Hartik, 1978;

Hudson & McIntosh, 1981; Hofeller, 1980 as cited in Hotaling & Sugarman, 1986), and two found a non-significant negative relationship (Lopez, 1981; Telch & Lindquist, 1984 as cited in

Hotaling & Sugarman, 1986). Hotaling and Sugarman (1990) revealed that self-esteem was not likely to be a risk factor of wife abuse when they used the data from the National Family

Violence study in 1975 (n = 699). Numerous findings have revealed that low self-esteem was an adverse psychological health consequence of IPV (Aguilar & Nightingale, 1994; Cascardi &

O'Leary, 1992; M. M. Haj-Yahia, 2000; Tuel & Russell, 1998). For example, Aguilar and

Nightingale (1994) conducted a comparative study to examine the self-esteem between abused women who sought help through various family violence and sexual assault programs (N = 48) and non-abused women who were randomly sampled from the general hospital (N = 49). The results revealed that the abused women were significantly lower in self-esteem scores than those

37 of non-abused women. Also, emotional/controlling abuse and miscellaneous abuse score were predictors of self-esteem, R2 = .24, t = -2.34, p = .02, b = .409; t = 2.45, p = .02, b = .369, respectively.

Cascardi and O’Leary (1992) conducted a cross-sectional study with 33 currently abused women who sought help from the Nassau County against Domestic Violence Association to assess the relationship of IPV, depression, and self-esteem. The investigators found that self- esteem contributed a more unique variance in IPV than depression by using multiple regression analyses (R2 combined = .369, R2 after depression removed = .323). Approximately one-third

(32%) of the variability of self-esteem was predicted by physical violence. The limitations of this study were a small sample size and all participants were self-reported victims of IPV.

Another comparative study collected data from 17 heterosexual victims of IPV and 23 lesbian women with results revealing that almost two-thirds (63%) of the variance in the depression score and half (51%) of the variance of self-esteem were predicted by the variance of the gender of the batterers, demographic data, and IPV. By using hierarchical regression to compute the partial correlation of the independent variables, the findings suggested that physical abuse was a significant predictor of IPV and non-physical abuse was a significant predictor of self-esteem (Tuel & Russell, 1998). In contrast, Lewis et al. (2006) conducted a study with 102 women in an emergency domestic violence shelter to examine the effects of child and adult abuse and psychological adjustment. The researchers found no relationship between frequency of physical abuse and self-esteem (r = -.389, p = .706).

It is difficult to determine whether low self-esteem causes IPV or whether low self- esteem results from IPV due to the lack of longitudinal studies. In addition, the results above did not consistently demonstrate that self-esteem was predictive of IPV. Although self-esteem and

IPV have been examined in several studies, almost all of the studies were cross-sectional and had self-reported data, a small sample size, and utilized non-random sampling. The relationship between self-esteem and IPV from available studies cannot be generalized to the population at large. However, the majority of evidence favors a relationship between self-esteem and IPV.

Taking into account those issues, low self-esteem may have a significant direct negative effect on pregnant Thai women’s experience with IPV. Hence, it is essential to explore how self-esteem plays a role in IPV/domestic violence among pregnant Thai women.

Acceptance of Violence and IPV

Constructs of acceptance of violence have been studied for more than two decades.

Gracia and Herrero (2006) stated that the social enviroment reflect on whether or not violent behaviors were acceptable or unacceptable. General attitudes of acceptance of violence may indicate a community context. Sampson and Lauritsen (1994) found that those community contexts “…seem to shape what can be termed cognitive landscapes or ecologically structured norms (normative ecologies) regarding appropriate standards and expectations of conduct” (p.

63). Gracia (2004) described that societal attitudes influence a climate of tolerance and acceptability of IPV, and as a result, victims of IPV may not disclose or leave violent relationships and perpetrators may not receive any social stigma. Robertson and Murachver

(2009) noted that an important step to eliminate the cycle of violence within the home is to identify attitudes of male- and female-perpetrated IPV because societal attitudes shape reactions of victims, perpetrators, and communities to IPV.

Negative consequences of IPV have been acknowledged. Nevertheless, acceptance of violence in intimate relationship is widely and strongly justified. The acceptance of violence is strong in many countries; perhaps due to the social acceptance of violence in a specific culture or

39 country (Dhaher, Mikolajczyk, Maxwell, & Krämer, 2010). For example, findings from a study by Dhaher et al. (2010) reported that of the participants, 85% of women in Zambia and 65% of women in West Bank, Palestine accepted violence in an intimate relationship. Rani and Bonu

(2009) conducted a survey with 121,461 women and 9,942 men from seven countries in Asia

(Armenia, Bangladesh, Cambodia, India, Kazakhstan, Nepal, and Turkey). The results revealed that acceptance of wife beating ranged 29% to 56% in women, while the range of acceptance was 27% to 56% in men. Another study estimated between 24% and 36% of 507 Chinese,

Korean, Vietnamese, and Cambodia adults living in the U.S. accepted wife abuse (M. R.

Yoshioka, DiNoia, & Ullah, 2001). Marshall and Furr (2010) collected data with 8,075 Turkish women and reported that 41% of participants agreed with justification for violence under certain conditions, such as burning the food, arguing with her husband, and refusing intercourse. Most participants named multiple conditions in which violence toward the wife was justified.

In Bangladesh, 94% of women and 92% of men approved of at least one circumstance of wife beating, including the refusal to have sex with her husband, going out without permission, and disobeying (S. R. Schuler & Islam, 2008). In the WHO multi-country study, the percentage of women who could justify one or more circumstances where wife beating was accepted varied greatly between 5% in Serbia and Montenegro and 94% in Ethiopia province (Garcia-Moreno, et al , 2005). More than two-thirds (68%) of women in Bangladesh, Peru, Ethiopia, Samoa,

Thailand, and the United Republic of Tanzania accepted wife beating for one or more circumstances. Recently, Uthman, Lawoko, and Moradi (2010) used meta-analysis to synthesize the results from the Demographic and Health Survey (DHS) of 17 countries in sub-Saharan

Africa and found that women were more likely to accept wife beating than men (OR = 1.97, 95%

CI [1.53-2.53]).

Acceptance of violence has been recognized as one of the leading predictors of IPV perpetration (Hanson, Cadsky, Harris, & Lalonde, 1997; S. M. Stith, Smith, Penn, Ward, & Tritt,

2004; S. M. Stith & Farley, 1993; Sugarman & Frankel, 1996). However, research that has been focused on correlations of IPV victimization and acceptance is less extensive and the results are also ambiguous. Several studies that investigated the relationship between IPV and acceptance of violence were found in the literature. Boyle, Georgiades, Cullen, and Racine (2009) examined area patterning of IPV of 68,466 married women in India and focused on attitudes to mistreatment, women’s education, and living standards at individual and community levels. The results revealed that acceptance of mistreatment was a significantly positive association with IPV at individual levels (OR = 1.324, 95% CI [1.283, 1.366]) and at community levels (OR = 1.225,

95% CI [1.108, 1.354]). Similarly, Gage and Hutchinson (2006) used multilevel modeling to determine the risk of sexual abuse among 2,240 married or cohabiting women aged 15-49 years in Haiti. The researchers presented that the wife’s approval of wife beating under specific conditions significantly affected sexual abuse (E = 0.88, SE = 0.20, p < .001). These results are consistent with those of Smith (1990) and O’Keefe and Treister (1998) in that the results revealed that approval of violence against women was a significant predictor of IPV ( E = 0.44,

SE = 0.10, p = .00; β = .12, p = .000, respectively). Faramarzi, Esmailzadeh, and Mosavi (2005) conducted a case-controlled survey with 2,000 women who attended a public health center at

Bobal University of Medical Sciences in Iran to examine the general attitudes of acceptance of male dominance and IPV. The researchers reported that women with positive attitudes toward male dominance were at increased risk of physical abuse (OR = 4.8, 95% CI [2.9, 8]) compared with women who had a negative attitude toward male dominance. These same women had significantly lower acceptance or tolerance of physical, psychological, and sexual violence than

41 did the women with positive attitudes toward male dominance (p < .05). This study implied that a woman’s attitude toward male dominance affected acceptance of violence and IPV.

Klomegah (2008) conducted a cross-sectional study to investigate the correlation between

IPV and demographic and socioeconomic status with 4,731 women in Zambia. The findings for the acceptance of wife beating revealed that women who had a positive attitude about wife beating under the certain condition of going out without telling husband were at 1.62 (p < .001) times the risk of abuse than were women with a negative attitude about wife beating.

Hindin, Kishor and Ansara (2008) analyzed data from the following 10 Demographic and

Health Surveys: Bangladesh (2004), Bolivia (2003/2004), the Dominican Republic (2002), Haiti

(2005), Kenya (2003), Malawi (2004), Moldova (2005), Rwanda (2005), Zambia (2001/2002), and Zimbabwe (2005/2006). The report focused on predictors and health outcomes related to women’s experiences of IPV. The results for acceptance of violence and victimization of IPV revealed that women in four countries (the Dominican Republic, Malawi, Zambia, and

Zimbabwe) who accepted that wife abuse was justified were at a greater risk of physical or sexual violence in their current marital relationship. The adjusted odds ratio ranged from 1.37 in

Zimbabwe to 1.97 in the Dominican Republic, p < .05. However, the relationship between acceptance of violence and the experience of sexual or physical abuse was not positive in six countries. In this study, the percentage of women who agreed that wife beating in one or more than one circumstance ranged from 29% in Moldova to 59% in Bolivia.

Inconsistent results about the association between acceptance of violence and IPV were presented in Clark, Hill, Jabbar, and Silverman (2009). They found that no relationship existed between acceptance of violence and IPV during pregnancy. Women who were accepting of violence were not at an increased risk of violence (OR = 0.97, 95% CI [0.42, 2.27], p = .95).

Furthermore, this study found that occurrences of IPV during pregnancy were not statistically different between women who were accepting of IPV and women who were not accepting of

IPV (p = .19) (Clark et al., 2009). The results that emerged from above study resembled those in

Reilly, Lott, Caldwell, and DeLuca (1992). Reilly et al. found that rape myth acceptance was not a predictor of female sexual victimization in a dating relationship.

It has been recognized that acceptance of violence is associated with the experiencing of

IPV. However, it is difficult to interpret the direction or the causal ordering of the association between the attitude of acceptance of violence and experiencing of IPV because of lack of longitudinal studies. Experiencing IPV may change a woman’s attitude from IPV as acceptable to unacceptable, and if women who justify wife beating as acceptable experience IPV themselves, they may be more likely report the experience. The majority of evidence favors an attitude of acceptance of violence as a risk factor or a predictor of IPV. Due to the lack of research about the direction between the acceptance of violence and the experiencing of IPV among pregnant women in Thailand, and due to the research findings about IPV during pregnancy being inconsistent with the broader IPV literature, the researcher examined the direction between both variables to clarify what role of the attitude of acceptance of violence plays in Thai society.

Exposure to Violence and IPV

Edelson (1999) stated that exposure to violence is composed of direct and indirect forms.

Exposure to violence in the study focused on exposure to family violence including direct

(experiencing of physical, psychological, or sexual violence) and indirect exposure (witnessing of physical or psychological interparental violence). Riggs, Marie, and Street (2000) suggested that one of the strong factors influencing victimization was the observing of violence in the

43 family. Victims of IPV frequently came from abusive homes (Auerbach Walker & Browne,

1985; L. E. Walker, 1981), because children who grew up in violent homes may continue to repeat this behavior as adults (Chambliss, 2008). A proposition of learning theory explains that learned maladaptive beliefs, attitudes, and behaviors may result from child abuse (Wheeler &

Berliner, 1988 as cited in Messman & Long, 1996). Women whose mothers were abused may perceive that women are men’s victims and may learn that the male partner in their life will abuse them as well, translating to an increased risk for revictimization of women who experience interparental violence (Herman, 1981). Also, experienced physical or sexual child abuse may be related to insufficient skills of self-protection, impairment of self- worth, and accepting violence as part of being women (Auerbach Walker & Browne, 1985). In further support for female revictimization, Cappell and Heiner (1990) found that women who grew up within a violent family “may be provoking their own victimization in their current families” (p. 130) to repeat violent behavior that occurred and was learned when they were young (as cited in Lee, 2003).

The association between witnessing and experiencing violence during childhood and IPV victimization has been documented for more than ten years. Hotaling and Sugarman (1986) conducted a comprehensive review and found that the only consistent risk factor for female victimization was witnessing violence as a child. They found a significant positive relationship in

11 of 15 studies. In a cross-sectional study with 1443 women who sought medical care in South

Carolina, Coker, Smith, McKeown, and King (2000) found that women whose father physically or emotionally abused their mother were at an escalated risk of physical and sexual abuse

(adjusted OR = 3.5, 95% CI [ 2.6, 4.8]), physical abuse (adjusted OR = 2.5, 95% CI [1.8, 3.5]), and emotional abuse (adjusted OR = 1.8, 95% CI [1.3, 2.6]) after adjusting for insurance status.

In a population-based study in Vietnam researchers also found similar results: woman who

44 witnessed physical interparental violence as a child were at a significant increased risk of life time physical/sexual violence (OR = 2.85, 95% CI [1.88, 4.34]) and/or physical and sexual violence in the past year (OR = 2.33, 95% CI [1.31, 4.15]) (Vung & Krantz, 2009). In a cohort study that used two time survey with adult members (4,674 women and 3,955 men) of Kaiser

Health Plan, Health Appraisal Center (ACE), in San Diego County, Whitfield, Anda, Dube, and

Felitti (2003) reported that childhood physical violence and childhood sexual violence elevated risk of victimization among women (adjusted OR = 2.4, 95% CI [1.9, 3.2] and adjusted OR =

1.8, 95% CI [1.4, 2.8], respectively). Women who had a battered mother had a two-fold risk of victimization (adjusted OR = 2.0, 95% CI [1.5, 2.7]). The research findings demonstrated in the above studies was comparable to numerous other studies (Bensley, Van Eenwyk, & Wynkoop

Simmons, 2003; Jeyaseelan et al., 2007; Kerley et al., 2010; Kimerling, Alvarez, Pavao,

Kaminski, & Baumrind, 2007; Schewe, Riger, Howard, Staggs, & Mason, 2006; Simonelli,

Mullis, Elliott, & Pierce, 2002).

With reference to association between child abuse and victimization during pregnancy,

Clark et al. (2009) conducted cross-sectional study with 517 Jordanian women who attended family planning and protection clinic. The researchers reported that pregnant women with exposure to violence in childhood were at aggravated risk for violence during pregnancy (OR =

3.90, 95% CI [1.78, 8.57]). The results that emerged from Clark et al.’s study were similar to that in Casto, Peek-Asa, and Ruiz (2003). The study examined data from 914 pregnant women in health clinics in Mexico. Physical and emotional abuse in women’s childhood increased the risk for violence during pregnancy by almost three times (PR = 2.33, 95% CI [1.70, 3.19] and PR =

2.75, 95% CI [2.14, 3.53]) (Casto, Peek-Asa, & Ruiz, 2003).

In contrast, Hotaling and Sugarman (1990) used the data of the female respondents to

National Family Violence data in 1975 to perform a secondary analysis. They reported that witnessing and experiencing parental violence as a child did not significantly identify IPV victims. They argued that the effect of witnessing violence may be confounded with other risk factors such as marital conflict. Eng, Li, Mulsow, and Fischer (2010) examined the effects of family violence, including experiencing and witnessing physical abuse on IPV, with 1,707 married Cambodian women by using structural equation modeling. The result revealed that family violence was a predictor of psychological violence (β = .19, p < .05). Ernst et al. (2007) conducted a cross-sectional cohort study with 280 adult patients who were treated in an emergency room during 46 randomized four-hour shifts. The results revealed that there was no relationship between witnessing of violence during childhood and adult victimization, but experiencing violence as a child were positive to IPV (OR = 9.1, 95% CI [4.2, 19.6]).

The relationship between exposure to violence – composed of witnessing of violence and experiencing of violence during childhood – has been examined in many countries and various ethnic groups. However, the results were inconsistent between exposure of violence and adult victimization. In Thailand, there was one study that using a sample of married women in

Bangkok to explore the exposure to family violence in childhood and intimate partner victimization or perpetration (Kerly et al, 2010). However, no study could be found that studied exposure to family violence and IPV in pregnant Thai women, so this study filled the gap in knowledge.

Fear of Partner and IPV

Fearfulness and coercion within marital relationships may lead to IPV because a male partner who has ability to cause fear can create greater dominance and control in the relationship

(Ulloa, Baerresen, & Hokoda, 2009; Wekerle & Wolfe, 1999). Also, the feeling of fear and lack of control may be related to the expectancy of being abused. As a result, maladaptive responses to dangerous situations, such as reacting to a threat and assessing of violence, may occur. A recent representative study on self-reported fear with 9,687 men and 13,903 women in New York revealed that 2.7% of women and 2.2% of men reported fear of a partner (Olson et al., 2008). A prospective pregnancy cohort study with 1,507 women in Australia revealed that nearly one-fifth

(19%) reported being in fear of an intimate partner, and women who had fear of a partner were at increased risk of urinary incontinence, fecal incontinence, vaginal bleeding, anxiety, and depression compared with pregnant women who had never been in fear of their partner (Brown et al., 2008).

In addition, fear may make women more vulnerable to control and violent relationships

(Ulloa et al., 2009). The research that explored the above issues was done by Stith, Smith, Penn,

Ward, and Tritt (2004). They conducted a meta-analysis using 85 studies to identify risk factors and to calculate the composite effect size for IPV victimization and perpetration. The researchers reported women’s fear of partners was a risk factor for female victimization of physical abuse across five studies (N = 4,388) and the composite effect size was .27, p < .001. Ulloa, Jaycox,

Marshall, and Collins (2004) suggested that fear within dating relationships was a potential predictor of violence. Women who felt fear in a dating relationship had less knowledge about dating violence (r = -.32, p < .001). Further supportive evidence was found in Ulloa et al. (2009), who found that recent fear of dating violence directly affected violence victimization (β = .471, p

< .001).

Dearwater et al. (1999) collected data from 4,641 women attending 11 community emergency departments (ED) in Pennsylvania and California. The researchers found that fear of

47 a partner or ex-partner was strongly associated with past-year and life time IPV (OR = 17.6, 95%

CI [13.6, 22.7] and OR = 29.9, 95% CI [19.7, 45.2], respectively). Hammoury et al. (2009) investigated the factors associated with IPV among 351 pregnant Palestinian women in Lebanon.

The results showed that fear of husband or someone else in the house was related to IPV during the women’s marital life (OR = 5.05, 95% CI [2.26, 11.28]) and within the past year (OR = 2.65,

95% CI [1.34, 5.25]), but not during pregnancy. Hynes, Ward, Robertson, and Crouse (2004) studied 365 East Timor women and found that women who were afraid of their husbands were five times more likely to experience physical and verbal abuse and eight times more likely to experience sexual abuse in the past year than women who were not afraid of their husbands. The findings from the above three studies were similar to that of Bradley, Smith, Long, and O’Dowd

(2002). They found that women who reported that they sometimes or often times feared their husbands were 32 times more likely to experience violent incidents by their partner than women who did not report fearing their husbands (OR = 32, 95% CI [17, 64]). Stith, Smith, Penn, Ward, and Tritt (2004) conducted a meta-analysis using 85 studies to identify risk factors and to calculate composite effect size for IPV victimization and perpetration. They reported fear was a risk factor for female victimization of physical abuse across five studies (N = 4,388) and composite effect size was .27, p < .001.

Victim’s fear is a predictive of recidivism or repeated instances of IPV (N. Z. Hilton et al., 2004; N. Z. Hilton & Harris, 2005; Zarza, Ponsoda, & Carrillo, 2009). Fear of partner as a predictor of recidivism is important because most of the victims of IPV experienced violence more than one time. In a retrospective cohort study with 3,568 women in the U.S., 67% of physical abuse victims, 54% of sexual abuse victims, 74% of threat/anger victims, and 97% of controlling behaviors victims had from two to more than 50 experiences of abuse (R. S.

Thompson et al., 2006). With regard to the relationship between fear and wife assault recidivism,

Hilton et al. (2004) reported that there was a relationship between fear and repeated episodes of

IPV (r = .14, p < .01). Further confirmations of the relationship between fear and IPV were found by Sackett and Saunders (2001) and Van Hightower and Gorton (1998). Fear of a partner was associated with a significant positive relationship on amount of violence (r =. 42, p < .001)

(L. A. Sackett & Saunders, 2001). Relationships were found to exist between fear of a partner and frequency of abuse (rho = .44), and fear of a partner had a significant association with the occurrence of abuse, (rho = .50) (Van Hightower & Gorton, 1998).

Fear of a partner was strongly associated with both the severity and frequency of IPV.

Fear may serve as a predictor of IPV, recidivism, or lethality, or it may identify the level of severity in the past. No studies were found in the Thai literature associating fear and IPV and none with pregnant Thai women. It is important to know whether or not fear plays a role in Thai culture and IPV due to the potential development of effective intervention programs to eliminate

IPV.

Exposure to Violence and Fear

Children exposed to violence as a child may suffer a wide range of physical, psychological, and interpersonal difficulties that may persist into adulthood (Runyon, Deblinger,

Ryan, & Thakkar-kolar, 2004). Fear is a common consequence related to exposure to violence during childhood. Davis and Petretic-Jackson (2000) noted that some victims of childhood sexual abuse were extremely fearful and distrustful of men, women, and relationships. This study showed that the fear and anxiety of child abuse victims was associated with a lack of control, and can be explained by a Traumagenic Dynamic Model. This model explains that child sexual abuse creates traumatic sexualization, stigmatization, betrayal, and powerlessness and four traumagenic

49 models lead to negative behavior. Not surprisingly, victims of child abuse are more likely to harbor chronic feelings of anxiety and fearfulness. They may feel a sense of betrayal, insecurity, and mistrust toward adults who are usually seen as trustworthy and protective (J. N. Briere &

Elliott, 1994; Davis & Petretic-Jackson, 2000) and victimization may obstruct a child’s developing belief in safety and a sense of security (J. Briere, 1992).

Cohen, Deblinger, Maedel, and Stauffer (1999) conducted a comparative study with 30 victims of childhood sexual abuse who attended the Center for Children’s Support in New Jersey and 30 non-abused children who attended a general pediatric clinic in New Jersey. They found that victims of childhood sexual abuse had high levels of anxiety and fearfulness compared with non-abused children. Women who experienced sexual abuse as a child reported significantly higher levels of phobic anxiety, hostility, psychoticism, somatization, paranoid ideation, depression, and psychological distress compared with women who did not report such abuse (M.

M. Haj-Yahia & Tamish, 2001).

Ulloa et al. (2009) conducted a cross-sectional study with 327 undergraduate women from an urban southern California university and found that child abuse directly affected a fearful dating experience, β = .243, p < .001. Leeb, Barker, and Strine (2007) examined the relationship between child abuse and weapon carrying with 3,487 students in a survey of high risk youth. The results revealed that victims of child sexual abuse were 1.90 times as likely to report weapon carrying (Adjusted OR = 1.90, p = .002), suggesting that exposure of violence was associated with vulnerability, feelings of trauma, and powerlessness. Fear of revictimization led to the need of protection by a weapon.

Based on the literature reviewed above, the exposure to violence has demonstrated predictive fear. However, no study about fear and the exposure to violence was found in the Thai literature. This research examined the relationship between fear and exposure to violence.

Fear Mediating Exposure to Violence and IPV

Only one study was found that examined fear as mediating exposure to violence and IPV.

Ullao et al. (2009) found that fear was a mediator in child sexual abuse victimization and relationship violence victimization. The relationship between child abuse and fear with a dating experience was significant, β = .243, p < .001, and the relationship between fear with a dating experience and violence victimization was significant, β = .471, p < .001. The researchers suggested that the findings were congruent with that of Ronfeldt, Kimerling, and Arias (1998).

That is, the experience of fear and deference that may develop from maladaptive relationships can cause relationship violence victimization. The findings support the idea that relationship between fear and victims of dating violence may be bidirectional (Riggs & O'Leary, 1989).

Specifically, women who were in a violent relationship were more likely to feel fearful of their partners and feelings of fear may make women more vulnerable to controlling and violent dating relationships. Victims of child abuse who did not solve their fear problem may be faced with maladaptive responses to threatening or frightening situations in adolescents or adulthood. These victims may be at an increased risk of revictimization.

Even though only one study could be found on fear mediating exposure to violence as a child and dating violence victimization, the findings suggest that fear is strongly associated with experience of IPV and exposure to violence was significantly related to fear. The exposure to violence may have an indirect effect on a pregnant woman’s IPV through fear. This relationship was examined in this research.

Relationships between Self-Esteem, Acceptance of Violence, and Exposure to Violence

Self-Esteem and Acceptance of Violence.

Self-esteem influences human behavior (M. Rosenberg, 1989) and many studies support that low self-esteem shapes externalizing and deviant behaviors and delinquency (Baumeister,

Campbell, Krueger, & Vohs, 2003; M. Rosenberg, Schooler, & Schoenbach, 1989). MacDonald,

Holmes, and Murra (1997 as cited in Ali and Toner, 2001) explained that the attitude toward violence was influenced by self-esteem and an individual who had a high level of self-esteem was less likely to accept wife abuse. Burke et al. (1988) viewed a determinant of accepting aggression to be low self-esteem. The finding emerged that self-esteem had a direct negative effect on acceptance of aggression for women and men who had sustained abuse (β = -.20, p <

.01 and β =-.16, p <. 01, respectively). Ali and Toner (2001) conducted a cross-sectional study to examine attitudes toward wife abuse and self-esteem in 20 Muslim men and 20 Muslim women in Canada. The result showed that self-esteem and acceptance of violence was a significant negative correlation (r = -.42, p < .01) after controlling for gender. They found that self-esteem and acceptance of violence had a significant negative correlation for men (r = -.39, p < .01) and women (r = -.54, p < .01). Inconsistent results about the association between self-esteem and acceptance of violence were obtained by O’Keefe and Treister (1998). For women, there was no relationship between self-esteem and acceptance of violence, while self-esteem in men was found to be related to acceptance of male to female violence (r = .13, p < .05) and acceptance of female to male violence (r = .13, p < .05). As mentioned above, relationships between self- esteem and acceptance of violence have been explored in several studies, however, the results were not consistent and it is difficult to make a strong connection between self-esteem’s relationship to the acceptance of violence. This relationship needs for further study.

Self-Esteem and Exposure to Violence

Numerous studies have demonstrated a relationship between exposure to violence and self-esteem. Low self-esteem in women who were exposed to violence may result from a feeling of stigmatization that is a negative psychological consequence of childhood abuse (Messman &

Long, 1996) and stigmatization decreases the sense of self value and self worth. Low self-esteem is linked to stigmatization, with victims defining themselves as “spoiled merchandise,” due to the negative attitude to abuse victims (Finkelhor & Browne, 1985). This association between self- esteem and exposure to violence was found in many studies. Jumper (1995) conducted a meta- analysis to examine the association between childhood sexual abuse and adult psychological adjustment as measured by self-esteem, depression, and psychological symptoms using 26 published studies. The meta-analysis showed significant heterogeneity among effect size estimates. For self-esteem, the total sample size was 2,362 subjects and the overall effect size estimate was .17 across 12 studies.

Lewis et al. (2006) conducted a study with 102 women in an emergency domestic violence shelter to examine the effects of child and adult abuse and psychological adjustment.

They found that childhood emotional abuse and emotional neglect in childhood was related to adult self-esteem (r = -.398, p < .001). Results from Burke et al. (1988) and O’Keefe and Treister

(1998) revealed that parental abuse was related to adult self-esteem (r = -.28, p < .01; r = .18, p <

.001, respectively). In addition, Briere (1990) conducted a retrospective study with 227 female undergraduate students using random selection to examine childhood abuse including sexual, physical, and psychological abuse and psychological dysfunction including self-esteem, sexual behavior, and aggression. Canonical correlation was used to analyze the data. The results showed two independent relationships in the data; r 1c = .36, F (9,659.69) = 5.71, p ≤ .001; r 2-3c = .20, F

(4,544.00) = 2.85, p ≤ .024. The second test should not be interpreted as most researchers do not interpret it when r c < .30. Canonical correlation equation was:

(-.03) x child sexual abuse + (-.21) x child physical abuse + (-.91) x child

psychological abuse = (-.79) x self-esteem + (-.28) x sexual behavior + (-.18) x

aggression.

When meaningful canonical coefficient was ≥ 40, the findings were interpreted that childhood psychological abuse was correlated to adult self-esteem (J. Briere & Runtz, 1990).

The findings from multiple studies consistently demonstrated that self-esteem was related to childhood exposure to violence. However, no study was found that looked at the association between self-esteem and exposure to violence during childhood in pregnant Thai women. The relationship warranted investigation in this population.

Acceptance of Violence and Exposure to Violence

In the past two decades, a number of research studies have been conducted investigating the relationships between exposure to violence and acceptance of violence. Theoretically, learning behavior can be used to explain an association between exposure to violence and acceptance. Such violence as a normal part of family life may be perceived by women who witnessed parental violence; as a result women tend to have higher acceptance of violence (Vung

& Krantz, 2009). Cognitive schemas are developed and constructed early in life by individual’s experience (Ponce, Williams, & Allen, 2004). Constructive Self Development Theory (CSDT) that explains trauma creates negative, over-generalized, disrupted schemas that are possible links to explain why women experiencing or witnessing violence during childhood accept an abusive relationship. A person with distorted schemas and distorted beliefs about abuse may have an

54 increased risk of negative psychological and behavioral outcomes, including acceptance of violence (Ponce et al., 2004).

With regard to studies that focused on exposure to violence and acceptance of violence,

Ponce and associates (2004) conducted a cross-sectional study with 315 female and 118 male undergraduate students at a northeastern university in the U.S. to explain the relationship among child maltreatment, which included sexual abuse, punishment, and negative home atmosphere, distorted schemas, and acceptance of violence. The results revealed that (a) men reported more acceptance of violence than women did, (b) acceptance of violence was associated with child maltreatment (r = 0.15, p < .01), (c) child maltreatment directly affected violence acceptance (R2

= .02, β = .15, p < .01), and (d) child abuse was not significantly indirect effect acceptance of violence through cognitive distortions. The standardized coefficient for child abuse to violence acceptance was β = -.02, p > .05 and for child abuse to cognitive distortions was β = .45, p <

.001. Riggs and O’Leary (1996) studied 232 undergraduate female and 113 undergraduate male students from a university in the U.S. to test a predictive model for dating violence using structural equation analysis. All participants were recruited via advertisement. The investigators found that the witnessing of interparental violence directly affected the acceptance of violence during a dating relationship (β = 23, p < .05), but being a victim of physical violence during childhood was not a significant direct effect to violence acceptance for women (β = .12, p > .05).

For men, witnessing and experiencing violence during childhood was not a significant direct effect to violence acceptance (β = .19, p > .05 and β = .18, p > .05, respectively). One of the strengths of this study is that the investigators assessed the attitude toward three types of violence: verbal, sexual, and physical. Lawoko (2006) found a significant association between history of abuse as a child and acceptance of violence among women in Zambia (OR = 1.66,

95% CI [1.34, 2.07]). Khawaja, Lions, and El-Roueiheb (2008) reported that Palestine women who had never been abused were significantly less likely to support acceptance of violence (OR

= 0.52, p < .01).

In a cross-sectional, population-based study, Vung, and Krantz (2009) sampled 730 married women ages 17-60 years in northern Vietnam and found that 16% of participants reported witnessing interparental violence. Women who witnessed interparental violence during childhood reported acceptance of wife beating to a higher extent than women who did not witness violence between parents. Of women who witnessed interparental violence, 34% reported acceptance of violence related to the statement “not completed housework satisfactorily” while 19% of women with no such experience accepted this statement. This study, however, did not establish association between child abuse and violence acceptance.

Inconsistent results about the relationship between child abuse and violence acceptance was obtained by O’Keefe and Treister (1997). The investigators found that interparental violence during childhood and parent–child abuse did not have a significant correlation with acceptance of violence (r = .08, p > .05 and r = .03, p > .05). Although links exist between exposure to violence that include experiencing abuse and witnessing abuse during childhood and a later acceptance of violence, the results are inconsistent. This could be the result of different definitions of violence during childhood and acceptance of violence. Moreover, dating relationship violence and marital relationship violence is not significantly consistent across groups in the population.

Relationships between IPV and Maternal Health

Experiences with IPV in the past and/or during pregnancy associated with numerous adverse health consequences for women and their unborn babies have been well documented.

Physical and mental health problems, negative health behaviors, and pregnancy complications are negative maternal health outcomes that may result directly or indirectly from IPV (A. L.

Coker et al., 2004). The literature review involving IPV affecting adverse consequences included: (a) pregnancy complications; (b) physical health problems; and (c) mental health problems.

Pregnancy complications.

There are many research studies whose findings imply a direct link between IPV and pregnancy complications. With regard to associations between IPV and pregnancy complications, Silverman, Decker, Reed, and Raj (2006) conducted a population-based study among 118,579 women giving birth in 26 U.S. states between 2000 and 2003 to examine the relationships of IPV in the year before and during pregnancy with maternal and neonatal health.

The results showed that women who reported IPV one year before pregnancy were at greater risk for high blood pressure or edema (adjusted OR = 1.37-1.40), vaginal bleeding (adjusted OR =

1.54 -1.66 ), severe nausea, vomiting, or dehydration (adjusted OR = 1.48-1.63), diabetes

(adjusted OR = 1.39-1.48), kidney infection or UTI (adjusted OR = 1.43-1.55), premature rupture of membrane (adjusted OR = 1.30-1.62), placenta problems (adjusted OR = 1.37), preterm labor (adjusted OR = 1.58), and related hospitalization or ER visit before delivery

(adjusted OR = 1.45-1.48) than women who did not report IPV. Women who experienced IPV during pregnancy but not before pregnancy had a 1.35-fold increase risk of preterm labor, 1.90- fold increased risk of severe nausea, vomiting, or dehydration, 1.64-fold increased risk of UTI, and 1.32-fold increased risk of related hospitalization.

Kim, Cain, and Viner-Brown (2010) conducted a cross-sectional study with 5,662 women during 2004-2007 collecting data using the Rhode Island Pregnancy Risk Assessment

Monitoring System (PRAMS) and included IPV before or during pregnancy. The results showed that 5.5% of participants reported physical IPV before and/or during their most recent pregnancy.

These women who experienced IPV were at elevated risk for vaginal bleeding (adjusted OR =

1.7, 95% CI [1.2, 2.4]), urinary tract infection (adjusted OR = 1.8, 95% CI [1.3, 2.5]), severe nausea, vomiting, or dehydration (adjusted OR = 2.0, 95% CI [1.5, 2.8]), preterm labor (adjusted

OR = 1.7, 95% CI [1.3, 2.4]), and premature rupture of membrane (adjusted OR = 1.8, 95% CI

[1.2, 2.8]) after adjusting for socio-demographic factors (maternal age, race, ethnicity, marital status, household income, and educational level.

Another retrospective population-based study was conducted utilizing 4,833,286 hospital discharge records that were linked to birth and death certificates in California from 1990 to 1999

(El Kady et al., 2005). The investigators found that 0.04% of women were hospitalized after sustaining abuse during pregnancy. Abused women delivering after the assault were at increased risk of maternal death (OR = 19.0, 95% CI [2.7, 144.7]), premature birth (OR = 2.4, 95% CI [1.8,

3.3]), uterine rupture (OR = 46.0, 95% CI [6.5, 337.8]), and infections (OR = 2.0, 95% CI [1.2,

3.4]) compared with non-abused women. Women abused during the prenatal period who gave birth at a later hospitalization had higher rate of maternal death (OR = 3.9, 95% CI [0.5, 28.38]), abruption (OR = 1.8, 95% CI [1.3, 2.5]), infection (OR = 1.68, 95% CI [1.35, 2.08]), and premature rupture of membrane (OR = 1.63, 95% CI [1.19, 2.24]) compared with pregnant women who did not sustain abuse.

In addition, a prospective cohort study was conducted in the U.S. with a sample size of

1,203 African American, Hispanic, and White women (J. McFarlane et al., 1996). The investigators found that the prevalence of abuse during pregnancy was 16% and abuse during

58 pregnancy was associated with increased risk of low maternal weight gain (RR 1.6, 95% CI [1.2,

2.3]), infections (RR 1.6, 95% CI [1.2, 2.1]), and anemia (RR 1.6, 95% CI [1.2, 2.1]).

Sanchez et al. (2008) conducted a case-controlled study to test the relationship between

IPV and risk of preeclampsia among 339 Peruvian women, finding that women reporting IPV were at increased risk for preeclampsia (adjusted OR = 2.4, 95% CI [1.7, 3.3]) compared with those not reporting IPV. Rachana, Suriaya, Hisham, Abdulaziz, and Hai (2002) examined the association between self-reported physical violence and fetal-maternal complications and birth outcomes with 7,105 pregnant women in Saudi Arabia from 1996 to 1999. The researchers found that pregnant women who reported physical violence were at an elevated risk for kidney infection (OR = 2.3, 95% CI [1.3, 2.5]), premature labor (OR = 3.4, 95% CI [1.4,2.8]), abruption- placenta (OR = 3.3, 95% CI [0.8, 5.5]), trauma due to blow/kick to abdomen (OR = 24.6, 95% CI

[1.9, 220.2]), and antenatal hospitalization (OR = 1.5, 95% CI [1.1, 2.0]) compared with non abused women. Bacchus, Mezey, and Bewley (2004) conducted a cross-sectional study with 200 women aged 16 and over between July 2001 and April 2002 in a London teaching hospital.

Women reporting IPV were at significant risk of combined obstetric complications (OR = 3.6,

95% CI [1.6, 8.2]).

With regard to research that focused on IPV and antepartum hemorrhage, Moraes,

Reichenheim, and Nunes (2009) gathered data from 528 women who gave birth at one of three public maternity wards in Rio de Janeiro, Brazil. The results showed that women who experienced severe physical violence were at greater risk of vaginal bleeding during pregnancy

(OR = 2.74, 95% CI [1.37, 5.48]) compared with those who did not. Similarly, a larger population based-study examined the data from 4,750 women giving birth in Vancouver and

British Columbia between January 1999 and December 2000. The results showed physical

59 violence was related to elevated risk of antepartum hemorrhage (adjusted OR = 3.79, 95% CI

[1.38, 10.40]) (Janssen, 2003).

Pregnancy complications caused by IPV can be devastating and take their toll on pregnant women who were victims of IPV. Pregnancy complications resulting from IPV have been examined in many studies. Based on the research that was reviewed above, IPV is significantly associated with numerous pregnancy complications; however, the research findings are not consistent across all studies. Only preterm labor, kidney infection or urinary tract infection, severe nausea or vomiting, and related hospitalization were found to be significantly associated with abuse among women who experienced IPV before and during pregnancy in all studies reviewed (El Kady et al., 2005; Janssen, 2003; Kim, Cain, & Viner-Brown, 2010; J.

McFarlane et al., 1996; Moraes, Reichenheim, & Nunes, 2009; Rachana, Suraiya, Hisham,

Abdulaziz, & Hai, 2002; Sanchez et al., 2008; Silverman et al., 2006).

Table 2.1 Pregnancy Complications in Victims of IPV

Pregnancy Complications Silverman, El Kady, et Janssen, et al Mc Farlance, et al (1996) Rachana,et al Sanchez, et Moraes, et al Kim,et al et al (2006) al (2005) (2003) (2002) al (2008) (2009) (2010) a b c d b a b b b b e Preterm labor S S S S S NM NM S NM NM S High blood pressure , edema or S NS NM NM NM NM NM NM S NM NM preeclampsia Vagina Bleeding S S S S S NS NS NM NM S S Placenta problems S NS S S NM NM NM S NM NM NM Severe nausea, vomiting, or S S NM NM NM NM NM NM NM NM S dehydration Diabetes S NS NM NM NM NM NM NM NM NM NM Kidney infection or UTI S S NM NM NM NM NM S NM NM S Premature rupture of membrane S NS S S NM NM NM NM NM NM S Incompetent cervix NS NS NM NM NM NM NM NM NM NM NM Related hospitalization or ER S S NM NM NM NM NM S NM NM NM visited Maternal death NM NM S S NM NM NM NM NM NM NM Infection NM NM S S NM NS S NM NM NM NM Low maternal weight gain NM NM NM NM NM S S NM NM NM NM Anemia NM NM NM NM NM NS S NM NM NM NM Note: a= Experience of IPV before pregnancy. b= Experience of IPV during pregnancy. c= Assault at Delivery. d= Prenatal Assault. e= Experience of IPV before or during pregnancy. NM= not measured in study. S= significant (p<.05), relative risk or odd ratio higher than 1. NS = not significant

Physical health problems.

IPV is a significant direct and indirect risk factor for physical health problems (J. C.

Campbell, 2002). There are many studies focused on the associations between IPV and physical health consequences. Campbell and collogues (2002) found that poor general health, headaches, back pain, sexually transmitted diseases, vaginal bleeding, vaginal infections, pelvic pain, painful intercourse, urinary tract infection, loss of appetite, abdominal pain, and digestive problems were more frequently reported by women who experienced IPV. Coker, Smith, and Fadden (2005) conducted a cross-sectional survey in the U.S. with 1,152 women aged 18-65 years who attended family practice clinics from 1997 to 1998 to examine the types of disabilities among IPV victims

(including physical, psychological, and sexual abuse) compared with non-abused women. The investigators found that women with current and past IPV were more likely to report any disability preventing work (adjusted OR = 1.9-3.2), generalized chronic pain (adjusted OR = 2.5-

2.8), nervous system disorder (adjusted OR = 2.2-5.4), respiratory problems (adjusted OR = 1.5-

3.1) epilepsy or migraines (adjusted OR = 1.1-3.2), chronic disease (adjusted OR = 1.5-2.5), autoimmune condition (adjusted OR = 1.3), and blindness or glaucoma (adjusted OR = 3.3-10.6).

However, women with current IPV had a stronger association with disability by category except generalized chronic pain than those with past IPV.

Coker and associates (2002) analyzed data from the National Violence against Women

Survey (NVAWS) of women and men aged 18-65 who were sampled by a random-digit-dial telephone survey (N=16,006) to assess relationships between IPV, including physical, psychological, and sexual abuse, and physical and mental health among victims. The result showed that women who were victims of IPV were at greater risk of poor health (adjusted RR ranged 1.5 to 2.1), chronic disease (adjusted RR ranged 1.2 to 1.6), and injuries (adjusted RR

62 ranged 1.6 to 2.8) after adjusting for age, race, insurance status, and childhood physical and sexual abuse.

McCauley et al. (1995) conducted a cross-sectional study in primary care setting with

1,952 women to identify clinical characteristics that related to IPV by using a self-administered anonymous survey. The results showed that abused women had more physical symptoms than women who were never abused when the patient’s age was controlled (McCauley et al., 1995).

These included loss of appetite (OR = 3.5, 95% CI [ 2.3, 5.1]), frequent or serious bruises (OR =

3.4, 95% CI [2.2, 5.2]), nightmares (OR = 3.2, 95% CI [2.1, 4.8]), vaginal discharge (OR = 2.9,

95% CI [ 2.0, 4.1]), eating binges (OR = 2.9, 95% CI [1.8, 4.8]), diarrhea (OR = 2.6, 95% CI

[1.8, 3.7]), broken bones (OR = 2.5, 95% CI [1.5, 4.2]), pelvic pain (OR = 2.5, 95% CI [1.7,

3.6]), fainting (OR = 2.4, 95% CI [1.4, 4.1]), stomach pain (OR = 2.4, 95% CI [1.7, 3.5]), breast pain (OR = 2.5, 95% CI [1.5, 3.2]), severe headaches (OR = 2.2, 95% CI [1.5, 3.2]), problem passing urine (OR = 2.2 95% CI [1.3, 3.8]), chest pain (OR = 1.9, 95% CI [1.3, 2.8]), and insomnia (OR = 1.7 95% CI [1.1, 2.4]).

Ruiz-Pérez, Plazaola-Castaño, and del Río-Lozano (2007) investigated the associations between IPV and physical health by using bivariate and multivariate analysis on data from 1,402 randomly selected women who visited 23 family practice offices in Spain from May to October

2003. Women who experienced any type of IPV were at greater risk of physical disease (OR =

1.16, 95% CI [0.87, 1.55]), hypertension (OR = 1.03, 95% CI [0.62, 1.70]), asthma (OR = 1.30,

95% CI [0.37, 2.17]), and other diseases (OR = 1.30, 95% CI [0.92, 1.83]) compared with women who reported no experience of IPV (Ruiz-Perez, Plazaola-Castano, & del Rio-Lozano,

2007).

Table 2.2 Physical Symptoms and Chronic Diseases in Victims of IPV

Symptoms Campbell Coker et Coker et McCauley Ruiz- Bonomi et al( al.(2005) al.(2002) et al. Perez et et al 2002) (1995) al (2007) (2006) Poor general health problem S S S S NM S Headaches S S NM S NM NM Back pain or chronic neck pain S S NM NS NM NM Sexual transmitted disease(STD) S S NM NM NM NM Vagina bleeding S NM NM NM NM NM Vagina infection S NM NM S NM NM Pelvic pain S S NM S NM NM Painful intercourse S NM NM NM NM NM Urinary tract infection S S NM S NM NM Loss of appetite S NM NM S NM NM Abdominal pain S S NM S NM NM Digestive problem S S NM S NM NM Fainting NS NM NM S NM NM Seizures, epilepsy, migraine NS S NM NM NM NM Fibroid NS S NM NM NM NM High blood pressure NS S NM NM S NM Cold or flu NS NM NM NM NM NM Asthma or respiratory problem NM S NM NM S NM Diabetes NM NS NM NM NS NM Physical disease or injuries NM NM S S S NM Blindness or glaucoma NM S NM NM NM NM Chronic disease( hypertension, NM NM S NM NM NM heart disease, diabetes, arthritis, asthma, and cancer NM= not measured in study. S= significant (p<.05), relative risk or odd ratio higher than 1. NS = not significant

The above studies clearly indicate that victims of IPV are at increased risk for diverse physical health problems. Consistently, poor general health outcomes, headache, sexually transmitted diseases, vaginal infection, urinary tract infection, physical disease or injuries, asthma or respiratory problem, digestive problem, abdominal pain and loss of appetite were found to be significantly associated with IPV in all studies where symptoms were measured.

Physical health problems were significantly elevated among victims of physical, psychological, and sexual violence. Physical health problems may serve as potential indicators of past or current

IPV.

Psychological health problems.

Battered women often develop mental disorders (Stein & Kennedy, 2001). The impact of

IPV lingers on and results in depression and posttraumatic stress disorder (PTSD) among victims of IPV (Amaro et al., 1990; Golding, 1999; Pereira, Lovisi, Pilowsky, Lima, & Legay, 2009) .

Additionally, IVP results in depression and PTSD (J. C. Campbell, 2002). A number of studies have examined IPV in association with depression and PTSD. For instance, in Golding’s (1999) meta-analysis, the results showed that the mean prevalence of depression and PTSD among abused women was 47.6% and 63.3%, respectively. The prevalence of depression ranged between 10.2% to 21.3% and PTSD rates ranged from 1.3% to 12.3% amongst general population. The weighted mean odds ratio relating IPV to depression was 3.8, 95% CI [3.16,

4.57] across 18 studies and PTSD was 3.7, 95% CI [2.1, 6.8] across 11 studies.

Rodriguez et al. (2008) conducted a cross-sectional study among 210 pregnant Latina women at a prenatal clinic in Los Angeles to examine the relationship between IPV and PTSD or depression. Findings reported that pregnant women who had experienced IPV were at greater risk of depression after adjusting for age, language of interview, and site effects (OR = 2.43, 95%

CI [1.16, 5.11]) than women who did not experience of IPV. Pregnant women who were positive for IPV and had experienced more than 2 traumas were had significantly more PTSD symptoms

(OR = 5.97, 95% CI [1.25, 25.8]) and greater depression symptoms (OR = 6.31, 95% CI [2.44,

16.30]) compared to pregnant women who were negative for IPV and had not experienced trauma or had experienced fewer than two traumas.

Lee, Pomeroy, and Bohman (2007) used structural equation modeling to test a hypothesized model for examining the mediating effects of social support and coping on the association between IPV - physical abuse, physical abuse, sexual abuse and injuries - and

65 psychological outcomes which were depression and PTSD with 100 Caucasian women and 61

Asian women. For combined-group analysis, the level of IPV had no significant direct effect on psychological health (β = 0.10, p > .05). However, the level of IPV indirectly affected psychological outcomes through coping and social support. For a separate group analysis, there was a direct effect of the level of IPV on psychological outcomes for Asian women (β = 0.72, p

< .05), but there were no effect for Caucasian women (β = 0.09, p > .05).

A representative sample of 6,451 American women from the National Survey of Families and

Households (NSFH) who were married or cohabitating was used to examine the relationship among IPV, psychological functioning, psychological factors, and gender. With regard to the relationship between the degree of physical violence and depression, the investigators found that the degree of physical violence was significantly associated with depression scores, F(8, 6283) =

104.25, β = 0.61, p < .0001 by using regression and controlling for all demographic data. At a five-year follow-up, the relationship between IPV and a range of psychological outcomes among women who reported or denied IPV at wave one was examined. IPV at wave one significantly related to the wave two depression score F(1, 10, n = 3,104) = 15.18, β = 6.96, p = .003 after controlling for age and depression at wave one (C. Zlotnick, Johnson, & Kohn, 2006).Women who experienced IPV were at greater risk for long term depression and more excessive degrees of depression. The limitation of the study was that hitting, shoving, and throwing things by the partner were the only behaviors of physical violence that were included. Additionally, IPV was significantly associated with minor and severe depression in women who experienced IPV for greater than five years and women who experienced IPV longer than five years prior to the study

(Bonomi et al., 2006).

A population-based study was conducted with 2,400 women in Yokohama, Japan aged

18-49 years to examine the relationship between health indicators and IPV in a stratified cluster sample. The study found relationships between IPV and 9 of 11 health indicators among women who experienced emotional abuse (adjusted OR ranged 1.35 to 2.15) and women who reported emotional abuse plus physical or sexual abuse (adjusted OR ranged 1.52 to 5.04). Women who reported emotional abuse plus physical or sexual abuse were at greater risk of a number of distress symptoms (adjusted OR = 2.13, 95% CI [1.67, 2.72]) and suicidal ideology (adjusted OR

= 5.04, 95% CI [3.24, 7.83]) after adjusting for age, relationship status, number of children, education, and socioeconomic status compared to women who reported no IPV. Those who experienced only emotional abuse reported significantly higher suicidal ideology (adjusted OR =

2.15) and a greater amount of distress (adjusted OR = 1.60) (Yoshihama, Horrocks, & Kamano,

2009).

Research has consistently demonstrated a strong association between mental health problems and both short- and long-term exposure to IPV. In addition, IPV directly affected mental health issues, especially depression and PTSD. There were inconsistent results across ethnic groups, which could be related to cultural norms or stigmas.

Philosophy Underpinning the Current Study

The goal of philosophy helps humans understand themselves within a world which is controlled by traditional science (Polifroni & Welch, 1999). Meanwhile, the goal of knowledge development in the nursing discipline strongly emphasizes improved patient care by integrated theory and practice (Polifroni & Welch, 1999). Van de Ven (2007) state that the underlying of research is a philosophy of sciences that enlighten scholars “of the nature of phenomenon examined (ontology) and methods for understanding it (epistemology)” (p. 36). Philosophical

67 perspectives are patterns of beliefs and practices (Weaven & Olson, 2006). Understanding philosophical tradition is helpful to describe suitable areas of study, pose and address proper questions, and to choose appropriate methodological frameworks for research (Geanellos, 1997;

Polifroni & Welch, 1999). Furthermore, the meanings, logical relations, and consequences of observation and theoretical statements are construed by philosophy (Van de Ven, 2007).

The assumption and underpinnings of the post-positivism perspective and feminist theory fitted perfectly well to make the investigator understand the current study. The post-positivism is recognized as a suitable philosophy for nursing research, where studies require “systematically collected and analyzed data from representative samples, technical knowledge about specific intervention, and predictive theories for at-risk individuals and population” (Bunkers, et al, 1996;

Horsfall, 1995; Norbeck, 1987 cited in Weaven & Olson, 2006, p. 461). The current study applied post-positivism to understand the phenomenon since the primary concern of post- positivism is that reality exists, but reality cannot be completely known or completely predicted because of the complexity of human phenomena (Weiss, 1995). The research was guided by a methodology that included research design, research goal, objectivity, hypothesis testing, systematic inquiry, and measurements.

A post-positivism perspective guided measurement in the study by allowing the researcher to be concerned about validity, reliability, and sensitivity of the instrument.

Additionally, the hypotheses were tested by using statistics and generalized findings that were dependent on the context. As mentioned above, this study principally aimed to determine the potential factors influencing IPV such as low self-esteem, high acceptance of violence, high exposure to violence and high fear of partner that may influence IPV among representative

68 sample of pregnant women in Thailand. The secondary goal was to determine the effect of IPV on adverse maternal health among a representative sample of pregnant women in Thailand.

Feminist theory considers IPV as an expression of structural society that sanctions male domination and maintains gender bias (Dobash & Dobash, 1979). In the patriarchal societies, gender relations were created and held by male domination of women. Men use male-female abuse to express power over women (Dutton & Nicholls, 2005). Also, there is an acceptance that men have greater power both in families and in society and as a result, the culture of acceptance of violence is higher (Chen & White, 2004). Feminist empirism rejects social bias such as sexism and androcentrism, therefore, this paradigm is aimed to making change to eliminate gender bias in the existing social and science system. The feminist empirism point of view provided much more focus about the ignored issue of women, the silencing of women voices, and the denial of women’s experiences, and raises women’s issues to be more important in Thai society.

Moreover, the feminist perspective encouraged the consideration of ethical issues, with which the researcher was concerned during the research processes.

Conclusion

Post-positivism and feminism were philosophical perspectives that were suitable for understanding the study. The epistemology of post-positivism supported the use of experiments, observation and non-observation to attain knowledge. The post-positivist approach was objectivist and subjectivist. The methodology that was appropriate for the current research was of a quantitative design because it had potential to provide the evidence those made research findings more efficient and more effective. Another perspective assumption, feminist philosophy, provided the way of women- centered in order to conduct the research based on rights and dignity of women groups. Also, the impact of research finding may lead to ways for

69 changing women’s lives. The combination of the two philosophies helped to create an effective nursing research design that may lead to the improvement of the health of women.

Summary

IPV is a problem in Thailand. A body of research had been conducted examining the risk factors and its predictors in Western and South Asia countries. Multiple factors influencing IPV had been determined including self-esteem, acceptance of violence, exposure to violence, and fear of partner. The goal of this current study was to understand the experience of IPV in pregnant women in Thailand in order to decrease the prevalence of IPV in Thailand and to reduce health problems associated with IPV.

CHAPTER THREE: METHODOLOGY

This chapter presents the specific research plan involved in the conduct of the study. This chapter includes the research design, setting, population and sample, instruments, data collection, data management and data analysis, and protection of human participants.

Research Design

A cross-sectional survey research design was implemented in the study. The cross- sectional survey research design was examined the effects of: a) self-esteem; b) exposure to violence; c) acceptance of violence; and d) fear of partner in pregnant Thai women and to examine the effects of IPV, then, on adverse maternal health.

Study Setting

The study was conducted at the Prenatal Care Unit at Phraphutthabat Hospital, Saraburi

Province, Thailand. Phraphutthabat Hospital is the largest secondary hospital in Saraburi

Province and is located in the central part of Thailand. Phraphutthabat Hospital was chosen as the setting of this study because the hospital provides outpatient and inpatient services to pregnant women in rural area Saraburi Province, Lopburi Province, and Ayutthya Province. The

Prenatal Care Unit at Phraphutthabat Hospital provides a service five days a week on Monday through Friday. Pregnant women come to the prenatal care unit by making appointments. The clinic provides a service for old cases on Monday to Wednesday and Friday. New cases can walk-in to the clinic without an appointment; however the clinic provides a service for new cases only on Thursday. It is estimated that there are 100-120 old cases of pregnant women at the prenatal care unit per week and there are 20-30 new cases per week. In addition, there is only one larger hospital than Phraphutthabat Hospital, which is a tertiary hospital that serves complicated maternal and fetal condition cases. The researcher has lived in Phraphutthabat and has been

71 employed as a nurse educator at Boromarajonani College of Nursing, Praputhabat, a government service, for more than 15 years. The researcher’s familiarity with the population of interest, social and cultural issues, and the geographical area are an additional asset to this study.

Sample

Pregnant women who attended the prenatal care unit at Phraphutthabat Hospital and met inclusion criteria during June 2011 until September 2011 were invited by the researcher to participate in this study. It is important to note from the viewpoint of the scientific method, the participants constitute a sample and not an infinite population (Cochran, 1939; Deming &

Stephan, 1941). Cochran stated that

“Even a complete census, for scientific generalizations, describes a population that is

but one of the infinity of populations that will result by chance from the same underlying

social and economic cause systems. This infinity of populations may itself be thought of

as a population, and might possibly be called a super-population. A sample enquiry is

then a sample of a sample, and a so-called 100 percent sample is simply a larger

sample, but is still only a sample” (1941, p.1033).

Similarly, Deming and Stephan stated that

“A so-called 100 percent sample from the viewpoint of scientific method is, as soon as

taken, a sample of the past. The usefulness of such a sample is only as a basis for

drawing an inference about the future and in this case the sample (even a 100 percent

sample) is but a finite sample of a potentially infinite one that might result from the

cause system existing at the time the sample was taken” (p.46).

Cassel, Sarndal, and Wretman (1977), Cochran (1939), and Deming (1941) pointed out that the superpopulation idea was finite population that was drawn from infinite population. The

72 parameters of the superpopulation have realization when the superpopulation is considered to be a generalization of finite populations.

“Characterizing the superpopulation will correspond to characterizing the causal system.

Knowing the causal system will help predict the special case (population) in the future”

(Stanek, 2000, p.11).

“The motivation for introducing a superpopulation can be to draw inference to the

superpopulation parameter, and thus, generalize the results of a given study” (Stanek,

2000, p. 12).

With regard to the power of test of a hypothesis, the minimum sample size to achieve power of .80 was calculated. Kline (1998) indicated that more complicated models with more parameters may require larger samples and he states, as a general rule, that a ratio of 20 respondents per parameter should be considered, but that a ratio of 10 participants per parameter would be more realistic. There are eight variances and 12 coefficients in the hypothesized model.

A minimum of 15 subjects per predictor is recommended in social science research for a reliable equation that will have good predictive power (Stevens, 2002). A sample size of 300 was required for the study based on the 15:1 ratio. The researcher estimated around 10% for incomplete survey and missing data. Then, the researcher desired a final sample size of 330 in order to prevent incomplete data from decreasing the sample size below 300 in this study.

A random sample was recruited from Phraphutthabat Hospital located in Central part of

Thailand. The inclusion criteria in this study were as follows:

1. Pregnant Thai women between 18 and 45 years old

2. Able to understand, read, and write in Thai

3. Attending a prenatal care unit in the Phraphutthabat Hospital setting

4. Willing to participate in this study

Measurements

Data was collected using one questionnaire that composed of six sections. The independent or exogenous variables were compounded with self-esteem, acceptance of violence, and exposure to violence and the dependent or endogenous variable are fear of partner, IPV, and adverse maternal health including negative physical and psychological as well as pregnancy complications. The details of each section were described in the following section.

Self-Esteem

In the current study, self-esteem was operationally defined as a Thai pregnant woman’s score on the Thai version of the Rosenberg’s Self-Esteem Scale (RSS) (M. Rosenberg et al.,

1989) which was translated by Srisaeng (2005). This instrument is comprised of 10 items. There are five negatively worded and five positively words items (Srisaeng, 2003). Participants were asked to rate their agreement with each item on a four-point scale, ranging from one to four, from strongly disagree (1) to strongly agree (4). The negative items was reversed the score before the overall score was be calculated. The scale composes of self- value and self-respect as well as self-competence and ability. Item number 1, 2, 3, 5, 6, 7, 8, and 10 measures feeling of self-value and self-respect and item number 4 and 9 measures feeling of self-competence and ability. If the score is high, it indicates women with high self-esteem, while low scores declared low self-esteem. The scale has been widely used because of the evidence of its validity (M.

Rosenberg, 1965).

Over 5,000 high school juniors and seniors from 10 randomly selected schools in New

York were used as a sample when the scale was developed. The Cronbach’s alpha reported was

.82 (M. Rosenberg et al., 1989). Low internal consistency reliability of the RSS were obtained in

Zlotnick, Johnson, and Kohn (2006) who reported the Cronbach’s alpha of .67 in 3,173 married or cohabiting women who completed questions about physical victimization. High internal consistency was .86 in a study involving 33 currently battered women ages 19 to 50 years who attended a support service in Nassau County, New York (Cascardi & O'Leary, 1992).

This current study used the Thai version of the RSS translated by Srisaeng (2005). In this translated version that was used with 119 adolescents mother in Khon Kaen and Udorn Thani

Provinces, internal consistency was .72. Nirattharadorn and co-authers (2005) employed

Srisaeng’s translated version of RSS in 340 pregnant adolescents and reported a Cronbach’s alpha of .80 at the antepartum data period and .79 at the post partum data period. Internal consistency of Srisaeng’s translated version of the RSS was demonstrated as .88 in 31 Thai adolescents (Vongsirimas & Sitthimongkol, 2009). Beeber et al. (2007) noted that 11 other Thai studies used the Thai-language version of the RSS and reported a Cronbach’s alpha between .68 and .90.

The criteria for RSS scoring presented as following. Participants were asked to rate the feeling about how much they evaluate themselves in the last month from strongly disagree to strongly agree. The score of each level was follows:

Level of evaluate Self-esteem Score

Strongly disagree 1

Disagree 2

Agree 3

Strongly agree 4

For five negatively worded items (3, 5, 8, 9, and 10): Strongly disagree = 4, Disagree = 3, Agree

= 2, and Strongly agree = 1. For five positively words items (1, 2, 4, 6, 7): Strongly disagree = 1,

Disagree = 2, Agree = 3, and Strongly agree = 4. In the final analysis, item 8 was removed because of low and negative factor loading score.

Acceptance of Violence

Acceptance of violence for this study was operationally defined as a Thai pregnant woman’s attitudes that physical, psychological, and sexual violence was acceptable, tolerable, or justifiable, and Thai stereotypical beliefs about IPV were generally false but were widely and persistently held or accepted by Thai pregnant woman. The Thai Acceptance of Intimate Partner

Violence Scale (TAIPVS) developed by the investigator was used in this study. The scale was composed of 25 items with nine positively-worded and 16 negatively-worded statements. The respondent used a 4-point ordinal response scale with 4 anchors (“Strongly agree”, “Agree”,

“Disagree”, “Strongly disagree”). High scores indicate high acceptance of violence while low scores indicate low acceptance of violence.

To develop the scale the investigator explored concepts of acceptance of violence by collecting data from a review of the literature. Concepts were generated for measurement and operational definitions created for acceptance of IPV. A pool of items was created. The investigator used qualitative and quantitative procedures to identify the items. Using qualitative process, one dissertation committee member who has expertise in IPV and one Thai expert who has expertise in tool development reviewed the first version of the scale. They were asked for suggestions to delete ambiguous statements, redundant items, and double-barreled items. Also, necessary items that were not in the questionnaires were suggested from the two experts. The investigator improved items on the scale following expert suggestions. Using a quantitative process, the second version of the scale based on the construct definitions of acceptance of violence was evaluated for relevance by eight Thai experts. The experts were asked to rate the

76 relevance of each item on a 4-point scale. The item-level content validity index valid (I-CVI) and kappa coefficient (Cohen, 1968) were calculated to determine the degree of expert agreement.

The recommendation was that in order for a scale to have excellent content validity, it would be composed of items that had I-CVIs of .78 or higher and kappa coefficient of .75 or higher

(Cicchetti & Sparrow, 1981; Polit, Beck, & Owen, 2007). If the item was below .78 in CVI and

.75 kappa coefficients, the item was deleted from the questionnaire or revised by using experts’ suggestions. No item was deleted but five items were slightly changed. Also, five items were added to the scale using experts’ suggestions.

The criteria for TAIPVS scoring presented as following. Participants were asked to rate the attitude about how much they accept IPV, from strongly disagree to strongly agree. The score of each level was follows:

Level of evaluate TAIPVS Score

Strongly disagree 1

Disagree 2

Agree 3

Strongly agree 4

For five negatively worded items (2, 3, 5, 6, 7, 8, 9, 10, 12, 13, 15, 18, 20, 21, 22, and

23): Strongly disagree = 1, Disagree = 2, Agree = 3, and Strongly agree = 4. For five positively words items (1, 4, 11, 14, 16, 17, 19, 24, and 25): Strongly disagree = 4, Disagree = 3, Agree = 2, and Strongly agree = 1.

In the final analysis, all positive items were deleted because all items had the negative factor loading and were lower than .30 of factor loading. So, only 16 items were analyzed.

Exposure to Violence

Exposure to violence for this study was operationally defined as experiences of physical or psychological abuse committed by a parent, stepparent, or adult living in the same house as the Thai pregnant woman in her first 18 years of life, experience of sexual abuse committed by an adult, relative, family friend, or stranger who was five or more year older than the Thai pregnant woman in her first 18 years of life. Witnessing of interparental violence was operationally defined as experiences of physical or psychological abuse between parents including watching, hearing, and experiencing aftermath in their first 18 years of life. There were three parts of exposure to violence

First, ten questions that were translated and adapted from the Conflicted Tactic Scale

(Straus, 1979) by Jirapramukpitak (2005) were modified by the investigator and used to measure experiencing of physical and psychological abuse (Straus, 1979).(T. Jirapramukpitak, Prince, &

Harpham, 2005) The response categories were changed from “never”, “once or twice”,

“sometimes”, “often”, or “very often” to “yes” or “no”. A yes response to any one of the four questions classified a respondent as having experienced abuse. Physical abuse was evaluated by six questions: ‘‘Did a parent or other adult(s) in the household (1) actually push, grab, or shove you? (2) Throw something at you? (3) Slap you on the face, ear, or head? (4) Hit you so hard that you had marks or bruises? (5) Kick, punch, or hit you with a fist? (6) Threaten to hurt you or actually hurt you with a gun, knife, or other weapon?’’. A Cronbach’s alpha coefficient of .78 was reported (Jirapramukpitak, 2005). Psychological child abuse evaluation was composed of four items: ‘‘Did a parent or other adult(s) in the household (1) Insult? (2) Belittle? (3) Yell? (4) publicly criticize you, consequently, making you feel bad, inferior or humiliated?” The internal consistency, which was measured by Cronbach’s alpha coefficient, was .80.

Second, four questions from Wyatt (1985) were adapted and translate to Thai by

Jirapramukpitak (2005) were used to measure experiencing sexual abuse. The response categories were “yes” or “no”. The questions are as follows: During the first 18 years of life, did an adult, relative, family friend or stranger who is five or more years older than you ever: (1)

Touch or fondle your body including your breasts or genitals or attempt to arouse you sexually against your will? (2) Try to have you arouse them or touch their body in a sexual way against your will? (3) Attempt to have intercourse with you against your will? (4) Have intercourse with you against your will? A yes response to any one of the four questions classified a respondent as having experienced child sexual abuse. The internal consistency of child sexual abuse, which was measured by Kuder-Richardson 20 coefficient, was .77 (Jirapramukpitak, 2005).

Last, six questions that were translated and adapted from the Conflicted Tactic Scale

(Straus, 1979) by Jirapramukpitak and associates (2010) were slightly modified by the investigator and were used to measure witnessing interparental violence. The experiences of witnessing interparental violence included watching, hearing, and experiencing aftermath in their first 18 years of life. The questions were as follows: During the first 18 years of life ‘‘did your father (or stepfather) or mother’s boyfriend do any of these things to your mother (or stepmother): (1) Push, grab, slap, or throw something at her? (2) Kick, bite, hit her with a fist, or hit her with something hard? (3) Repeatedly hit her over at least a few minutes? (4) Threaten her with a knife or gun, or use a knife or gun to hurt her? (5) Swear, yell, or scream at her? and (6)

Insult or belittle her?” The response categories were changed from “never”, “once or twice”,

“sometimes”, “often”, or “very often” to “yes” or “no”. A yes response to any one of the four questions classified a respondent as witnessing of interparental violence during childhood.

The criteria for Exposure to violence scoring presented as following. Participants were asked to rate the experiences of abuse during the first 18 years of life from yes or no. The score of each answer was follows:

Answer Exposure to violence Score

Yes 1

No 0

The pregnant Thai woman’s score on three parts including physical or psychological abuse, sexual abuse and witnessing interparental violence during childhood were used to measure exposure to violence. The Z-scores of each part were calculated and the combined Z- scores of three parts were brought to analyze. A high score indicated high exposure of violence.

Fear of Partner

In the current study, fear of partner was operationally defined as a Thai pregnant woman’s feeling of apprehension, fright, dread, or tension toward her partner. The Thai Intimate

Partner Violence Fear Scale (TIPVFS), which was developed by the investigator, was used. The scale was composed of 10 items. The respondent uses a 4-point ordinal response scale with four anchors (“Strongly agree”, “Agree”, “Disagree”, “Strongly disagree”). The process of tool development of TIPVFS was identical to that in the TAIPVS development. One item was deleted from the scale due to item with very low I-CVI and kappa coefficient. One the other hand, one item was added to the scale using experts’ suggestions.

The criteria for TIPVFS scoring presented as following. Participants were asked to rate the attitude about how much she fear toward her partner, from strongly disagree to strongly agree. The score of each level was follows:

Level of evaluate TIPVFS Score

Strongly disagree 1

Disagree 2

Agree 3

Strongly agree 4

Possible total summed unit-weighted scores range from 10 to 40. High scores indicated higher amounts of fear toward a partner while low scores indicate lesser amounts of fear toward a partner.

IPV

In the current study, IPV was operationally defined as Thai pregnant woman’s experiences of physical violence, psychological violence, forced intercourse and other forms of sexual coercion, and various controlling behaviors such as isolating a person from family and friends or restricting access to information and assistance that occurred during their recent pregnancy and was committed by an intimate partner including a spouse, ex-spouse, boyfriend, or ex-boyfriend.

The questionnaire was used in the current study to measure IPV was modified from

“WHO Violence against Women Instrument”: section 7 (Experience of partner violence)

(Archavanitkul et al., 2005; C. Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). The violent questions included acts of physical, sexual and emotional abuse as well as controlling behaviors by a current or former intimate male partner. The violent questions asked a limited number of questions about specific acts that commonly occur in violent partnerships rather than a list of acts of violence. “This approach has been shown to encourage greater disclosure of violence than approaches that require respondents to identify themselves as abused or battered”

(García-Moreno et al., 2005, p.14). About questions regarding emotional violence and

81 controlling behavior because the acts were likely to vary, the acts in this questionnaire were considered as a starting-point, rather than a comprehensive measure of all forms of emotional abuse. The response categories were “yes” or “no”. Psychometric analysis was performed on the violence questions. The internal consistency among the items for each measure was accepted and validity of the violent question ascertained the appropriateness of the behavioral items included in the different measures of physical, emotional and sexual violence (C. Garcia-Moreno et al.,

2005). The violent questions that were used in the current study were translated to Thai by WHO

Thailand research team (Archavanitkul et al., 2005). The content of the violence question was divided into four parts: 1) emotional violence composes of four questions (question number 1-4),

2) physical violence composes of six questions (question number 5-10), 3) sexual violence composes of four questions (question number 11- 13), and 4) controlling behaviors composed of

7 questions (question number 14-20). When WHO research team used the violence question to collect the data in Thailand in 2002, the reliability was not reported. Sangwan (2008) employed the violent question with 360 pregnant women attending the prenatal care unit in Bangkok and reported that the reliability of emotional, physical, and sexual violence was .70, .77, and .74.

The criteria for experience of IPV scoring presented as following. Participants were asked to rate the experiences of emotional, physical, and sexual violence as well as controlling behaviors from yes or no. The score of each answer is follows:

Answer Experiences of IPV score

Yes 1

No 0

The pregnant Thai woman’s score on experience of emotional, physical, and sexual violence as well as controlling behaviors was used to measure experiences of IPV.

Item 9 and 10 had a zero variance so they were deleted. The scores are ranged between 0 and 18. High scores indicated higher amounts of IPV experience while low scores indicate less amounts of IPV experience.

Adverse Maternal Health

Adverse maternal health for this study was operationally defined as a Thai pregnant woman’s adverse health during pregnancy. There were 2 parts of adverse maternal health: (1) negative physical and psychological and (2) pregnancy complications were measured.

First Part: Negative physical and psychological physical health was measured using PCS in the 12-Item Short- From Health Survey (SF-12) (Ware et al., 1996), the Edinburgh Postnatal

Depression Scale (EPDS) and the Thai Screening Test for PTSD.

First, the SF-12 is a shorter version of SF-36; however, SF-12 was proved to be a practical alternative to SF-36 in nine countries (Gandek et al., 1998). There are two components in SF-12, Physical Component Summary (PCS) and Mental Component Summary (MCS).

Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP), and General Health are in the

PCS; while Vitality (VT), Social Functioning (SF), Role Emotional, and Mental Health are in the

MCS. During the construction of SF-12, the reliability and content validity was tested with over

2,000 general people in the U.S. The test-retest reliability of PCS-12 and MCS-12 was .89 and

.76, respectively. The RV of PCS-12 was lower than the PCS-36. In the original version, there were six questions in PCS-12. A 4-week recall period was used in the current study. The SF-12 was translated to Thai by Sricumsuk (2006). The completed SF-12 was used with pregnant and postpartum Thai women and the reliability was reported between .72 and .80. For the analysis, the item 1 of PCS-12 was deleted due to the item with negative and low of factor loading score; so, five items were used for analysis. The criteria for PCS-12 scoring presented as following.

Participants were asked to recall their physical health within the 4-week period. For all scales in

PCS-12 were coded, summed and transformed on to a scale from 0 to 100. Then, the score was minus with 100 (Sricamsuk, 2006) and transformed to Z-scores to evaluate negative physical health.

Second, the Edinburgh Postnatal Depression Scale (EPDS) was used in the current study.

Depression was assessed by using EPDS developed by Cox (1987). The instrument has been a widely used standard for screening and diagnosis of postnatal depression and accepted for use antenatally (J. L. Cox, Chapman, Murray, & Jones, 1996; Jomeen & Martin, 2005).This self- administered instrument is composed of 10 items with four rating scales for each item ranging from 0 to 3. There are two subscales: (1) depression and (2) anxiety (Jomeen, 2005). The total possible scores range from 0 to 30. Higher scores indicated more depression symptoms. The validation sample of the EPDS was 63 puerperal women who attended a health care center in

Livingston, the UK. The sensitivity of the scale reported was 85% and specificity was 77%. The spit-half reliability of the tool was .88 and the standardized α-coefficient was found to be .87

(Cox, 1987). The validity for non-postnatal women reported that at the 12/13 cut-off the sensitivity was 88% and the false-positive rate was 20% (J. L. Cox et al., 1996). The EPDS is widely accepted and was translated into multiple languages including Chinese, Dutch, Arabic,

Japanese, and Thai (Affonso, De, Horowitz, & Mayberry, 2000; Ghubash, Abou-Saleh, &

Daradkeh, 1997; D. T. S. Lee, Yip, Leung, & Chung, 2004; Okano, Nagata, Hasegawa, Nomura,

& Kumar, 1998; Pitanupong et al., 2007; Pop, Komproe, & van Son, 1992). The validity of all versions was reported to be fairly good.

The Thai EPDS that was constructed by Pitanupong and co-authors (2007) was used in the current study. The Thai version of the EPDS was developed by using back translation and

84 validated with structured clinical interviews based on the criteria of the Diagnostic and Statistical

Manual for Mental Disorders-Fourth Edition (DSM-IV). Item number 6, “Things have been getting on top of me,” was difficult to understand and it is a idiomatic that does not commonly used in Thailand. Therefore, item number 6 was changed to “Things have made me unhappy and anxious” in the Thai EPSD. The validity sample was 351 postpartum women. The internal consistency reported .81. At the 6/7 cut-off point the sensitivity was 74% but had lower specificity give it. Sukkasem (2008) used the Thai EPDS with 10 postpartum women and found a

Cronbach’s alpha of .89. For screening depression during late pregnancy, the 10 cut-off point score was used to classify depression mood for the Thai EPDS and the specificity reported was

83% (Limlomwongse, 2006). Another Thai-language version of the EPDS with eight items for non-postnatal women was found in two Thai studies and with Cronbach’s alpha reported between .70 and .77 (Chatchawanwit, 2008;Thananowan, 2004). In the current study, only eight items were used because both items were deleted from the analysis due to the items with negative and low of factor loading score. The total possible scores ranged from 0 to 24. The scores were transformed to Z-scores.

Last, The Thai Screening Test for PTSD was developed by Arunpongpaisal et al. (2007).

The scale consists of 5 items and the response categories were “yes” or “no”. The questions are as follows: 1) Do you always think of the situation against you will? ; 2) Do you have had a picture about the situation that have come into your mind against you will? ;3) Do you have had trouble falling asleep or staying asleep because pictures about the situation came to your mind? ;

4) Do you have had difficulty falling asleep or staying asleep? Do you have felt depressed almost all the time? Of five items, the factor loading reported between .721 and .783. The scale was tested with 298 flood victims in Songkha Province and the Cronbach alpha coefficient was .936.

With cutoff point of 10, sensitivity was 74% and specificity was 68%. Only three items were used in the current study. The score of each answer was follows: (Arunpongpaisal et al., 2007)

Answer PTSD score

Yes 1

No 0

There were different weighted score in each item. The weighted scores of item1 to item3 were one, two, and three, respectively. The possible scores ranged from one to six. Then, the raw scores were transformed to Z-scores.

All of three Z scores from three instruments were combined to evaluate negative physical and psychological health. The high score indicated more negative physical and psychological health.

Second Part: The Pregnancy Complications Scale was used to measured complications during pregnancy. The scale was developed by the researcher. There are 11 questions: During pregnancy, have you experienced: (1) Diabetes or sugar in your urine? (2) Pregnancy-induced hypertension or albumin in your urine? (3) Urinary tract infection? (4) Reproductive tract infection? (5) Severe nausea, vomiting, or dehydration? (6) Poor weight gain (weight gain less than 0.5kg/week or weight gain more than 1 kg/week)? (7) Anemia (Hct lower than 30g% or Hb lower than 10g/dl)? (8) Vaginal bleeding, abruption of placenta or placenta previa? (10) Preterm labor? (11) Premature rupture of membranes? A yes response to any one of the 11 questions classified a respondent as having a complication during pregnancy. The score of each answer was follows:

Answer Complications during pregnancy

Yes 1

No 0

The possible scores were ranged between 0 and 11. A high score indicated high complications during pregnancy.

Demographic Information and Pregnancy History

Demographics of the participants were collected, which included age, education.

Pregnancy history included three questions: (1) Is it planned pregnancy? ; (2) What is your expectation date confinement? ; (3) How many weeks pregnant you were when you first visited prenatal care unit?

In summary, the instruments used in the current study were selected for their reliability and validity. The existing instruments were used in similar populations of women with the experience of IPV and the newly created instruments were developed to capture additional data needed to answer the research questions.

Data Collection

Recruitment

Pregnant women come to the prenatal care unit by a making appointment, which allowed the researcher to know number of pregnant women expected each day. To maintain confidentiality, the staff did not know who decided to participate in the study. In-person recruitment was used in the current study.

Procedure

Once the permission to conduct the research was obtained, the investigator approached the head nurse and staff members of the prenatal care unit to introduce her, explained the objectives of the research and asked for cooperation in data gathering. The head nurse provided the number of pregnant women who would access the clinic per day by appointment through a

87 week. Also, the head nurse assisted during the data collection. The investigator collected the data by oneself until the desired sample size was obtained. After getting the estimated number of pregnant women who would access the clinic each day from the appointment list, the researcher used random selection without replacement by using the queue number. Twelve queue numbers from estimated total number of potential participants in each day were randomly selected. All pregnant women were informed by the staff of the prenatal care unit that the researcher may approach them when they were in the examination room. The pregnant women got a queue number after they checked in. The investigator approached the first eight pregnant women who were randomly selected to be recruited into the study. If the women from the first eight on the list of random selection refused to participate, the next person on the list was invited. At least eight pregnant women who were randomly selected and met the inclusion criteria were recruited each day. The researcher collected the hospital identification numbers who those completed the questionnaire in order to avoid double data collection. Each woman approached was asked if she had been invited to participate.

The investigator collected data using pencil-paper measures. The investigator explained the nature, purpose of study, the potential risks and benefits, and the participant’s rights to refuse or discontinue participating in the study. To avoid stigmatization, the study was not labeled as a study of IPV, but participants were clearly informed that the study was addressed sensitive issues, including IPV. A participant could refuse or withdraw from this study any time without consequences. If refusal or withdrawal from this study were occur, the participant would receive standard care from her health care providers. If the pregnant woman agreed to participate in the study, she was asked to read an information sheet and the instructions for the study. If the woman had any questions, she could ask the investigator directly.

After the woman finished reading the information sheet, she was given a copy. However, she leave it in the private room, if she did not want it. The participants did not need to sign the informed consent because if found, the participant could be at an increased risk of violence from the perpetrator. The participant was notified that her completed questionnaire was kept in confidentiality. The researcher administered the questionnaire to the participant in a private room of the hospital and the participant had ample time to complete them in this safe environment. A partner, relative, and/or child over the age of two were not allowed to be present while the woman completed the questionnaire. The approximate time for each participant to fill out all of the surveys was 30-40 minutes. If a participant could not read the questionnaire, for instance forgetting the glasses, the investigator read the questionnaire and recorded the answers. All completed questionnaire was checked by the investigator prior to the end of the encounter to avoid missing data. The completed questionnaire was returned directly to the investigator. There was no identifying information on the questionnaire. Each participant gave an incentive gift of

150 Bath ($5). One hundred and fifty baths was an amount approximately sufficient to purchase three lunches.

If the participant had signs and symptoms that were representative of depression while she was completing the questionnaire, she was notified and she was given referrals to health care providers for follow up. During the completion of the questionnaire, there was a chance that the participant may become mildly upset and/or tearful. The participant was allowed time to rest.

The participant could decide to withdraw or continue the participation at this time. The participant was referred for mental health counseling if necessary.

Data Management and Data Analysis

The completed questionnaire was sealed in an envelope and only the investigator had access. The investigator coded the questionnaire. Statistical Package for the Social Science

(SPSS/PC 20.0) and Mplus version 6.12 were utilized for data management.

“Mplus allows the use of sampling weights and controls for the clustering effects due to

the multistage sampling design when estimating path analyses or structural equations

models. It is important to appropriately weight complex survey data such as these, so that

the statistics that are estimated, such as the path coefficients, are correct (Lehtonen &

Pahkinen, 1995; Wolter, 1985) In addition, multicluster samples generally have a

clustering effect that causes standard errors” (Schafer,Caetano,& Cunradi, 2004, p.131).

The data were entered into a SPSS file. Then, data management and analysis were performed as following:

Data Cleaning

Before the data were analyzed, the researcher checked the original data against the computerized data file in order to examine for accuracy of data entry and missing values.

Frequency of each variable was performed for data screening data. The smallest and largest values of all measure were checked to make sure that they were plausible. Also, the researcher created frequency tables that showed the member of time each variable occurred in the data file in order to check data values.

Univariate Analysis.

Descriptive statistics, including means, standard deviation, skewness, kurtosis, frequency, histogram and scatterplot of each variable were performed to explain the characteristic of participants, examined the distribution of the values, and described the normality of the study

90 variables. The mean and the standard deviation were commonly used to measure variability and central tendency. From a histogram and scatterplot, the distribution of the values of all study variables and outliers could be examined. To support the results from descriptive and graph analysis, the researcher were perform Kolmogorov-Smirnov and Shapiro-Wilk test to determine the normality of study variables.

Bivariate Analysis

Pearson’s product moment correlation and Kendall’s tau were used to examine the relationship among implicit study variables. Path analysis used to identify linear relationship among variable; therefore, all relationship among variable were assumed to be linear. The

Pearson’s correlation was used to measure the linear relationship under the assumption of normality; while the Kendall’s tau was used when the normality assumption may be violated. In addition, among variables that were perfect correlation could produce extremely highly correlated. Also, the researcher can inspect in correlation matrix. A high correlation coefficient may produce a problem with multicollinearity (Munro, 2005). Furthermore, “Linear relationship among pair of measured variables can be accessed through inspection of scatterplots” (Ullman,

2007, p.683). So, the scatterplot matrixes (SPLOMs) among study variables were examined. The

SPLOMs that contained all the pairwise scatter plots of the variables usually inspected pairwise relationship between variables and clustering by groups in the data. Moreover, the SLOPMs used to look for curve linearity, smooth regression lines and break point relationship in each pairwise scatter plot.

Multivariate Analysis

Path analysis that was developed by Wright (1928) is an extended generalized form of regression. The multiple effects among variables in a path diagram are estimated simultaneously.

The path coefficients in paths diagram point out the direct effects of an independent or exogenous variable on the dependent or endogenous variable. The values of chi-square goodness of fit (GOF) are not significant in path analysis which may indicate an adequate-fitting. In addition, multiple indices for GOF may be used to evaluate overall model fit. The purpose of the present research was to test a hypothesized model explaining the relationship among factors influencing IPV, IPV during pregnancy, and adverse maternal health. In this study, the maximum likelihood estimator with robust standard errors (MLR) was used rather than typical maximum likelihood estimator to deal with non-normally distributed variables. In this case, IPV was especially identified as non-normal. The chi- square GOF, chi square/degree of freedom, Root

Mean Square Error of Approximation (RMSEA), Tucker –Lewis Index (TLI), and Comparative

Fit Index (CFI) were used to evaluate the model fit.

Protection of Human Participants

The research on IPV clearly indicates that it is a sensitive research topic because it fits well with the definition that Lee and Renzetti (1990) described that a sensitive topic may “pose a substantial threat to those involved in the research and that therefore makes the collection, holding, and/or dissemination of research data problematic” (p. 512). The sensitive research topic “sharpens ethical dilemmas [and] tends to reveal the limits of existing ethical theories” (R.

M. Lee & Renzetti, 1990, p. 522). According to the principles on research of violence against women, respect for persons, minimizing harm to participants and research staff sensitivity, maximizing benefit to participants and communities were be ensured ( R. M. Lee & Renzetti,

1990; World Health Organization and Program for Appropriate Technology in Health (PATH),

2005).

Respect for Persons

The Institutional Review Boards at the University of Cincinnati reviewed and approved the study. No drugs or other invasive procedures were employed during the study. Women participated by completing the questionnaire. Participants could refuse or withdraw from this study any time without penalty. If refusal and withdrawal from this study occurs, the participant did not receive a negative effect from the health care providers.

Informed consent for participants: The participant who experiencing IPV may be at an increased risk to provoke of future violence from the perpetrator if he knew the participant was in the study. Also, granting informed consent may inspire the fear that the identity could be known in many women (Fontes, 2004). Therefore, the participants did not need to sign the inform consent in the current. The participant gave the information sheet for research to potential participants. There was still no consensus about research on IPV whether warning the participants that they involved with the sensitive research topic was sufficient or whether participant should explicitly acknowledge to answer IPV questions (World Health Organization and Program for Appropriate Technology in Health (PATH), 2005).In this study, the investigator clearly informed that the study addressed sensitive issues during the initial consent process to potential participants. To avoid stigmatization, the study was not labeled as a study of IPV.

However the participant was informed that they could refuse to answer any questions that they did not want to answer or some questions that may make them uncomfortable.

Mandatory reporting abuse: Concerning about ethic principles including respect for autonomy, respect for confidentiality, and need to protect vulnerable population, “there is consensus among most researchers that the principles of autonomy and confidentiality should prevail and that researchers should do everything within their power to avoid usurping a

93 woman’s right to make autonomous decisions about her life” in case of adult women (World

Health Organization and Program for Appropriate Technology in Health (PATH), 2005, p. 37).

The investigator did not report cases of IPV to authorities or social service agencies. If the women needed support in reporting her abuse, the investigator would oblige.

Minimizing Harm

Participant’s safety: For the women experiencing IPV, the participation in the research study may place women at increased risk for further violence. The WHO guideline provide a suggestion how to minimize risk to participants as followings: “1) Interviewing only one woman per household (to avoid alerting other women who may communicate the nature of the study back to potential abusers); 2) Not informing the wider community that the survey includes questions on violence; and 3) Not conducting any research on violence with men in the same clusters where women have been interviewed” (World Health Organization and Program for

Appropriate Technology in Health (PATH), 2005, p. 38).

Confidentiality and privacy: The Institutional Review Boards at the University of

Cincinnati reviewed and approved the study. The questionnaire was anonymous. There were no participants’ names or addresses on the questionnaire. No identifying data that could link participant’s answer to them were collected. The investigator ensured that she conducted the research in an ethical and sensitive manner that protects the safety of all participants. While the women completed the questionnaire, no partner or other individual presented in the private room at the hospital. The completed questionnaire was kept in the locked room in the locked cabinet at the University of Cincinnati, College of Nursing for five years. After five years the questionnaires will be destroyed by shredding.

Minimized participant distress: Completing the sensitive topic questionnaire, there was a chance that participants may become mildly upset and/or tearful. The investigator was aware that the questionnaire may affect emotional distress on the participants. Also the investigator knew how to measure the emotional distress, how best to respond, how to terminate the data collection if the impact of the question become worse (World Health Organization, 1999).

Referrals for care and support: the WHO guideline suggested that the investigator have an ethic obligation to provide information or services that can help participant’s situation. In

Thailand, the One Stop Crisis Centers (OSCC) have established at public hospital around

Thailand for helping women and child suffering from violence in 1998. Each center provides multidisciplinary team to suitable support for victims including health, emotional, and social support need of victims (Office of Women’s Affairs and Family Development, 2004). The

OSCC is available on site. All participants offered a card containing phone number of social and counseling services for IPV, including phone number of OSCC at Phraputthabat Hospital. If the participants wanted to talk to someone because this research made them feel upset, the investigator could give you information about people who may be able to help you. Mental health counseling is available on site.

Maximizing Benefit

The maximum possible benefit to participants and the groups that they belong is principle of beneficence. The participants did probably not get any benefit from taking part in the current study. However, being in this study probably helped health care providers to understand life experience and maternal health among pregnant Thai women. Pregnant women in the future may get benefit from the research findings. Moreover, completed the questionnaire and talked with the investigator may give the opportunity to participate about IPV information.

Safety Plan

Safety plan when first contacting potential research participants by in person at hospital:Potential participants were alone before approaching in the examination room.

Safety plan when completing the questionnaire: considered safety issues about future violence for women before, during, and after the completing questionnaire.

x Did not inform wider community that the questionnaire included IPV questions.

x Used the information sheet for research instead of consent form.

x The examination room in the Phraputthabat Hospital was used to complete the

questionnaire.

x There were no participants’ names or addressed on the questionnaire. No

identifying data that could link participant’s answer to them were collected.

x No other adults and any child older than two years old presented during the

completing the questionnaire for any reason.

x Candy, games, paper and color pencils were used to distract children during

completing the questionnaire.

x Had dummy questionnaires in place in case other adults interrupt the completing

the questionnaire when the investigator read the questionnaire for participants.

x Be prepared to stop and continue at another time if safety was compromised.

x Offered a small card provided the phone number of organizations assisting victims

of domestic violence such as information about One Stop Crisis Center (OSCC) at

Phraphutthabat Hospital.

x Stayed on site while the participant completed the questionnaire and concern about

participant safety.

x Ask participants if safety was an immediate concern: Were you safe right now?

Where could you go that you would feel safer? Could I give you the number of the

local domestic violence shelter program?

x Returned the completed questionnaires directly to the investigator. The completed

questionnaire was kept in the locked box.

Safety plan when completing the questionnaire: considered emotional distress during the completing questionnaire.

x Allowed time to rest if participants became mildly upset and/or tearful during the

completion of the questionnaire. Let the woman knew that they could decide to

withdraw or continue the participation at this time.

x Offered referral to mental health counseling.

CHAPTER FOUR: RESULTS

In this chapter, the data from participants, psychometrics of the measurements, and the results from testing each hypothesis are presented. All variables in the analysis were examined to evaluate the data for completeness and error. Univariate analysis was used to assess the normality of the data and to explain characteristics of participants and bivariate analysis was performed to test linearity, multicollinearity, and relationship among the data. The hypotheses of this study were then tested by using path analysis (Loehlin, 2004; Wright, 1928).

Participants

A total of 1078 pregnant women who had an appointment to visit the Prenatal Care Unit at Phraphutthabat Hospital during June to September 2011 were selected by using computer random number generators. Among these 305 pregnant women out of 1,078 pregnant women were approached. Only one pregnant woman refused to participate in the study. Three hundred and four pregnant women participated in the study and completed the questionnaire. All of the participants returned the questionnaire, so the response rate was 100%.

Psychometrics of Study Instruments

Construct Validity

Confirmatory factor analysis (CFA) was performed to test the factor construct of the instruments. Factor analysis is important to content validity, predictive validity, and construct validity. For predictive validity, factor analysis suggests predictors that will work well in practice. For content validity, it suggests how to revise the scale. For construct validity, it provides the tools needed to define cross structures and internal structure (Nunnally & Bernstein,

1994).

Thai version of the Rosenberg’s Self-Esteem Scale (RSS).

Results of the test factor structure of the Thai version of RSS indicated that the ten items loaded on two factors with the range of a factor loading from -.50 to .73. According to

Rosenberg (1965), the Rosenberg Self-Esteem Scale is an attempt to achieve a unidimensional measure of global self-esteem. After performing factor analysis with a single factor, the factor loading of 10 items ranged from -.35 to .64. Item 8 was deleted from the scale because the factor loading of the item was lower than .30 and had negative factor loading. The remaining nine items ranged from .40 to .59 as shown in Table 4.1.

Table 4.1. Factor loading for Confirmatory Factor Analysis of the RSS

Items Factor loading 1. On the whole, I am satisfied with myself. .459 2. At times, I think I am no good at all. .500 3. I feel that I have a number of good qualities. .447 4. I am able to do things as well as most other people. .502 5. I feel I do not have much to be proud of. .398 6. I certainly feel useless at times. .429 7. I feel that I am a person of worth, at least on an equal plane with others. .560 9. All in all, I am inclined to feel that I am a failure. .593 10. I take a positive attitude toward myself. .567

Thai Acceptance of Intimate Partner Violence Scale (TAIPVS).

Results of test factor structure of the TAIPVS indicated that the 25 items loaded on 7 factors with range of factor loading from -.321 to .773. The scale was developed by using unidimensional measure of justification of four types of IPV including physical, psychological, and sexual abuse as well as controlling behaviors. Therefore, a single factor was assessed using confirmatory factor analysis (CFA). After extracting the single factor, the factor loadings of 25 items ranged from -.229 to .638. The factor loading of items 1, 4, 11, 14, 16, 17, 19, 24, and 25

99 was lower than .30 and had negative factor loadings. Therefore, nine items were deleted from the scale. The factor loading of 16 items ranged from .343 to .679, as shown in Table 4.2.

Table 4.2. Factor loading for Confirmatory Factor Analysis of the TAIPVS

Items Factor loading 1. If the wife/girlfriend has a relationship with other men or has an affair … .345 3. When the wife/girlfriend has been physically or mentally abused her… .444 5. It is acceptable that the husband/boyfriend has a mistress if he… 343 6. The husband/boyfriend can express in public that he has the right… .568 7. The husband/boyfriend has the right to discipline his wife/girlfriend…. .679 8. To throw, smash, or break an object may solve the relationship … .498 9. Physical or mental abuse by a husband/boyfriend is a shameful subject… .634 10. The wife/girlfriend should not anger her husband/boyfriend when he… .493 12. Physical or mental abuse by a husband/boyfriend is a private matter … .517 13. A husband/boyfriend can yell and swear at his wife/girlfriend if she … .560 15. The relationship of the wife/girlfriend and husband/ boyfriend is … .498 18. A husband/boyfriend, who has a higher income than his wife/… .450 20. To preserve the wife/girlfriend’s roles, wife/girlfriend’s occupation … .472 21. A good wife/girlfriend should fulfill her husband/boyfriend's sexual … .511 22. To keep the relationship between husband/boyfriend and wife/… .533 23. A good wife/girlfriend should allow her husband/boyfriend to have … .404

Thai Intimate Partner Violence Fear Scale (TIPVFS).

The scale was developed by using unidimensional model of fear of partner. Results of testing the factor structure of the TIPVFS indicated that the 10 items loaded on a single factor with a range of factor loading from .423 to .887, as shown in Table 4.3.

Table 4.3 Factor loading for Confirmatory Factor Analysis of TIPVFS

Items Factor loading 1. I feel unsafe when I am alone with my husband/boyfriend. .751 2. When my husband/boyfriend looks at me I feel afraid. .851 3. I feel like I have to use an usually high level of caution around my husband… 860 4. I avoid staying alone with my husband/boyfriend. .887 5. I fear and worry about what my husband/boyfriend will do to me when we… 634 6. I avoid all conflicts with my husband/boyfriend or something that makes … .423 7. I do not dare tell people about the things my husband/boyfriend does to me. .617 8. I worry that what I do will make my husband/boyfriend angry. .585 9. I do things my husband/boyfriend wants me to do rather than doing things… .460 10. When my husband/boyfriend got mad I was terrified, even though he … .620

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Exposure to violence.

As shown in Table 4.4, the 20 items loaded on three factors including experiencing of child physical and psychological abuse, experiencing of child sexual abuse, and witnessing interparental violence. Average of the factor loadings of each factor were .721, .943, and .872, respectively.

Table 4.4 Factor loading for Confirmatory Factor Analysis with Promax of Exposure to Violence Scale Items Factor loading Factor 1 Factor 2 Factor3 1. Actually push, grab, or shove you? .645 2. Throw something at you? .705 3. Slap you on the face, ear, or head? .800 4. Hit you so hard that you had marks or bruises? .666 5. Kick, punch, or hit you with a fist? .852 6. Threaten to hurt you or actually hurt you with a gun, knife…? .367 7. Insult you, consequently, making you feel bad, inferior or …? .868 8. Yell, swear, or scream? .772 9. Belittle you, consequently, making you feel bad, inferior …? .725 10. Publicly criticize? .809 Average .721 1. Touch or fondle your body including your breasts or …? .980 2. Try to have you arouse them or touch their body in a …? .956 3. Attempt to have intercourse with you against you will? .939 4. Have intercourse with you against you will? .895 Average .943 1. Push, grab, slap, or throw something at her? .864 2. Kick, bite, hit her with a fist, or hit her with something hard? .902 3. Repeatedly hit her over at least a few minutes? .914 4. Threaten her with a knife or gun, or use a knife or gun to…? .850 5. Yell, swear, or scream at her? .942 6. Insult, belittle, or publicly criticize her? .760 Average .872 Note. Factor 1= Experiencing of child physical and psychological abuse; Factor 2 = Experiencing of child sexual abuse; Factor 3= Witnessing interparental violence WHO Violence Against Women Instrument

Item 9 and item 10 had zero variance so both of items were deleted from the analysis.

Results of test factor structure of the WHO Violence against Women Instrument indicated that the 18 items loaded on four factors including physical, psychological, and sexual violence as

101 well as controlling behaviors. The correlation coefficient among four factors ranged from .741-

.924. Therefore, analysis by performing the factor analysis with single factor was assessed. The range of factor loadings were from .543 to .965, as shown in Table 4.5.

Table 4.5. Factor Loading for Confirmatory Factor Analysis of the WHO Violence against Women Instrument Items Factor loading 1. Insulted you or made you feel bad about yourself? .856 2. Belittled or humiliated you in front of other people? .822 3. Did things to scare or frighten you on purpose (e.g. by the way he looked .835 at you, by yelling, and smashing things)? 4. Threatened to hurt you or someone you care about? .884 5. Slapped you or threw something at you that could hurt you? .965 6. Pushed you or shoved you? .918 7. Hit you with his fist or with something else that could hurt you? .852 8. Kicked you, dragged you, or beat you up? .864 11. Physically forced you to have sexual intercourse when you did not...? .813 12. Did you ever have sexual intercourse you did not want he might do? .792 13. Did he ever force you to do something sexual that you found …? .949 14. Tried to keep you from seeing friends? .548 15. Tried to restrict contact with your family of birth? .567 16. Insisted on knowing where you were at all times? .609 17. Ignored you and treated you indifferently? .543 18. Got angry if she spoke with another man? .729 19. Was often suspicious that she was unfaithful? .694 20. Expected her to ask permission before seeking health care for herself? .572

Negative physical and psychological heath.

Six items of the Physical Component Summary (PCS) of SF-12, 10 items from

Edinburgh Postnatal Depression Scale (EPDS), and 5 items of Thai Screening Test for PTSD were used to measure maternal physical and psychological health. The 21 items loaded on three factors with loading scores from -.76 -.92. All items with negative loading scores were deleted from the scale. In the end, there were 16 items loaded on three factors with loading scores from

.45 to .96, as shown in Table 4.6.

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Table 4.6. Factor Loading for Confirmatory Factor Analysis with Promax of Negative Physical and Psychological Heath Items Factor loading Factor 1 Factor 2 Factor3 3. I have blamed myself unnecessarily when things went ... .509 4. I have been anxious or worried for no good reason. .668 5. I have felt scared or panicky for no very good reason. .690 6. Things have been getting on top of me. .740 7. I have been so unhappy that I have had difficulty sleeping. .784 8. I have felt sad or miserable. .720 9. I have been so unhappy that I have been crying. .677 10. The thought of harming myself has occurred to me. .454 Average .656 1. You always think of the situation against you will. .901 2. You have had a picture about the situation that have … .963 3. You have had trouble falling asleep or staying asleep … .904 Average .923 2. Moderate activities such as moving a table, pushing a … .564 3. Climbing several flights of stairs .503 4. Accomplished less than you would like .670 5. Were limited in the kind of work or other activities .509 6. During the past 4 weeks, how much did you pain interfer… .651 Average .580 Note. Factor1= depression; Factor 2 = PTSD; Factor3= physical health

Reliability

“Internal consistency describes estimates of reliability based on the average correlation among items within a test” (Nunnally & Bernstein, 1994, p. 251). Cronbach’s alpha was used to estimate the reliability of the RSS, TAIPVS, TIPVFS, EPDS, and PCS of SF-12. The Kuder-

Richardson Formula 20 was used to test the reliability with dichotomous responses on the WHO

Violence against Women Instrument, the Thai Screening Test for PTSD, and exposure to violence. As shown in Table 4.7, coefficient alphas for the RSS (.74), the TAIPVS (.84), the

TIPVFS (.90), the exposure to violence (.75-.84), the PCS (.71), the EPDS (.85), and the Thai

Screening Test for PTSD (.84) within the present study indicate respectable internal consistency for these scales. For the Pregnancy Complications Index, assessing the internal consistency was

103 not appropriate because it was index formative rather than scale reflective. Overall, the measures demonstrated acceptable internal consistency for this study.

Table 4.7.Internal Consistency Reliability Estimates of Instruments

Instruments Items Coefficient Thai version of the Rosenberg’s Self-Esteem Scale (RSS) 9 .74 Thai Acceptance of Intimate Partner Violence Scale (TAIPVS) 16 .84 Thai Intimate Partner Violence Fear Scale (TIPVFS) 10 .90 Exposure to Violence Experiencing of childhood physical and psychological abuse 10 .75 Experiencing of childhood sexual abuse 4 .84 Witnessing interparental violence during childhood 6 .77 WHO Violence Against Women Instrument 18 .80 Negative Physical and Psychological Health Physical Component Summary (PCS) of SF-12 5 .71 Edinburgh Postnatal Depression Scale (EPDS) 8 .86 Thai Screening Test for PTSD 3 .84 The Pregnancy Complications Index 11 N/A

Study Variables Univariate Analysis Descriptive statistics, including means, standard deviation, and frequency were performed to explain the characteristics of participants. Means, standard deviations, range skewness, and kurtosis were performed on each variable to examine the distribution of the values and to describe the normality of the study variables. The outliers were identified using boxplots.

Kolmogorov-Smirnov and Shapiro-Wilk tests and Q-Q plots were used to assess the normality of study variables. Univariate analyses was conducted with the variables of demographic characteristics, self-esteem, acceptance of violence, exposure to violence (included experiencing of child physical and psychological abuse, experiencing of child sexual abuse, and witnessing interparental violence, fear of partner, IPV, maternal physical and psychological health included in the Physical Component Summary (PCS), depression and PTSD, and pregnancy complications.

104

Demographic characteristics.

The average age of participants was 26.19 years (SD = 6.35) with an age range from 18 to 43. Most of the participants (63.5%, n= 193) were primary school or junior high school graduates, 121 (36.5%) had high school or higher degree. Two hundred thirty six participants

(77.6%) were married, 60 (19.7%) were cohabiting, 7 (2.3%) were divorced, widowed or separated, and 1 (0.3%) was single. The average duration of living together was 5.42 years (SD =

4.26) with a range from less than one year to 21 years. Almost 30% of the participants (n= 87) had a relationship for 5-10 years. Participants’ income averaged $220 per month and ranged from 0 to $1,700 USD. Two hundred participants (65.8%) had planned pregnancies while 104

(34.2%) of the pregnancies were unplanned. For the majority of participants, the gestational age ranged from 28 to 42 weeks (58.2%, n=177). One hundred and fifty six participants (51.5%) visited ANC before 12 weeks of gestation. Seven participants (2.3%) smoked and 39 participants

(12.8%) drank alcohol before pregnancy. Only one participant smoked or drank alcohol during pregnancy. No one reported abusing substances before or during pregnancy (Table 4.8).

Table 4.8. Frequencies of Participants Demographic Characteristics

Demographic Characteristics Participants Number Percent Age (N=304) 18-35 years 277 91.1% 36-43years 27 8.9% Education Level (N=304) 6th grade or lower 86 28.3% 9th grade 107 35.2% 12th grade 79 26.0% Associate degree 15 4.9% Bachelor degree or higher 17 5.6% Status (N=304) Married without marriage certificate 138 45.4% Married with marriage certificate 98 32.2% Cohabiting (Not married) 60 19.7% Divorced, Widowed or Separated 7 2.3%

105

Single 1 0.3% Duration of living together ( N=295) 6 months-1 year 57 19.3% 1-3 years 72 25.4% 3-5 years 45 15.3% 5-10 years 87 29.5% 10 years or longer 34 11.5% Income/month (N=303) No income 66 21.8% $40-$166 45 14.8% $167-$333 151 49.9% $334-$1,000 39 12.8% $1,000 or higher 2 0.7% Planned to become pregnant (N=304) Yes 200 65.8% No 104 34.2% Current gestational age (N=304) 1-12 weeks 1 0.3% 13-27 weeks 126 41.5% 28-42 weeks 177 58.2% First visited ANC (N=303) Before 12 weeks 147 48.5% After 12 weeks 156 51.5% Smoking before pregnancy (N=304) Yes 7 2.3% No 297 97.7% Smoking during current pregnancy (N=304) Yes 1 0.3% No 303 99.7% Drinking alcohol before pregnancy (N=304) Yes 39 12.8% No 265 87.2% Drinking alcohol during current pregnancy (N=304) Yes 1 0.3% No 303 99.7% Substance abuse before or during current pregnancy (N=304) No 304 100%

Experience of IPV during current pregnancy.

More than half of participants reported no experience of IPV during their current pregnancy (53.7%) and the majority of those who did experience of IPV during pregnancy experienced controlling behaviors (31.8%). Thirty three of the participants (11.7%) reported

106 experiences of IPV during current pregnancy of more than one type. Few of them (0.4%) experienced all four types of IPV. Only 26.9% of respondents had no exposure to violence during childhood. More than one-fourth of pregnant women experienced witnessing of interparental violence and abuse as a child (Table 4.9).

Table 4.9. Frequencies of Experience of IPV during Pregnancy and Exposure to Violence

Experience of IPV during Pregnancy Participants Number Percent No experience 152 53.7 Psychological abuse 8 2.8 Controlling behaviors 90 31.8 Physical abuse and sexual abuse 1 .4 Physical abuse and controlling behaviors 1 .4 Psychological abuse and sexual abuse 1 .4 Sexual abuse and controlling behaviors 2 .7 Psychological abuse and controlling behaviors 18 6.4 Psychological abuse, sexual abuse, and controlling 4 1.4 behaviors Physical abuse, psychological abuse, and controlling 5 1.8 behaviors Physical abuse, psychological abuse, sexual abuse, and 1 .4 controlling behaviors Total 283 100 No exposure to violence 76 26.9 Any type of child abuse 78 27.6 Witnessing of interparental violence 12 4.2 Any type of child abuse and witnessing interparental 117 41.3 violence Total 283 100

In order to check for outlier variables, boxplots were examined. Points outside the whiskers were identified as outliers. In other words, outliers were all data that were below 1.5 inter-quartile range (IQR) of the lower quartile or above 1.5 IQR of the upper quartile, as shown in Figure 4.1. Twenty-one cases were deleted from the analysis. The total cases for analysis were

283. Seven percent of the cases were trimmed. There was no any missing data in model variables.

107

Figure 4.1.Boxplots of the Study Variables

In order to examine the normality of variables used in this study, the skewness, kurtosis,

Kolmogorov-Smirnov test, Shapiro-Wilk test and Q-Q plot were calculated. Perfect normal

108 distribution has kurtosis of three and skewness should be zero. However, kurtosis and skewness of within -2 and +2 is considered acceptable (Garson, December 16, 2011). In the current study, all study variables except IPV were considered as approximately normal distributions. Kurtosis and skewness were within -2 and +2 (see Table 4.11), and the results from the Q-Q plot (see in

Figure 4.2) indicated that all variables except IPV were approximately normally distributed because almost all of the points fall on or near the straight line. The p-values of Kolmogorov-

Smirnov test and Shapiro-Wilk test for all variables are significant (see Table 4.10). Parameter estimates may remain valid in the face of non-normality (McDonald & Ho, 2002). Failure to meet this assumption, however, will result in increased uncertainly in the p-values.

Table 4.10. Test of Normality of Study Variables

Variables (n=283) Kolmogorov- Smirnov Shapiro-Wilk Statistic sig Statistic sig Maternal Physical and Psychological Health .054 .05 .988 .02 Pregnancy Complications .179 .00 .922 .00 IPV .292 .00 .722 .00 Fear of Partner .111 .00 .948 .00 Exposure to Violence .153 .00 .889 .00 Self-Esteem .166 .00 .950 .00 Acceptance of Violence .101 .00 .978 .00

Table 4.11. Means, Standard Deviation, Range, Skewness, and Kurtosis of Study Variables

Variables M SD Range Skewness Kurtosis Maternal Physical and -0.06 2.19 -4.56-5.86 0.22 -0.59 Psychological Health Pregnancy Complications 1.90 1.39 0.00-6.00 0.38 -0.60 IPV 1.10 1.58 0.00-11.00 1.97 5.91 Fear of Partner 17.10 4.93 10.00-31.00 0.12 -0.86 Exposure to Violence -0.12 1.86 -2.02-6.92 0.99 0.55 Self-Esteem 26.84 2.74 21.00-36.00 0.68 1.30 Acceptance of Violence 27.90 5.63 14.00-48.00 -0.30 0.08

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Figure 4.2. Q-Q Plots of Study Variables

Bivariate Analysis

In order to assess bivariate relationships, linearity, and multicollinearity among the variables, the scatterplot matrixes (SPLOMs) and both Pearson’s and Kendall’s tau correlation coefficients among study variables were examined. The Pearson’s Product-Moment correlation was used to measure the linear relationship among study variables. Kendall’s tau was used to evaluate the relationship between IPV and study variables because IPV extremely violated the normality assumption. As can be seen in Table 4.11 and Table 4.12 and Figure 4.3, the correlations among some study variables were statistically significant. Results indicated that some correlations were not in the expected direction. For example, IPV was slightly, but statistically significantly associated with self-esteem (r = -.12, p < .05) and acceptance of violence (r = .16, p < .01). Self-esteem had a slight, but statistically significant correlation with exposure to violence (r = -.13, p < .05), but acceptance of violence was not significantly associated with exposure to violence (r = .06, p > .05). Also, fear of partner was slightly correlated with exposure to violence (r = .15, p < .01). However, some results are consistent with

110 previous studies. IPV was positively associated with fear of partner (r = .25, p < .01) and exposure to violence (r = .37, p < .01), and fear of partner was moderately significantly associated with acceptance of violence (r = .55, p < .01). In sum, examination of SPLOMs and

Pearson’s Product-Moment correlations indicated that variables were and were not associated in expected directions. In regard to multicollinearity, which means an unacceptably high level of intercorrelation among the independent or exogenous variables (Garson, 2011), there was no significance among study variables. All of the correlation coefficients appeared to be low.

Figure 4.3. Scatterplot Matrixes (SPLOMs) of the Study Variables

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Table 4.12. Variances, Covariances, Correlations, Means and Standard Errors of the Means of the Study Variables in the Path Analysis Variables 1 2 3 4 5 6 7 Negative Physical and 4.80 .37** .32** .26** .32** -.22** .04 Psychological Health Pregnancy Complications 1.13 0.53 .24** .19** .24** -.16** .07 IPV 1.09 .53 2.49 .25** .37** -.12* .16** Fear of Partner 2.78 1.32 1.95 24.24 .15* -.36** .55** Exposure to Violence 1.28 0.63 1.10 1.38 3.45 -.13* .06 Self-Esteem -1.31 -0.60 -0.51 -4.88 -0.66 7.50 -.33** Acceptance of Violence 0.51 0.52 1.38 15.11 -4.86 -5.09 31.57 Mean -0.06 1.90 1.10 17.10 -0.12 26.84 27.90 SE of the Mean .13 .08 .09 .29 .11 .16 .33 Note ** Correlation is significant at the 0.01 level (1-tailed) * Correlation is significant at the 0.05 level (1-tailed). Variances are on main diagonal in italics, with covariances below the main diagonal and correlations above.

Table 4.12. Kendall’s Tau Correlation Matrix of Study Variables

Variables 1 2 3 4 5 6 7 Negative Physical and Psychological 1.00 .28** .24** .17** .22** -.14** .04 Health Pregnancy Complications .21** .15** .20** -.12** .05 IPV .20** .32** -.08 .13** Fear of Partner .11* -.25** .41** Exposure to Violence -.10* .06 Self-Esteem -.21** Acceptance of Violence 1.00 Note ** Correlation is significant at the 0.01 level (1-tailed) * Correlation is significant at the 0.05 level (1-tailed)

Path Analysis

To answer the research questions, a path analysis model was assessed and modified. Path analysis that was developed by Wright (1928) is an extended generalized form of regression. The multiple effects among variables in a path diagram are estimated simultaneously. The path coefficients in a paths diagram point out the direct effects of an independent or exogenous variable on the dependent or endogenous variable. The values of chi-square goodness of fit

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(GOF) are not significant in path analysis, which may indicate an adequate fitting. In addition, multiple indices for GOF may be used to evaluate overall model fit. The purpose of the present research is to test a hypothesized model explaining the relationship among factors influencing

IPV and IPV and maternal health during pregnancy. In this study, the maximum likelihood estimator with robust standard errors (MLR) was used rather than a typical maximum likelihood estimator to deal with non-normally distributed variables. In this case, IPV was especially identified as non-normal. The chi-square GOF, chi square/degree of freedom, Root Mean Square

Error of Approximation (RMSEA), Tucker-Lewis Index (TLI), and Comparative Fit Index (CFI) were used to evaluate the model fit. The hypothesized model was tested for GOF by comparing the observed variance-covariance matrix to the model implied variance-covariance matrix.

Subtraction of the model implied variance-covariance matrix from the variance-covariance matrix yielded the residual matrix, which is used to construct most GOF indexes including chi- square GOF test. The results for the research question were reported as following:

Research question one.

Does the hypothesized model fit the observed data?

Hypothesis one: The hypothesized model will fit the observed data as indicated by multiple tests of goodness of fit (GOF).

The fit indices of the model were χ² (6, N = 283) = 125.115, p = .000, χ²/df = 20.852,

RMSEA = .265, CFI = .569, and TLI = -.293. The fit indices indicated that the hypothesized model was not a good fit the observed data. The path coefficients and the correlations among the variables in the model were examined. The path from acceptance of violence to IPV and the path from self-esteem to IPV were not significant, while other paths were significant. There was no correlation between acceptance of violence and exposure of violence. Based on the results of the

113 hypothesized model as above, the model that was developed based on the Western study and

South Asian study did not fit the empirical data in the pregnant Thai women who live in the rural area. The model needed to be modified based on theoretical reasonability and modification model indices.

Figure 4.4. Hypothesized Model with Standardized Estimates

Note * Correlation is significant at the 0.05 level (1-tailed). ** Correlation is significant at the 0.01 level (1-tailed).

Several paths, including: (a) that path from self-esteem to acceptance of violence, (b) the path from exposure to violence to self-esteem, (c) the path from acceptance of violence to fear of partner, (d) the path from self-esteem to fear of partner, (e) the path from exposure to violence to negative physical and psychological health, (f) the path from fear of partner to maternal physical and psychological health, (g) the path from exposure to violence to pregnancy complication, and

(h) the path of fear of partner to pregnancy complications, were added based on the model modification indices. Based on theoretical plausibility, all paths were added to the model for following reasons.

First, the path from exposure to violence to self-esteem was added using the following findings. Low self-esteem in women who were exposed to violence may result from a feeling of

114 stigmatization that is a negative psychological consequence of childhood abuse (Messman &

Long, 1996). Previous research has indicated that women with experiences of childhood abuse and/or exposure to parental violence had significantly lower self-esteem than non-abused women

(Banyard, Williams, Saunders, & Fitzgerald, 2008; Chan, Brownridge, Yan, Fong, & Tiwari,

2011). As noted as in Finzi-Dottan and Karu (2006), emotional abuse in childhood had a negative direct effect on adult self-esteem (β = -.32, p < .0001). Additionally, women who experienced childhood victimization reported feelings of worthlessness (Schuck & Widom,

2001).

Next, the path from self-esteem to acceptance of violence was deemed scientifically valid to be added to the model because self-esteem can override other behaviors. MacDonald, Holmes, and Murra (1997 as cited in Ali and Toner, 2001) explained that the attitude toward violence was influenced by self-esteem and an individual who had a high level of self-esteem was less likely to accept wife abuse. Burke et al. (1988) found that accepting aggression was related to low self- esteem. The finding emerged that self-esteem had a direct negative effect on acceptance of aggression for women and men who had sustained abuse (β = -.20, p < .01; β = -.16, p < .01, respectively).

Third, the path from acceptance of violence to fear of partner was added based on the literature. There is no research that directly studied the relationship between acceptance of violence and fear of partner; however, there are some clues in the literature to support the statement above. Previous research has revealed that IPV is justified in various situations (Douki,

2003). Comparing two genders in 17 sub-Saharan countries, women were more likely to justify violence under certain circumstances than men (Uthman, Lawoko, & Moradi, 2009). Physical abuse that does not leave a physical mark may be acceptable to some populations (Maman,

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2002). The battered women’s rationales frequently mentioned that staying with their abusive partner was based on beliefs that violence will end and women will be able to endure it (Alsdurf

& Alsdurf, 1989 cited in Rhodes & McKenzie, 1998). Also, women who fear their partner remained in abusive relationships (Morash, 2008). In regard to fear of partner, it is male’s opinion in rural Bangladesh that it is necessary and natural for wives to fear their husbands (S. S.

R. Schuler, 2011). Previous research has revealed that there was a relationship between fear arousal and attitude change (Leventhal, 1966). Both studies found that the higher the level of fear, the higher the level of acceptance. That is, the fear functions to promote the acceptance of

“recommendation action” (Leventhal, 1965). The high fear would facilitate attitude change

(Dewolfe, 1964). In the case of IPV, a woman who fears her partner tries to escape the fear of the tension-building phase when it increases (Rhodes, 1999). However, the general recommendation on attitude to violence based on religious practice, economic dependence, and Thai social norms and culture may result in acceptance of violence. Based on the above information, fear of partner may affect acceptance of violence.

Fourth, the path from self-esteem to fear of partner was added using the following rationales. Self-esteem buffers anxiety for threats in many domains. People need self-esteem because it can help coping with emotional distress, promoting effective behavioral functioning and the growth and expansion of one’s capacities (Pyszczynski, 2004). Smith and Petty (1995) summarized that people with high self-esteem assured in their ability and their effort to succeed, with continued stability of mood, had more skill to protect them against adverse situations.

People with low self-esteem, conversely, had more responses to unwanted feedback and negative effects (S. M. Smith & Petty, 1995). Previous research has suggested that fear is associated with self-esteem. Sackett and Saunder (1999) found that self-esteem was negatively correlated with

116 fear in both groups of battered women who had lived and who did not live in shelters (r = -.25, p

< .05). Likewise, Pillemer and Suitor (1992) stated that family caregivers with low self-esteem reported more fear of violence than caregivers with high self-esteem. Concerning fear of death, there was a negative relationship between the level of self-esteem and fear of death (Stephen,

Martin, Wilee, & Vorhees, 1978). According to Terror Management Theory (TMT), self-esteem seems to lead to useful psychological consequences and provides protection against the fear of death. As discussed above, the path was therefore drawn from self-esteem to fear of partner.

Additionally, the path from exposure to violence to negative physical and psychological health was added. Violence affects health across the life span. A large number of studies examined the relationship between abuse during childhood and its direct effect on health during adulthood. For example, Banyard and co-authors (2008) collected the data from 283 women obtaining social services for family violence and found that multiple types of trauma during childhood including child sexual abuse, child physical abuse, and witnessing IPV were associated with mental health symptoms and psychological distress in adulthood. Similarly, van

Harmelen and collogues (2010) revealed that individuals reporting child abuse including physical, sexual, and emotional abuse and emotional neglect was related to automatic self- anxiety and self-depression associations in a cohort study with 2,981 adults. According to

Igarashi et al. (2011), childhood emotional and sexual abuse had an effect on borderline personality and depression among undergraduate students in Japan. Additionally, child abuse was associated with perceived poorer overall health and adverse physical health outcomes among

1,225 women in Seattle, Washington (E. A. Walker et al., 1999). Due to the findings above, the path from exposure to violence to maternal physical and psychological health was included in the modified model.

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Also, the path from fear of partner to negative physical and psychological health was added. Fear may result in physical and psychological health problems. Fear destroys mental and emotional stability (Teays, 2005). Many studies found that fear was related to mental health problems. According to Brown and authors (2008), women who were afraid of their partners reported higher levels of anxiety. Additionally, fear, stress, and injuries associated with IPV cause several long-term physical health problems including chronic pain and central nervous system symptoms (J. Campbell et al., 2002). Also, fear of partner was associated with sexual

HIV risk (N. N. El-Bassel, 2004; Go, 2006) .

Next, the path from fear of partner to pregnancy complications was added using research findings. According to Brown, McDonald, and Krastev (2008), pregnant women with fear of partner were at increased risk of urinary incontinence, fecal incontinence, and vaginal bleeding.

Last, the path from exposure to violence to pregnancy complications was added. Many studies have examined the effects of childhood exposure to violence on adult health including overall health and complications during pregnancy. According to Lukasee and co-authors (2009), physical, emotional, and sexual abuse as a child affected 16 common complaints in pregnancy such as heartburn, urinary tract infection, headache, and back pain. These data were based on the

Norwegian Mother and Child Cohort Study that included 61,865 pregnancies. Another study focusing on childhood sexual abuse found that pregnant women with experiences of abuse were more likely to have symptoms of discomfort including heartburn, back pain, and pelvic joint syndrome than nonabused women (Grimstad & Schei, 1999). Likewise, Leeners and colleagues

(2010) found that women with experiences of childhood sexual abuse had significantly more pregnancy complications such as premature contractions, cervical insufficiency, and premature birth as well as more frequent hospitalizations during pregnancy (Leeners, Stiller, Block, Görres,

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& Rath, 2010). With regard to emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect as a child, pregnant women with a history of such abuse were significantly more likely to experience pregnancy complications than pregnant women without such a history

(Möhler et al., 2008). As mentioned above, it was therefore reasonable to add the path from exposure to violence to pregnancy complications.

Although several paths were added to the model, the relationships among self-esteem, acceptance of violence and exposure to violence were deleted, as was the path from acceptance of violence to IPV and self-esteem to IPV. Dropping the paths was considered reasonable per the following arguments. There are many studies revealing that IPV results in low self-esteem

(Aguilar & Nightingale, 1994; Cascardi & O'Leary, 1992; M. M. Haj-Yahia, 2000; Tuel &

Russell, 1998). However, it is difficult to determine whether low self-esteem causes IPV or whether low self-esteem results from IPV due to the lack of longitudinal studies. Acceptance of violence may associate with IPV but is not a causal factor for IPV. Also, some women did not accept violence, but they did experience IPV. Concerning the relationships among self-esteem, exposure of violence and acceptance of violence, the relationship between exposure to violence and acceptance of violence was removed from the model because this relationship was not significant. The relationship between acceptance of violence and exposure to violence was changed to test the cause and effect instead of correlation because the correlation coefficient between both variable was weak (r = -.13, p < .05). Changing the status of these variables from the exogenous to endogenous part of the model allowed for a better test of these variables’ effects on IPV.

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The fit indices of the final model were χ² (7, N = 283) =12.865, p = .076, χ²/df = 1.84,

RMSEA = .054, CFI = .980, and TLI = .941. The fit indices indicated that the final model fit the observed data. The direct effects between variables in Figure 4.5 were all significant.

Figure 4.5. Final Model with Standardized Estimates.

Note * Correlation is significant at the 0.05 level (1-tailed). ** Correlation is significant at the 0.01 level

(1-tailed).

Research question two.

What factors influence IPV during pregnancy? Several hypotheses were tested to understand the relationship between the factors in the model and IPV. Both direct and indirect relationships were tested.

Hypothesis 2a. Pregnant Thai women’s acceptance of violence has a significantly direct positive effect on IPV during pregnancy.

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In the final model, the direct path from acceptance of violence to IPV was deleted because the path was not significant in the hypothesized model. This finding indicated that pregnant Thai women’s acceptance of violence did not positively affect pregnant women’s IPV.

Hypothesis 2b. Pregnant Thai women’s exposure to violence has a significantly direct positive effect on IPV during pregnancy.

Pregnant Thai women’s exposure to violence had a direct positive effect on IPV during pregnancy (β = .34, p < .01).

Hypothesis 2c. Pregnant Thai women’s exposure to violence has a significantly direct positive effect on pregnant women’s fear of partner.

Pregnant Thai women’s exposure to violence had a significantly direct positive effect on pregnant women’s fear (β = .11, p < .01).

Hypothesis 2d. Pregnant Thai women’s fear has a significantly direct positive effect on

IPV during pregnancy.

Pregnant Thai women’s fear had a significantly direct positive effect on IPV during pregnancy (β = .20, p < .01).

Hypothesis 2e. Pregnant Thai women’s self-esteem has a significantly direct negative effect on IPV during pregnancy.

In the final model, the direct path from self-esteem to IPV was deleted because the path was not significant in the hypothesized model. This finding indicated that pregnant Thai women’s self-esteem did not positively affect IPV during pregnancy.

Hypothesis 2f. Pregnant Thai women’s exposure to violence has a significantly indirect effect on IPV during pregnancy through pregnant women’s fear of partner.

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Hypothesis 2g. There has a significantly positive relationship between exposure to violence and acceptance of violence.

In the final model, the relationship between exposure to violence and acceptance of violence was removed because the relationship was not significant in the initial model. This finding indicated that there was no relationship between exposure to violence and acceptance of violence.

Hypothesis 2h. There is a significantly negative relationship between self-esteem and acceptance of violence.

The relationship between self-esteem and acceptance of violence was removed from the model. The path from self-esteem and acceptance of violence was added. The standardized coefficient from self-esteem to acceptance of violence was -.15 (β = -.15, p < .01). This finding indicated that pregnant Thai women’s self-esteem had a significant direct negative effect on pregnant women’s to acceptance of violence.

Hypothesis 2i. There has a significantly negative relationship between exposure to violence and self-esteem.

In the final model, the relationship between exposure to violence and self-esteem was removed. However, the path from exposure to violence self-esteem was added. The standardized coefficient from self-esteem to acceptance of violence was -.13 (β = -.13, p <. 01). This finding

122 indicated that pregnant Thai women’s exposure to violence had a significantly direct negative effect on pregnant women’s self-esteem.

Research questions three.

Does the experience of IPV during pregnancy have an effect on adverse maternal health among pregnant women in Thailand?

Hypothesis three. IPV during pregnancy will have a significant direct effect on their adverse maternal health.

IPV during pregnancy had a significant positive direct effect on both pregnancy complications and negative physical and psychological health. The standardized coefficient from

IPV to pregnancy complications and adverse physical and psychological health was .15 and .19, respectively (β = .15, p < .01; β = .19, p < .01)

Summary

In conclusion, all instruments that were used in the current study were tested for construct validity and reliability. There were changes in some instruments based on psychometric properties. Overall the instruments demonstrated acceptable internal consistency for this study.

With regard to the hypothesized model, the model did not fit the empirical data. Therefore, the hypothesized model was modified using theoretical perspectives and statistical results. All paths that were not significant were removed from the model and some variables were changed from the exogenous to endogenous part of the model. After performing path analysis on the modification model, this model fit very well with the empirical data. The findings were: (a) pregnant Thai women’s acceptance of violence did not positively affect IPV during pregnancy,

(b) pregnant Thai women’s exposure to violence had a direct positive effect on IPV during pregnancy, (c) pregnant Thai women’s exposure to violence had a significantly direct positive

123 effect on pregnant women’s fear of partner, (d) pregnant Thai women’s fear of partner had a significantly direct positive effect on IPV during pregnancy, (e) pregnant Thai women’s self- esteem did not positively affect IPV during pregnancy,(f) pregnant Thai women’s exposure to violence had a significant indirect effect on IPV during pregnancy through pregnant women’s fear of partner, (g) there was no relationship between exposure to violence and acceptance of violence among pregnant Thai women, (h) pregnant Thai women’s self-esteem had a significant direct negative effect on pregnant women’s acceptance of violence, (i) pregnant Thai women’s exposure to violence had a significantly direct negative effect on pregnant women’s self-esteem, and (j) pregnant Thai women’s IPV had a significant positive direct effect on both pregnancy complications and negative physical and psychological health.

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CHAPTER FIVE: DISCUSSION

The purpose of this research was to test a hypothesized model explaining the relationship between IPV and factors influencing IPV including self-esteem, acceptance of violence, fear of partner, and exposure to violence and the relationship between IPV and adverse maternal health including negative physical and psychological health as well as pregnancy complications, using path analysis. The direct and indirect effects of exogenous and preceding variables on endogenous variables were explored. This chapter presents a discussion of the study findings. In addition, implications to nursing, strengths and limitations of the study, and recommendations for the future are presented.

Discussion of the Study Findings

Research Question One

Does the hypothesized model fit the observed data?

Hypothesis one: The hypothesized model will fit the observed data as indicated by multiple tests of goodness of fit (GOF).

The hypothesized model did not initially have a good fit with the observed data based on multiple results of GOF. The hypothesized model needed to be modified based on both theoretical perspectives as well as statistical results. All paths that were not significant were removed from the model and the status of some variables changed from the exogenous to the endogenous part of the model. After performing path analysis on the modified model, the last model tested fit very well with the empirical data. The important modifications were that the path from self-esteem to IPV and the path from acceptance of violence to IPV were deleted. Also, many paths were added to the modified model including: (a) the path from self-esteem to acceptance of violence; (b) the path from exposure to violence to self-esteem; (c) the path from

125 acceptance of violence to fear of partner; (d) the path from self-esteem to fear of partner; (e) the path from exposure to violence to negative physical and psychological health; (f) the path from fear of partner to maternal physical and psychological health; (g) the path from exposure to violence to pregnancy complications; and, (h) the path of fear of partner to pregnancy complications. The plausible rationale to explain why the initial model did not fit with the observed data, but the modified model did fit well with the observed data, consists of two explanations given below.

The first plausible explanation accounting for the differences may be that the hypothesized model was developed based on the Western, south Asian and African literature of factors influencing IPV. The initial model cannot therefore completely transfer to pregnant Thai women living in rural areas due to culture differences. With regard to Thai culture, Thailand has the cultural norm of a patriarchal society where male domination and female subordination are accepted as natural and normal. The social definition of partner violence, including dating violence, is limited based on beliefs that husbands/partners have more authority and power than their wives (Pradubmook, 2005). As a result, women do not view some actions as abuse, such as forcing sex against their will (Brownmiller, 1975 as cited in Pradubmook, 2005). Furthermore, the differences may have to do with different target populations related to the hypothesized model being developed based on a variety of study samples such as teenagers, non-pregnant women, and pregnant women. The hypothesized model did not develop based on only the literature of IPV during pregnancy alone.

The second plausible explanation accounting for the differences may be that the hypothesized model was developed based on the previous literature that used correlation, regression, and odds ratios that could not detect indirect effects between both variables. In the

126 current study, path analysis was used to test and modify the model, and path analysis can examine both direct and indirect effects between variables in the path diagram.

Research Question Two

What factors influence IPV during pregnancy?

Hypothesis 2a: Pregnant Thai women’s acceptance of violence will have a significantly direct positive effect on IPV during pregnancy.

Pregnant Thai women’s acceptance of violence did not positively affect IPV during pregnancy. This result was not consistent with the results of the previous studies (Boyle et al.,

2009; Faramarzi, Esmailzadeh, & Mosavi, 2005; Hindin, Kishor, & Ansara, 2008; O'Keefe &

Treister, 1998; M. D. Smith, 1990; Xiaohe Xu, 2011). However, this was not the case among the studies examining violence during pregnancy. The findings in the current study were consistent with another study examining IPV during pregnancy (Clark et al., 2009), which determined that the acceptance of violence did not affect IPV during pregnancy.

According to a recent study conducted with 770 Thai wives living in an urban area, the wives who obtained higher scores on the ‘approval of wife abuse index’ had more experience in physical, psychological, and sexual abuse, but the authors cautioned that this association between approval of wife abuse and IPV was not a predictive finding and was an associative relationship instead (Xiaohe Xu, 2011). Likewise, the WHO study in Thailand found that abused women were more likely to report high levels of acceptance of violence compared to non-abused women

(Archavanitkul et al., 2005) .

The current study found that acceptance of violence was significantly associated with

IPV during pregnancy (r = .16, p < .01) and women abused during pregnancy scored higher on the acceptance of violence than non-abused women. Mean scores of abused women and non-

127 abused women were 28.70 and 27.20, respectively. It is important to note that acceptance of violence was not a predictor of IPV, although the two constructs were correlated. The findings of the current study provided some support for the model that acceptance of violence were related to IPV during pregnancy. As discussed in Chapter Two, Thai Buddhism’s gender hierarchy and traditional Thai family norms encourage women to tolerate or accept IPV if it “serves to maintain male superiority and to reestablish familial or social order” (Hoffman et al., 1994;

Limanonda, 1995 cited in Xiaohe Xu, 2011 p.793). The higher the acceptance of violence reported, the higher the level supported for traditional gender roles (Flood & Pease, 2009).

Most pregnant Thai women responding did not accept violence. The mean for acceptance of violence in the current sample was 27.90 out of 64. One plausible explanation was that many campaigns have been implemented such as: (a) the “Youth Say NO to Violence against Women” program that made a new generation in Thai schools fully cognizant of women’s rights; (b) awareness-raising events such as role-model contests and bicycle caravans; and, (c) special sessions organized by provincial public prosecutors with masses of people including teachers, students, civil servants, and other community members to educate people about their rights and responsibilities under anti-violence laws (United Nation, 2011). Community attitudes toward domestic violence against women (DVAW) affect, foster, condone, and inflict DVAW and shape the social environment (Gracia & Herrero, 2006). Not surprisingly, many campaigns in Thailand were social-level interventions aimed at increasing the community’s awareness. IPV will continue to be a problem in Thailand; not because women accept violence, but because men still strongly believe in patriarchal control as well as traditional gender roles and the community condones violence and blames the victims.

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With regard to the rate of IPV during pregnancy, the findings from the current study showed that the participants reported higher rates of IPV during pregnancy than previous research has reported. The occurrence of IPV during pregnancy was 49.2% while previous studies reported 4% to 48%, depending upon the definition, random or non-random samples, and the settings that were used in the studies. Comparing the current study to another random sample study, the rates were 49.2% and 4%, respectively, for women experiencing IPV during pregnancy (Archavanitkul et al., 2005). Three possible rationales may be considered to explain the different results. First, the IPV definitions of the studies were different. In the current study, the operationalization of IPV included physical, psychological, and sexual violence as well as controlling behaviors. Adding the latter construct may increase the calculated rate of IPV during pregnancy. Second, there were setting differences between the community setting used in the previous study and the hospital setting used in the current study. The hospital settings usually obtain higher rates of prevalence of IPV than rates from community settings or population-based study because samples would be expected to include a large proportion of abuse women

(Campbell, 2002). Last, the previous study asked women who had been pregnant to recall IPV during pregnancy; therefore, the prevalence may be underestimated or the memory effect may have an unknown consequence on the results.

Hypothesis 2b: Pregnant Thai women’s exposure to violence will have a significantly direct positive effect on IPV during pregnancy.

In the current study, nearly three-quarters (73.1%) of the respondents reported exposure to violence as a child. The respondents who were exposed to violence reported more IPV during pregnancy. The current study found that pregnant Thai women’s exposure to violence had a direct positive effect on IPV during pregnancy (β =.34, p <.01). This result was consistent with

129 several previous studies (Castro, Peek-Asa, & Ruiz, 2003; Clark et al., 2009). Additionally, this result supports the finding that exposure to violence during childhood is associated with later

IPV victimization among women (Bensley et al., 2003; Castro et al., 2003; Clark et al., 2009;

Hotaling & Sugarman, 1986; Jeyaseelan et al., 2007; Kerley et al., 2010; Kimerling et al., 2007;

Kishor & Johnson , 2004; Schewe et al., 2006; Simonelli et al., 2002). This current finding suggested this relationship between Thai women’s childhood exposure to violence and IPV during pregnancy was not spurious. According to Kerly and co-authors (2010), exposure to violence as a child was likely to place Thai women in a susceptible position because exposure to violence was related to later victimization and perpetration in adulthood. While Thai women were at increased risk to become a victim, Thai men were at increased risk to become an abuser.

Exposure to violence during childhood may lead Thai women to be in the vulnerable position of

IPV across their life span, including while pregnant.

A recent study conducted in Thailand with 202 young residents, a representative sample in a larger urban area, found that 38% of the participants experienced some form of abuse during childhood and 8.5% witnessed maternal battering. The results from the current study revealed that participants reported higher experiences of exposure to violence as a child than found in previous research. One possible explanation may be that the previous research collected data from teens of both sexes who were residents of a larger urban area in Thailand. However, both of these studies demonstrated this result using representative sampling, and the results therefore suggest that higher rates of both indirect exposure to violence as witnessing parental abuse and direct exposure as experiencing abuse during childhood may be found in Thailand, including in urban areas that have not been studied.

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Hypothesis 2c: Pregnant Thai women’s exposure to violence will have a significantly direct positive effect on pregnant women’s fear of partner.

The current study found that pregnant Thai women’s exposure to violence had a significantly direct positive effect on pregnant women’s fear of partner (β = .11, p <.01). This finding confirms the results reported by Ulloa et al. (2009) and Cohen, Deblinger, Maedel, and

Stauffer (1999). Women exposed to violence during childhood may suffer a wide range of physical, psychological, and interpersonal difficulties that may persist into adulthood (Runyon et al., 2004). However, this was not the case in the studies examining violence during pregnancy.

There is no research to date that directly studied the relationship between exposure to violence and fear of partner among pregnant Thai women. The possible explanations of why exposure to violence affected the variable of fear of partner are (a) long-term consequences of exposure to violence during childhood and (b) Thai culture.

In relation to long-term consequences of exposure to violence as a child, victims of child abuse are more likely to experience chronic feelings of anxiety and fearfulness (Davis &

Petretic-Jackson, 2000). They may feel a sense of betrayal, insecurity, and mistrust toward adults who are traditionally seen as trustworthy and protective (J. N. Briere & Elliott, 1994; Davis &

Petretic-Jackson, 2000) and victimization may obstruct a child’s developing belief in safety and a sense of security (J. Briere, 1992). Many common mental disorders in adulthood were associated with exposure to violence as a child (T. Jirapramukpitak et al., 2010). According to McGee

(2000), children who witnessed family violence had generalized fear of and anger to other abusers or any men at all. Participants in this study felt fearful of any men that might commit violence to them or their mothers. Additionally, the teenagers participating in the study who were involved in romantic relationships reported fear of being abused like their mothers.

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Concerning Thai culture, Thai husbands seem to have more power and authority than their Thai wives. Traditionally, the wives were required to honor, obey, and show respect to their husbands. Conversely, Thai husbands who showed control over their wives or not caring too much for their wives made the husbands heroes to their peers (Pinyuchon, 1997).

The findings from the current study suggested that the fear that exposure to violence during childhood inspires was linked to the fear of their partners among pregnant Thai women during adulthood. Also, the current study provided empirical data that exposure to violence as a child was a predictor of fear of partner in adulthood. The effect of exposure to violence may create long-term consequences and predict fear of partner, especially in Thailand where patriarchy is strong. Wives are expected to show respect to their husbands and fear them when necessary.

Hypothesis 2d: Pregnant Thai women’s fear will have a significantly direct positive effect on IPV during pregnancy.

Pregnant Thai women’s fear of partner had a significantly direct positive effect on IPV during pregnancy (β = .20, p <.01). The results of the current study were consistent with some previous literature (S. M. Stith et al., 2004; Ulloa et al., 2009). Fearfulness and coercion within marital relationships may lead to IPV because a male partner who generates fear can greater dominate and control the relationship (Ulloa et al., 2009; Wekerle & Wolfe, 1999). The feeling of fear and subsequent lack of control may be related to the expectancy of being abused. Fear may “make women more vulnerable to controlling and violent relationships” (Ulloa et al., 2009, p. 879), and wives become more fearful of their husbands. As a result, maladaptive responses to dangerous situations, such as reacting and poorly assessing to a threat, may occur (Ulloa et al.,

2009). On the other hand, wives who fear their partners or potential violent reactions may accept

132 degrading or humiliating sexual intercourse as well as condom negotiation (Wingood &

DiClemente, 1997). That is, women who felt fear of their husbands were likely to become abused. Findings from Ulloa, Jaycox, Marshall, and Collin (2004) revealed that women who experienced fear within dating relationships may have less knowledge and understanding of abuse and its associated consequences, leaving them vulnerable to dating violence victimization.

The results from the current study demonstrated empirical data that suggests that fear of partner is related to an increased risk for IPV victimization during pregnancy. The relationship between both variables was not spurious.

Hypothesis 2e: Pregnant Thai women’s self-esteem will have a significantly direct negative effect on IPV during pregnancy.

In the final model, the direct path from self-esteem to IPV was deleted because the path was not significant. This finding indicated that pregnant Thai women’s self-esteem did not positively affect IPV during pregnancy. The results from this current study were consistent with previous research (C. S. Lewis et al., 2006). Even though self-esteem failed to affect IPV, there was a significant negative association between self-esteem and IPV (r = - .12, p < .05). The findings in this study add support to the growing evidence showing that IPV is negatively related to self-esteem (Hartik, 1978; Hudson & McIntosh, 1981; Hofeller, 1980 as cited in Hotaling &

Sugarman, 1986). This relationship does not denote a causal relationship. It is not clear whether women had low self-esteem prior to being in the relationship or if it developed after the violence occurred in the relationship (Follingstad et al., 1998 cited in O’Keefe & Treister, 1998).

With regard to IPV and self-esteem, both variables may be causally bidirectional. IPV may make victims of IPV have less self-esteem, and women with low self-esteem may be more likely to become victims of IPV. The current study examined the effect between self-esteem and

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IPV including physical, psychological, and sexual abuse as well as controlling behaviors. In previous research, self-esteem demonstrated negative direct effects on sexual violence (Burke et al., 1988), and psychological maltreatment (Jezl, Molidor, & Wright, 1996; Stets, 1991). This study did not examine the effect between self-esteem and each type of IPV which might explain that self-esteem was not found to affect IPV during pregnancy.

Hypothesis 2f: Pregnant Thai women’s exposure to violence will have a significantly indirect effect on IPV during pregnancy through pregnant women’s fear of partner.

Pregnant Thai women’s exposure to violence had a significant indirect effect on IPV during pregnancy through pregnant women’s fear of partner (β = .018, p < .01). The direct effect from exposure to violence and IPV was .34 (p < .01). The total effect of exposure to violence on pregnant women’s IPV through pregnant women’s fear of partner was .319 (p < .01). The current findings were consistent with one previous study (Ulloa et al., 2009). However, there are some differences between these studies. In the previous study, the exposure to violence was measured only via sexual abuse as a child. The current study’s examination of exposure to violence included physical, psychological, and sexual abuse, as well as witnessing interparental violence during childhood. The findings from the current study fill the gap that exposure to violence during childhood (both direct and indirect violent experiences) linked fear of partner and IPV during pregnancy. Additionally, this finding adds support to the growing empirical evidence showing the importance of the mediated relationship between fear of partner, exposure to violence, and IPV during pregnancy (Ulloa et al., 2009). Exposure to violence caused extreme fear and may contribute to the development of fear toward any male. Fear may also be carried into teenage years or adulthood. Children with unsolvable fear issues had increased vulnerability to victimization during adulthood due to inadequately dealing with the threat later (Cassidy &

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Mohr, 2001). The current finding provided evidence that exposure to violence as a child caused fear and that those women carried fear into adulthood. Women with exposure to violence during childhood were more likely to fear their partners than women without such experiences. Women who had higher levels of fear of partner reported more experiences of IPV during pregnancy.

Findings from the current study suggest that fear is a predictor variable of IPV during pregnancy and fear is a criterion variable of exposure of violence, while fear is a mediator of exposure to violence and IPV during pregnancy. The fear resulting from exposure to violence during childhood was likened to revictimization during pregnancy.

Hypothesis 2g: There is a significantly positive relationship between exposure to violence and acceptance of violence.

The relationship between exposure to violence and acceptance of violence was removed from the final model because the relationship was not significant in the initial model. This finding indicated that there was no relationship between exposure to violence and acceptance of violence. This was consistent with a study conducted by O’Keefe and Treister (1998) that found interparental violence during childhood and parent–child abuse did not have a significant correlation with acceptance of violence in dating relationships (r = .08, p > .05 and r = .03, p >

.05). The finding that emerged from O’Keefe and Treister’s study (1998) is similar to that found by Smith & Williams (1992). The link exists between exposure to violence that includes both experiencing abuse and witnessing abuse during childhood, and a later acceptance of violence

(Khawaja, Linos, & El-Roueiheb, 2008; Lawoko, 2006; Ponce et al., 2004; Vung & Krantz,

2009). Exposure to violence is one factor that was studied, but many factors may influence attitudes toward violence against women including: (a) socioeconomic factors, (b) race and ethnicity, (c) the individual factors of age and development, (d) social relations, cultures,

135 policies, and other characteristics of formal organizations and institutions, (e) community factors such as pear groups and informal social relations, religion, spirituality, and church, and (f) the society factors of mass media, criminal justice policies, laws, and social movement (Flood &

Pease, 2009). As discussed in Chapter Two, many factors may produce IPV and tolerate attitudes to IPV in Thailand, such as Buddhism and family context. Traditional gender roles under Thai culture seem to strongly promote acceptance and tolerance of violence. It is impossible to infer that acceptance of violence is associated with exposure to violence as a child among pregnant

Thai women, based upon the results from the current study.

Hypothesis 2h: There is a significantly negative relationship between self-esteem and acceptance of violence.

In the final model, the relationship between self-esteem and acceptance of violence was removed. The path from self-esteem and acceptance of violence was added. The standardized coefficient from self-esteem to acceptance of violence was -.15 (β = -.15, p < .01). This finding indicated that pregnant Thai women’s self-esteem had a significant direct negative effect on acceptance of violence. The current finding was consistent with several previous studies (Ali &

Toner, 2001; Burke et al., 1988). Additionally, the current study provides empirical evidence to support the findings of MacDonald, Holmes, and Murra (1997) who explained that attitudes toward violence were influenced by self-esteem and an individual who had a high level of self- esteem was less likely to accept wife abuse. Findings also support the notion that some dysfunctional behaviors related to “low self-esteem reflect maladaptive attempts to increase one’s acceptance by other people” (Leary, 1995, p. 299 ). For example, women with low self- esteem may accept violence and humiliation in the pursuit of love (Rajani & Kudrati, 1996 cited in Lalor, 2004). From the current findings, we can infer that Thai women with low self-esteem

136 accepted violence in the marital relationship because they needed acceptance from their partners.

Similarly, pregnant women with low self-esteem may not refuse sexual abuse such as oral and anal sexual activity, because wives needed to please their partners so as to obtain acceptance from their husbands.

In this current study, the path from fear of partner to acceptance of violence was added to the final model. The results revealed that fear of partner have a significantly positive direct effect on acceptance of violence. The alternative explanation may be related to Thai culture, which puts a strong emphasis on family context. Traditionally, Thai wives were required to obey, honor, take care and support their husbands. Thai wives positions seemed less powerful, and were socially and economically inferior to their Thai husbands. Thai women were taught to place themselves behind their family, husband, and children. With regard to male opinion in patriarchal society, wives’ fear of their husbands was considered natural and important (S. S. R.

Schuler, 2011) and the dominant man used fear to control the woman, wanted care and nurturing, and showed little remorse (Saunders, 1992). As discussed above, fear of partner and tolerance of adverse situations were promoted in marital relationships among Thai women. Concerning tolerance and acceptance of violence as a “recommendation activity” for traditional Thai gender roles, the current findings adds empirical data to support the notion of fear promoting the acceptance of “recommendation activity” and fear facilitating attitude change (Rhodes, 1999). It was not surprising that fearful women scored higher on acceptance of violence. However, further empirical studies are needed to elaborate on this relationship.

The path from self-esteem to fear of partner was also added. The results revealed that self-esteem had a direct negative effect on fear of partner. Findings add support to the notion that self-esteem buffers anxiety about threats in many domains. According to Taylor-Loughran et al.

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(1989), fear is a feeling of dread with distinctive sources that one can identify and validate, but anxiety is a feeling of dread with a non-distinctive source that one cannot identify and validate.

As mentioned above, self-esteem can also buffer fear for threats in many domains.

It is important to note that self-esteem did not play a role influencing IPV during pregnancy, but self-esteem did affect fear of partner and acceptance of violence among pregnant

Thai women. However, further empirical studies are needed to elaborate this relationship among these variables.

Hypothesis 2i: There is a significantly negative relationship between exposure to violence and self-esteem.

The relationship between exposure to violence and self-esteem was also removed from the final model. Instead, the path from exposure to violence and self-esteem was added. The standardized path coefficient was statistically significant from self-esteem to acceptance of violence (β = -.13, p < .01). The current finding was consistent with several other studies

(Banyard et al., 2008; Chan et al., 2011; Sachs-Ericsson et al., 2010). One possible explanation of the current findings was that low self-esteem in women who were exposed to violence may result from a feeling of stigmatization that was a negative psychological consequence of childhood abuse (Messman & Long, 1996). Further, findings strongly support that having witnessed interparental violence in childhood and being abused as a child significantly increased low self-esteem in adulthood among pregnant Thai women. This effect can have long-lasting consequences in the victim’s mind. However, the results revealed that pregnant women with low self-esteem were not at significantly increased risks of IPV during pregnancy. Self-esteem therefore could be the sequelae of IPV rather than factors influencing IPV themselves among pregnant Thai women.

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Research Questions Three

Does the experience of IPV during pregnancy have an effect on adverse maternal health among pregnant women in Thailand?

Hypothesis Three: IPV during pregnancy will have a significant direct effect on their adverse maternal health.

IPV during pregnancy IPV had a significant, positive direct effect on both pregnancy complications and negative physical and psychological health. The standardized path coefficient from IPV to pregnancy complications and adverse physical and psychological health was .15 and

.19 respectively (β = .15, p < .01; β = .19, p < .01). Findings in this study were consistent with many previous studies. Current findings add support to growing evidence showing the effect of

IPV on pregnancy complications (Bacchus, Mezey, & Bewley, 2004; El Kady et al., 2005;

Janssen, 2003; Kim et al., 2010; J. McFarlane et al., 1996; Moraes et al., 2009; Silverman et al.,

2006). This finding strongly supported previous evidence that IPV during pregnancy affected negative physical and psychological health (Bonomi et al., 2006; J. Campbell et al., 2002; A. L.

Coker et al., 2005; J. Lee et al., 2007; McCauley et al., 1995; Rodriguez et al., 2008; Ruiz-Perez et al., 2007; Yoshihama et al., 2009; C. Zlotnick et al., 1998; C. Zlotnick et al., 2006).

Additionally, findings from the current study revealed that fear of partner affected pregnancy complications as well as negative physical and psychological health. Exposure to violence affected pregnancy complications as well as negative physical and psychological health.

These findings were consistent with previous studies (Brown et al., 2008; Leonard, 2005;

Lukasse et al., 2009; Möhler et al., 2008).

The results from the current study revealed that both fear of partner and exposure to violence influenced IPV and affected negative physical and psychological health and pregnancy

139 complications. An explanation for the effect from exposure to violence, and adverse maternal health, is that long-term effects of childhood abuse can continue to adulthood. Moreover,

McCauley and associates (1995) found that women with a history of childhood abuse had long- term health consequences as strong as for women experiencing current abuse. Heimstad and associates (2006) found that women who reported sexual and physical abuse in childhood had higher scores of fear of childbirth and subjective anxiety that led to abnormal labor. The results were comparable to Lukasse and co-authors (2010). It is notable that abuse in childhood is a risk factor for adverse maternal health.

One explanation of why fear of partner affected both negative physical and psychological health and pregnancy complications is that when fear is present human bodies initiate a physiological chain reaction by launching stress hormones into the body system. Significant adverse consequences such as heart tissue damage and/or a compromised immune system can happen, especially if the physiological responses are repeatedly generated by fear over an extended period of time. The heart tissue damage can lead to cardiovascular disease and a compromised immune system increases vulnerability to cancer and many other health concerns.

Fear can aggravate existing conditions such as diabetes mellitus, hypertension, coronary artery disease and peptic ulcer (Hassett, 2002). Carrington (1975) stated that “It is an interesting fact that fear and all depressing emotions of a similar nature serve to constrict or contract the body”

(p. 26). It is noteworthy that pregnant Thai women who were fearful of their partner were more likely to report abuse during pregnancy and poor maternal health.

Conclusion

The hypothesized model did not initially fit the data; thus, the model was modified based on theory and statistical suggestions. All study variables were retained in the modified model,

140 but some paths that were not statistically significant were deleted. Also, paths were added to the model and the status of some variables then changed from the exogenous to the endogenous part of the model. Finally, the modified model provided a good fit to the data. The results from the current study found that self-esteem and acceptance of violence did not affect IPV during pregnancy; meanwhile, exposure to violence and fear of partner did affect IPV during pregnancy.

IPV during pregnancy, fear of partner, and exposure to violence affected adverse maternal health. Exposure to violence affected fear of partner and self-esteem. Acceptance of violence was affected by both self-esteem and fear of partner. Additionally, exposure to violence had a significant indirect effect on IPV through fear of partner. The results were consistent with some previous studies, but several results need to be independently confirmed. In summary, the final model demonstrated the relationship among factors influencing IPV, IPV during pregnancy, and adverse maternal health in the context of Thai culture.

Implications for Nursing

The current findings provided comprehensive evidence to increase understanding of IPV during pregnancy, factors, and the effect of IPV on maternal health during pregnancy. Some implications based on the current findings are discussed below.

The results showed that exposure to violence, fear of partner, and IPV during pregnancy affected maternal health adversely, including negative physical and psychological health, as well as pregnancy complications. Screening for IPV in Obstetric and Gynecological Departments which provide prenatal, delivery, and postnatal services is not done routinely in many hospitals in Thailand. These findings have direct implications for routine screening of IPV, fear of partner, and a history of exposure to violence during childhood. The screening questions should have

141 good sensitivity for identifying IPV and fear of partner and should be included in the routine health assessment for any prenatal, delivery, and postnatal services.

The treatment of pregnant women with a history of exposure to violence as a child should be of concern. Thai nurses may not be aware of long-term negative effects of exposure to violence on maternal health during pregnancy, delivery, and the post-partum period. The current findings have shown that there are adverse consequences of exposure to violence on maternal health and pregnancy complications that should be addressed. In addition, exposure to violence as a child may affect self-esteem in adulthood.

Child and family health nurses and multidisciplinary teams must be developed to plan effective primary prevention programs for IPV. The programs may include parent training programs and home visiting programs for preventing child maltreatment to interrupt factors influencing IPV to protect future generations. Examples of these might be programs that educate how to manage children’s behavior positively with non-violent disciplinary techniques, and how to foster children’s problem-solving, anger management, impulse control, conflict resolution and social skills (Harvey, Garcia-Moreno, & Butchart, 2007). Also, training programs for children are necessary such as cognitive–behavioral skills training and social development programs to reduce aggressive behavior. There are no parents’ preparation programs and parenting programs to prevent child abuse in Thailand. So, the first part of the programs may begin by nurses providing primary care at prenatal care units and family planning units using individual training or group training. Then visiting nurses, home-health nurses, social workers, or teachers may continue the programs until the programs end.

Nurses are in a position to work practically in order to save women’s lives and reduce consequences of IPV. At least once during pregnancy, most pregnant women will visit their

142 health care provider. Obstetric/Gynecology nurses and Nurse-Midwives allow the opportunity to address IPV. Asking all women about their experience with violence is important. This must be done confidentially and can occur during any patient encounter including during prevention- related visits. Nurses should identify, and refer pregnant women who are victims of IPV.

Identification of pregnant women can make women feel that nurses are concerned about their health and safety and women can get appropriate treatment decreasing the women’s sense of helplessness and entrapment (Bryant & Spencer, 2002). In addition, nurses can help victims to get treatment, provide educational and community resources, and refer pregnant women who are victims of IPV to the “One Stop Crisis Centers”, at public hospitals around the country which were established for helping women and children suffering from violence. Each center provides multidisciplinary team support for health, emotional, and social needs of victims. After referring, nurses should continue to follow up with the victim; however it is the woman’s decision. Also, nurses should provide information about women’s rights to the victims because the primary care setting and hospital may be the first places that victims seek care, and the victims may not have chance to get any information about these rights. Nurses, additionally, have a significant role of empowering women to protect their rights, and promote their own health living without IPV, and to promote attitudes that proactively prevent IPV.

Several nursing training programs, nursing educational program and protocols for IPV need to be developed for Thai nurses such as training programs on what to do when a patient discloses IPV. Adequate provider training for IPV screening and IPV protocols can help nurses in prenatal, intrapartum, and postpartum care units for screening, identifying, and referring victims.

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Strengths and Limitation of the Study

The current study has three major strengths. First, the sample in the study was a probability sample and included a large enough sample to identify statistically significant differences in the study variables. Second, the measures demonstrated acceptable internal consistency for this study. Lastly, the model can be estimated and tested direct and indirect causal effects simultaneously.

The results of the study must be interpreted in light of the following limitations. First, it is cross-sectional in nature. Despite confirmation of the significant associations among factors influencing IPV, IPV during pregnancy, and adverse maternal health, the study was unable to establish causal relationships between the variables. Longitudinal data from representative samples may clarify this issue.

Second, the data were collected using a self-report questionnaire, so the prevalence of

IPV and maternal health may be underestimated or overestimated. Also, some of the questions used to gather information relied on recall of past events and it is likely that unreliable memories of childhood abuse may have an unknown effect on the results.

Third, the prevalence of IPV in the current study population may have been overestimated because controlling behaviors were included to measure IPV. On the other hand, the prevalence of IPV and complications during pregnancy may also have been underestimated, because the data collected from the pregnant women had varied current gestational ages ranging from 12 weeks to 42 weeks, and proportionately more pregnant women with gestational ages less than 38 weeks (86%).

Fourth, the findings of the current study can interpret IPV as overall IPV during pregnancy, but cannot classify each type of IPV such as physical or psychological abuse. The

144 exposure to violence measured the overall picture of exposure to violence including physical, psychological, and sexual abuse, as well as witnessing of interparental violence as a child.

The final limitation is that the target population did not include teenage pregnancy.

Factors influencing IPV during pregnancy and the effect of IPV on maternal health among teenage pregnancies may be different.

Recommendation for Future Research

The current study examined the direct effects of all study variables and only the indirect effects among exposure to violence, fear of partner, and IPV during pregnancy were tested.

Several indirect effects of some study variables to the outcome variable are recommended for study in future research.

The effect of IPV before pregnancy on maternal health outcome should be studied in future research. Also, the effect of each type of IPV including physical, psychological, and sexual abuse as well as controlling behaviors on specific symptoms and complications during pregnancy in each trimester need to be tested in future research.

The adverse maternal health variable measured only maternal health and complications during pregnancy. Studies of maternal health and complications during the delivery and postpartum periods, as well as fetal and neonatal outcomes, are recommended.

The target population of this study was adult pregnant women who attended the prenatal care unit of a secondary care public hospital in a rural area in the central part Thailand.

Replication of this study with other populations such as pregnant teens and in other settings such as public secondary care hospitals and tertiary care hospitals and private hospitals in different parts of Thailand is recommended to further validate the results.

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Development of interventions based on this research and subsequent testing of the new interventions are recommended.

Summary

IPV is a prominent problem all over the world including Thailand. Little is known about factors leading to IPV during pregnancy and maternal health among Thai women. It is difficult to apply the knowledge or research findings from different cultures to practice because each culture has some specific details and a "cultural unconscious" that shapes the behavior and attitude of its associates. Also, on the practice level, innovative and culturally specific design prevention and intervention programs for IPV are needed. As mention earlier, this current study was conducted to fill the gap. The current study provided a comprehensive examination of factors influencing

IPV during pregnancy and effect of IPV on maternal health. The findings from found the interesting points that exposure to violence, IPV during pregnancy and fear of partner affected the negative physical health and psychological health as well as pregnancy complication. Also, the exposure to violence and fear of partner were the predictor of IPV during pregnancy. The findings could be used in helping nursing to develop effective strategies to reduce the incidences and prevalence of IPV during pregnancy and therefore promote maternal health in Thai women.

Also, the findings could be guided the practice level to screen IPV during pregnancy and to ask women’s history of exposure to violence during childhood and their feeling of pregnant women toward partners.

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Appendix A

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Questionnaire: Life Experiences and Maternal Health among Pregnant Thai women There are six sections in this questionnaire.

Section1: Maternal Characteristics and Behaviors Instruction: In the following questions, please indicate your answers by a check9 answer that applies to you or by filling in the blanks. 1. Age :______( years) 2. What degree did you earn? ______3. Marital Status: _____Married with marriage certificate _____Married without marriage certificate _____ Divorced, Widowed or Separated _____ Cohabiting (Not married) _____ Single

4. If married, cohabiting, or dating: Number of years married, cohabiting, or dating with a current partner _____ (years) 5. Income: ______Monthly (Thai baht) 6. Was pregnancy planned? _____ Yes _____ No 7. What is your due date? ______8. How many weeks pregnant you were when you first visited prenatal care unit? ______weeks

Adverse Health Behaviors Now Before pregnancy yes no yes no 9. Do you smoke cigarettes? 10. Do you drink alcohol? 11. Do you use drug substance such as marijuana, heroin, amphetamine, inhalants, kratum, club drug, barbiturate, and others substance?

Section 2: Rosenberg Self -Esteem Scale Thai Version Instruction: For each statement below, please a check9 in the column that best describes your feeling or opinion. Items Strongly Disagree Agree Strongly disagree agree 1. On the whole, I am satisfied with myself. 2. At time, I think I am no good at all. 3. I feel that I have a number of good qualities. 4. I am able to do things as well as most other people.

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Items Strongly Disagree Agree Strongly disagree agree 5. I feel I do not have much to be proud of. 6. I certainly feel useless at times. 7. I feel that I am a person of worth, at least on an equal plane with others. 8. I wish I could have more respect for myself. 9. All in all, I am inclined to feel that I am a failure. 10. I take a positive attitude toward myself.

Section 3: Respondent’s Health 3.1 Instruction: Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each one carefully, please a check9 in the column that best indicates whether or not you have been bothered by that problem in the past month

Items No Yes 1. You always think of the situation against you will. 2. You have had a picture about the situation that have come into your mind against you will. 3. You have had trouble falling asleep or staying asleep because pictures about the situation came to your mind.

3.2 Instruction: For each statement below, please a check9 in the column that best describes your feeling or opinion

Items Never Hardly Sometimes Most of the ever time 1. I have been able to laugh and see the funny side of things. 2. I have looked forward with enjoyment to things. 3. I have blamed myself unnecessarily when things went wrong. 4. I have been anxious or worried for no good reason. 5. I have felt scared or panicky for no very good reason. 6. Things have been getting on top of me. 7. I have been so unhappy that I have had difficulty sleeping. 8. I have felt sad or miserable. 9. I have been so unhappy that I have been crying. 10. The thought of harming myself has occurred to me.

3.3 Instruction: For each statement below, please a check9 in the column that best describes your health. Items Very Poor Fair Good Excellent poor 1. In general, would you describe your overall health?

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The following question about activities you might do during a typical day. Does your health now limit you in these activities? If so how much Yes, Yes, limited No, not limited a a little limited at lot all 2. Moderate activities such as moving a table, pushing a vacuum cleaner, standing and bathing a dog, or mopping 3. Climbing several flights of stairs

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? All of the Most Some A little None of time of the of of the the time time the time time 4. Accomplished less than you would like 5. Were limited in the kind of work or other activities

6. During the past 4 weeks, how much did you pain interfere with your normal work (including both work outside the home and housework)?

____Not at all ____A little bit ____Moderate ____Quite a bit ____Extremely

3.4 Instruction: For each statement below, please a check9 in the column that best describes your prenatal health problem. Prenatal Problem No Yes During pregnancy, have you experienced 1. Diabetes or sugar in your urine? 2. Pregnancy induced hypertension or albumin in your urine? 3. Urinary tract infection? 4. Reproductive tract infection? 5. Severe nausea, vomiting, or dehydration? 6. Poor weight gain (weight gain less than 0.5 kg/week or weight gain more than 1 kg/week)? 7. Anemia (Hematocrit lower than 30 g% or Hemoglobin lower than 10 g/dl)? 8. Bleeding per vagina, abruption placenta or placenta previa? 9. Severe fatigue? 10. Preterm labor? 11. Premature rupture of membrane (PROM)? 12. Others? Please indicate…………………………………………………………………..

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Section 4: Respondent’s Feeling and Attitude 4.1 Instruction: For each statement below, please a check9 in the column that best describes your feeling or opinion with your husband/boyfriend. Items Strongly Disagree Agree Strongly disagree agree 1. I feel unsafe when I am alone with my husband/boyfriend. 2. When my husband/boyfriend looks at me I feel afraid. 3. I feel like I have to use a usually high level of caution around my husband/boyfriend. 4. I avoid staying alone with my husband/boyfriend. 5. I fear and worry about what my husband/boyfriend will do to me when we quarrel. 6. I avoid all conflicts with my husband/boyfriend or something that makes him angry. 7. I do not dare tell people about the thing my husband/boyfriend does to me. 8. I worry that what I do will make my husband/boyfriend angry. 9. I do things my husband/boyfriend wants me to do rather than doing things I want to do. 10. When my husband/boyfriend got mad I was terrified, even though he did not touch me. 4.2 Instruction: For each statement below, please a check9 in the column that best describes your feeling or opinion.

Items Strongly Disagree Agree Strongly disagree agree 1. The husband/boyfriend has no right to swear, yell or screamed at his wife/girlfriend even though she provoked his anger. 2. If the wife/girlfriend has a relationship with other men or has an affair with another man, her husband/boyfriend has the right to punish her by slapping or hitting. 3. When the wife/girlfriend has been physically or mentally abused by her husband/boyfriend she must be patient to preserve her own family for her kids. 4. The husband/boyfriend has no right to physically or mentally abuse his wife/girlfriend even if she breaks any agreements that she has made with him. 5. It is acceptable that the husband/boyfriend has a mistress if he continues his family responsibility. 6. The husband/boyfriend can express in public that he has the right and power over his wife/girlfriend.

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Items Strongly Disagree Agree Strongly disagree agree 7. The husband/boyfriend has the right to discipline his wife/girlfriend. If his wife/girlfriend does not obey, he can punish her by using swearing, yelling and screaming at her. 8. To throw, smash, or broke an object may solve the relationship conflict between husband/boyfriend and wife/ girlfriend. 9. Physical or mental abuse by a husband/boyfriend is a shameful subject, so the wife/girlfriend cannot disclose it to anyone. 10. The wife/girlfriend should not anger her husband/ boyfriend when he swears at her when drunk. 11. Divorce or separate is the way to solve the problem when the wife/girlfriend is frequently physically or mentally abused by her husband/boyfriend. 12. Physical or mental abuse by husband/boyfriend is a private matter and people should not intervene. 13. A husband/boyfriend can yell and swear at his wife /girlfriend if she fails in her duty as a wife. 14. Intimate partner violence is not bad karma that wife/girlfriend must accept and pay back. 15. The relationship of wife/girlfriend and husband/ boyfriend is compared to “teeth and tongue” so intimate partner violence is a common issue. 16. Although the husband/boyfriend is to be the "breadwinner", he should not treat his wife/girlfriend like an inferior. 17. It is illegal if husband/boyfriend threats to hurt or kill his wife/girlfriend. 18. A husband/boyfriend, who has a higher income than his wife/girlfriend has the right to control his wife/girlfriend on the spending of money. 19. After married or made a commitment, a husband/boyfriend has no right to intervene in wife/girlfriend’s relationship with her family members. 20. To preserve the wife/girlfriend’s roles, wife/girlfriend’s occupation should be under the decision of her husband/boyfriend. 21. A good wife/girlfriend should fulfill her husband/boyfriend's sexual anytime he wishes. 22. To keep the relationship between husband/boyfriend and wife/girlfriend, the wife/girlfriend must agree to have sex that her husband/boyfriend wants in anyway.

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Items Strongly Disagree Agree Strongly disagree agree 23. Good wife/girlfriend should allow her husband/boyfriend to have sex with other women if his wife/girlfriend cannot meet his demand for sexual intercourse. 24. Wife/girlfriend has the right to refuse to have sex with her husband/boyfriend when she thinks her husband/boyfriend may contract venereal disease or AIDS. 25. Wife/girlfriend has the right to refuse to have sex if she forgets to use contraceptives because unplanned pregnancy may occur.

Section 5: Experiences during Childhood 5.1 Instruction: For each question below, please a check9 in the column that best describes your answer: Before the age of 18, did a parent or other adults in the household Items No Yes 1. Actually push, grab, or shove you? 2. Throw something at you? 3. Slap you on the face, ear or head? 4. Hit you so hard that you had marks or bruises? 5. Kick, punch, or hit you with a fist? 6. Threaten to hurt you or actually hurt you with a gun, knife, or other weapon? 7. Insult you, consequently, making you feel bad, inferior or humiliated? 8. Yell, swear, or scream? 9. Belittle you, consequently, making you feel bad, inferior or humiliated? 10. Publicly criticize? 5.2 Instruction: For each question below, please a check9 in the column that best describes your answer: Before the age of 18, did any person who is five or more years older than you Items No Yes 1. Touch or fondle your body including your breasts or genitals or attempt to arouse you sexually against you will? 2. Try to have you arouse them or touch their body in a sexual way against you will? 3. Attempt to have intercourse with you against you will? 4. Have intercourse with you against you will? 5.3 Instruction: For each question below, please a check9 in the column that best describes your answer: As a child, did you watch, hear, being aftermath your father (or step father) or mother’s boyfriend doing any of these things to your mother (or stepmother)

Items No Yes 1. Push, grab, slap, or throw something at her? 2. Kick, bite, hit her with a fist, or hit her with something hard? 3. Repeatedly hit her over at least a few minutes? 4. Threaten her with a knife or gun, or use a knife or gun to hurt her?’ 5. Yell, swear, or scream at her 6. Insult, belittle, or publicly criticize her

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Section 6: Respondent and Partner Instruction: This questionnaire asks about actions you may have experienced in your relationship with your husband, ex-husband, boyfriend, or ex-boyfriend. Please a check in 9the column that best describes your experiences.

Experiences In the past 12 During your months current pregnancy No Yes No Yes 1. Insulted you or made you feel bad about yourself? 2. Belittle or humiliated you in front of other people? 3. Did things to scare or frighten you on purpose (e.g. by the way he looked at you by yelling and smashing things)? 4. Threatened to hurt you or someone you care about? 5. Slapped you or threw something at you could hurt you? 6. Pushed you or shaved you? 7. Hit you with his fist or with something else that could hurt you? 8. Kicked you, dragged you or beat you or beat you up? 9. Choked you or burnt you on purpose? 10. Threatened to use or actually used a gun, knife or other weapon against you? 11. Physically forced you to have sexual intercourse when you did not want to? 12. Did you ever have sexual intercourse you did not want he might do? 13. Did he ever force you to do something sexual that you found degrading or humiliating? 14. Tried to keep you from seeing friends 15. Tried to restrict contact with your family of birth 16. Insisted on knowing where you were at all times 17. Ignored you and treated you indifferently 18. Got angry if she spoke with another man 19. Was often suspicious that she was unfaithful 20. Expected her to ask permission before seeking health care for herself

THANK YOU FOR YOUR TIME

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Appendix B

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Estimate of the Intimate Partner Violence during Pregnancy’s Parameter

Indicators Standardized Standard Z R2 factor error loading(β) ( SE) 1. Insulted you or made you feel bad about .856 .044 19.666 .733 yourself 2. Belittle or humiliated you in front of other .822 .060 13.728 .676 people 3. Did things to scare or frighten you on .835 .049 17.141 .697 purpose (e.g. by the way he looked at you by yelling and smashing things) 4. Threatened to hurt you or someone you .884 .086 10.321 .781 care about 5. Slapped you or threw something at you .965 .036 26.936 .931 could hurt you 6. Pushed you or shaved you .918 .051 18.042 .843 7. Hit you with his fist or with something .852 .095 8.957 .726 else that could hurt you 8. Kicked you, dragged you or beat you or .864 .072 11.947 .747 beat you up 11. Physically forced you to have sexual .813 .118 6.914 .662 intercourse when you did not want to 12. Did you ever have sexual intercourse you .792 .077 10.240 .628 did not want he might do 13. Did he ever force you to do something .949 .067 14.238 .900 sexual that you found degrading or humiliating 14. Tried to keep you from seeing friends .548 .101 5.440 .301 15. Tried to restrict contact with your family .567 .118 4.804 .321 of birth 16. Insisted on knowing where you were at .609 .071 8.598 .371 all times 17. Ignored you and treated you indifferently .543 .096 5.658 .295 18. Got angry if she spoke with another man .729 .057 12.695 .531 19. Was often suspicious that she was .694 .069 10.072 .481 unfaithful 20. Expected her to ask permission before .572 .092 6.205 .327 seeking health care for herself Χ2 = 157.949, df = 135, p = .086, Χ2/df = 1.17, CFI= .987, TLI= .975 RMSEA= 0.024 | Z | > 1.96 is significant at p < .05; | Z | > 2.58 is significant at p < .01

201

Estimate of the Exposure to Violence’s parameter

Indicators Standardized Standard Z R2 factor error loading(β) ( SE) Child Physical and Psychological Abuse 1. Actually push, grab, or shove you .645 .077 8.367 .417 2. Throw something at you .705 .066 10.734 .497 3. Slap you on the face, ear or head .800 .057 14.034 .640 4. Hit you so hard that you had marks or .666 .077 8.645 .444 bruises 5. Kick, punch, or hit you with a fist .852 .116 7.335 .725 6. Threaten to hurt you or actually hurt you .367 .128 2.856 .134 with a gun, knife, or other weapon 7. Insult you, consequently, making you feel .868 .041 20.997 .754 bad, inferior or humiliated 8. Yell, swear, or scream .772 .054 14.264 .595 9. Belittle you, consequently, making you .725 .054 13.345 .526 feel bad, inferior or humiliated 10. Publicly criticize .809 .064 12.729 .655 Child Sexual Abuse 1. Touch or fondle your body including your .980 .028 35.109 .960 breasts or genitals or attempt to arouse you sexually against you will? 2. Try to have you arouse them or touch their .956 .032 29.672 .913 body in a sexual way against you will? 3. Attempt to have intercourse with you .939 .030 31.482 .882 against you will? 4. Have intercourse with you against you .895 .042 21.227 .801 will Witnessing of Interparental Violence 1. Push, grab, slap, or throw something at .864 .041 20.857 .746 her 2. Kick, bite, hit her with a fist, or hit .902 .052 17.408 .814 her with something hard 3. Repeatedly hit her over at least a few .914 .034 26.648 .835 minutes 4. Threaten her with a knife or gun, or use a .850 .059 14.482 .723 knife or gun to hurt her 5. Yell, swear, or scream at her .942 .042 22.311 .888 6. Insult, belittle, or publicly criticize her .760 .056 13.561 .578 Χ2 = 164.015, df = 132, p = .031, Χ2/df = 1.24, CFI= .987, TLI= .985 RMSEA= 0.028 | Z | > 1.96 is significant at p < .05; | Z | > 2.58 is significant at p < .01

202

Estimate of the Negative Physical and Psychological Health’s Parameter

Indicators Standardized Standard Z R2 factor error loading(β) ( SE) Depression

3. I have blamed myself unnecessarily when .509 .052 9.848 .259 things went wrong. 4. I have been anxious or worried for no .668 .042 15.790 .446 good reason. 5. I have felt scared or panicky for no very .690 .046 14.838 .476 good reason. 6. Things have been getting on top of me. .740 .045 16.534 .547 7. I have been so unhappy that I have had .784 .037 21.048 .615 difficulty sleeping. 8. I have felt sad or miserable. .720 .042 17.127 .519 9. I have been so unhappy that I have been .677 .049 13.764 .458 crying. 10. The thought of harming myself has .454 0.049 9.164 .206 occurred to me. PTSD 1. You always think of the situation against .901 .035 25.625 .813 you will. 2. You have had a picture about the situation .963 .033 29.500 .928 that have come into your mind against you will. 3. You have had trouble falling asleep or .904 .036 25.038 .817 staying asleep because pictures about the situation came to your mind. Physical Health 2. Moderate activities such as moving a .564 .069 8.124 .318 table, pushing a vacuum cleaner, standing and bathing a dog, or mopping 3. Climbing several flights of stairs .503 .062 8.067 .253 4. Accomplished work less than you would .670 .060 11.190 .449 like 5. Were limited in the kind of work or other .509 .061 8.363 .259 activities 6. Pain interfere with your normal work .651 .064 10.151 .423 Χ2 = 152.389, df = 101, p = .000, Χ2/df = 1.509, CFI= .955, TLI= .967 RMSEA= .041

| Z | > 1.96 is significant at p < .05; | Z | > 2.58 is significant at p < .01

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Appendix C

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Content Validity Evaluation

The Thai Intimate Partner Violence Fear Scale (TIPVFS) Experts’ Opinion N* Score of

1 2 3 4 5 6 7 8 I-CVI Kappa 1. I feel unsafe when I am alone with my husband/boyfriend. 4 4 4 4 4 4 4 4 8 1.00 1.00 2. When my husband/boyfriend looks at me I feel afraid. 4 4 4 4 4 4 2 4 7 .88 .87 3. I feel like I have to use a usually high level of caution around 4 4 4 4 4 4 4 4 7 .88 .87 my husband/boyfriend. 4. I felt ashamed of the things my husband/boyfriend did to me. 4 3 2 3 4 2 2 2 4 .50 .50 The original item was deleted due to low score of I-CVI and kappa. The “I avoid staying alone with my husband/boyfriend” was created using expert’s suggestion. 5. I fear and worry about what my husband/boyfriend will do to 4 3 4 1 4 2 4 4 7 .88 .87 me when we quarrel. 6. I avoid all conflicts with my husband/boyfriend or something 4 3 4 4 4 4 4 4 8 1.00 1.00 that makes him angry. 7. I do not dare tell people about the thing my husband/boyfriend 4 4 4 3 4 4 4 4 8 1.00 1.00 does to me. 8. I worry that what I do will make my husband/boyfriend angry. 4 4 3 3 4 4 4 4 8 1.00 1.00 9. I do things my husband/boyfriend wants me to do rather than 4 4 4 3 4 4 1 4 7 .88 .87 doing things I want to do. 10. When my husband/boyfriend got mad I was terrified, even 4 4 4 3 4 4 2 4 7 .88 .87 though he did not touch me. Note: 4 means that item was very relevant with the concept of fear of partner; 3 means quite relevant; 2 means somewhat relevant 1 means not relevant, N* =Number Giving Rating of 3 or 4

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The Thai Acceptance of Intimate Partner Violence Scale Experts’ Opinion N* Score of (TAIPVS) 1 2 3 4 5 6 7 8 I-CVI Kappa 1. When a husband/boyfriend abuses his wife/girlfriend because 2 4 4 3 4 4 4 4 7 .88 .87 he lost control of his temper. The original question was slightly change using expert’s suggestions. “The husband/boyfriend has no right to swear, yell or screamed at his wife/girlfriend even though she provoked his anger” was used in the current study. 2. Abusive husband/boyfriend should be forgiven if he beat his 4 4 3 4 4 2 2 3 6 .75 .72 wife/girlfriend who has a relationship with other men or has an affair with another man. The original item was slightly changed to “If the wife/girlfriend has a relationship with other men or has an affair with another man, her husband/boyfriend has the right to punish her by slapping or hitting. 3. When the wife/girlfriend has been physically or mentally 4 4 4 4 4 4 1 4 7 .88 .87 abused by her husband/boyfriend she must be patient. The item was changed to “When the wife/girlfriend has been physically or mentally abused by her husband/boyfriend she must be patient to preserve her own family for her kids”. 4. The husband/boyfriend has no right to physically or 4 4 4 4 4 4 3 4 8 1.00 1.00 mentally abuse his wife/girlfriend even if she breaks any agreements that she has made with him. 5. The husband/boyfriend can express in public that he has the 4 4 4 3 4 4 4 4 8 1.00 1.00 right and power over his wife/girlfriend. 6. The husband/boyfriend has the right to discipline his 4 4 4 4 4 4 1 4 7 .88 .87 wife/girlfriend. If his wife/girlfriend does not obey, he can punish her by using swearing, yelling and screaming at her. 7. To throw, smash, or broke an object may solve the 4 4 4 4 4 4 4 4 8 1.00 1.00 relationship conflict between husband/boyfriend and wife/ girlfriend. 8. Physical or mental abuse by a husband/boyfriend is a 4 4 4 4 4 4 4 4 8 1.00 1.00 shameful subject, so the wife/girlfriend cannot disclose it to anyone.

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The Thai Acceptance of Intimate Partner Violence Scale Experts’ Opinion N* Score of (TAIPVS) 1 2 3 4 5 6 7 8 I-CVI Kappa 9. The wife/girlfriend should not anger her husband/ boyfriend 4 4 4 4 4 4 4 4 8 1.00 1.00 when he swears at her when drunk. 10. Divorce is a stigma, failure and shame so acceptance of 4 3 4 2 4 4 1 4 6 .75 .72 violence is better than to divorce. The original item was slightly changed to “Divorce or separate is the way to solve the problem when the wife/girlfriend is frequently physically or mentally abused by her husband/boyfriend” due to item with low I-CVI and Kappa. 11. Physical or mental abuse by husband/boyfriend is a private 4 4 4 4 4 4 4 4 8 1.00 1.00 matter and people should not intervene. 12. A husband/boyfriend can yell and swear at his wife 4 4 4 3 4 4 4 4 8 1.00 1.00 /girlfriend if she fails in her duty as a wife. 13. Intimate partner violence is not bad karma that 4 3 4 3 4 4 4 4 8 1.00 1.00 wife/girlfriend must accept and pay back. 14. The relationship of wife/girlfriend and husband/ boyfriend is 4 4 4 4 4 4 4 4 8 1.00 1.00 compared to “teeth and tongue” so intimate partner violence is a common issue. 15. Although the husband/boyfriend is to be the "breadwinner", 4 4 4 4 4 4 4 4 8 1.00 1.00 he should not treat his wife/girlfriend like an inferior. 16. Husband/boyfriend should be arrested if he abused his 4 4 4 4 4 4 4 2 7 .88 .87 wife/girlfriend. This item was slightly changed to “It is illegal if husband/boyfriend threats to hurt or kill his wife/girlfriend”. 17. A husband/boyfriend, who has a higher income than his 4 4 4 4 4 4 4 4 8 1.00 1.00 wife/girlfriend has the right to control his wife/girlfriend on the spending of money. 18. After married or made a commitment, a husband/boyfriend 4 4 4 4 4 4 4 4 8 1.00 1.00 has no right to intervene in wife/girlfriend’s relationship with her family members.

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The Thai Acceptance of Intimate Partner Violence Scale Experts’ Opinion N* Score of (TAIPVS) 1 2 3 4 5 6 7 8 I-CVI Kappa 19. To preserve the wife/girlfriend’s roles, wife/girlfriend’s 4 4 4 4 3 4 4 4 8 1.00 1.00 occupation should be under the decision of her husband/boyfriend. 20. A good wife/girlfriend should fulfill her 4 4 4 4 4 4 4 4 8 1.00 1.00 husband/boyfriend's sexual anytime he wishes. Note: 4 means that item was very relevant with the concept of fear of partner; 3 means quite relevant; 2 means somewhat relevant 1 means not relevant, N* =Number Giving Rating of 3 or 4. Five items were added to the scale using experts’ suggestions: 1) It is acceptable that the husband/boyfriend has a mistress if he continues his family responsibility, 2) To keep the relationship between husband/boyfriend and wife/girlfriend, the wife/girlfriend must agree to have sex that Good wife/girlfriend should allow her husband/boyfriend to have sex with other women if his wife/girlfriend cannot meet his demand for sexual intercourse,3) Good wife/girlfriend should allow her husband/boyfriend to have sex with other women if his wife/girlfriend cannot meet his demand for sexual intercourse, 4) Wife/girlfriend has the right to refuse to have sex with her husband/boyfriend when she thinks her husband/boyfriend may contract venereal disease or AIDS,5)Wife/girlfriend has the right to refuse to have sex if she forgets to use contraceptives because unplanned pregnancy may occur.

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Appendix D

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