INSOMNIA AND SOCIAL SUPPORT AMONG THAI WOMEN WHO HAVE EXPERIENCED INTIMATE PARTNER VIOLENCE
A dissertation submitted to Kent State University College of Nursing in partial fulfillment of the requirements for the degree of Doctor of Philosophy
By:
Muntaha M. Alibrahim
July 2018
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Dissertation written by
Muntaha Alibrahim
BSN, Jordan University of Science and Technology, 2002
M.S.N, Jordan University of Science and Technology, 2005
Ph.D., Kent State University, 2018
Approved by
______, Chair, Doctoral Dissertation Committee
Patricia Vermeersch
______, Co-Chair, Doctoral Dissertation Committee
Ya-Fen Wang
______, Member, Doctoral Dissertation Committee
Ratchneewan Ross
______, Member, Doctoral Dissertation Committee
Marlene Huff
______, Member, Doctoral Dissertation Committee
Donna Bernert
Accepted by
______, Director, Joint Ph.D. in Nursing Program
Patricia Vermeersch
______, Associate Dean for Graduate Programs
Wendy Umberger
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ALIBRAHIM, MUNTAHA, Ph.D., August 2018 Nursing
INSOMNIA AND SOCIAL SUPPORT AMONG THAI WOMEN WHO HAVE EXPERIENCED INTIMATE PARTNER VIOLENCE (131 pp.)
Director of Dissertation: Patricia Vermeersch Yafen Wang
Insomnia is the most common of all sleep problems. Long-term insomnia affects an individual’s overall quality of life. Insomnia can arise from physiological, psychological, or environmental factors. Exposure to stressors such as Intimate Partner Violence (IPV) could lead to insomnia, which eventually affects physical and mental health. Social support is one strategy that alleviates and improves health outcomes. Limited studies in Thailand have addressed insomnia in women and its relationship with IPV and social support. This study aimed: 1) to examine the relationships between number of IPV types experienced, severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, social support, and insomnia; 2) to examine the moderating effect of social support on the relationships between number of IPV types experienced, perceived severity of IPV types (physical, sexual, and psychological abuse), and insomnia after controlling for age, education level, and income; and 3) to determine which social support form proved more effective: family support or friends support.
The transactional model of stress and coping guided this study (Lazarus & Folkman,
1984). This study used secondary data analysis with a correlational but non-experimental design. Two-hundred and eighty four Thai women aged 18 years and older receiving care in the obstetrics and gynecology unit, and read and write in Thai comprised the subjects of this study.
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Pearson r test and hierarchical multiple regression analysis were used to analyze the data.
The results reported significant relationships between the study variables, except that the relationship between perceived severity of sexual abuse and social support did not appear as significant. The results of hierarchical multiple regression indicated that social support was not a moderator between independents variable and insomnia. R2 change in insomnia variance was not significant when adding the interaction terms of social support with other variables to the regression model. Neither friend nor family support were significant as moderators between study variables. Still, friends support was significant as a predictor of reduced insomnia whereas family support was not.
This study findings can contribute to the existing Thai literature by providing new information about insomnia and associated factors. In practice, nurses can use the study findings in determining the underlying factors that might be associated with insomnia, such as IPV.
Nursing intervention can then be provided based on underlying factors. Where insomnia does not relate to IPV, available friends support can be provided to a woman to decrease insomnia and simultaneously improve her sleep quality.
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ACKNOWLEDGMENTS
I would offer my sincere and deepest appreciation and special thanks to Dr. Ratchneewan
Ross, who let me using her data to conduct this study. This study would not have been possible without her support and continous guidance. Many grateful thanks are likewise due to my advisor Dr. Patricia Vermeersch for her support and her willingness to provide her ideas and direction to help me in achieving my goals during my Ph.D. journey. I am also indebted to my co-advisor, Dr. Ya-fen Wang, who was with me step-by-step while writing this dissertation, and who was also willing to provide her excellent advice at any time. She remained a source of support by encouraging whenever I lost confidence and motivation. These three indeed served as remarkable inspirations during the writing of this dissertation. A mere “thank you” remains wholly inadequate for your real aid and comfort.
Many thanks are due to other committee members, Dr. Marlene Huff and Dr. Donna
Bernert, who played a remarkable role in developing my dissertation by rendering valuable comments and suggestions. Special thank goes to my loving and supportive husband, Shadi, who has always been my source of strength. Many thanks are also to my children, Roa`a,
Abdullah, and Zain, who provide endless inspiration. Most importantly, I would thank my dear mother, for her support by continuous prayers on my behalf. Special thanks go to my sisters,
Amneh and Amal, as well as my brother, Khalid. Finally, I could not forget the support from my friends Ghada and Aseel. I am most thankful for each of you.
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TABLE OF CONTENTS
Chapter Page 1-Introduction ...... 1 Background and Significance...... 4 Worldwide Prevalence and Significance of Insomnia ...... 4 Worldwide Prevalence IPV ...... 5 Significance of Social Support ...... 6 Prevalence of Insomnia in Thailand ...... 6 Prevalence of IPV in Thailand ...... 7 Problem Statement ...... 8 Theoretical Framework ...... 10 Constructs Definitions and Theoretical Correlations ...... 10 Substruction Framework ...... 13 Relationships between Constructs and Study Variables ...... 14 Study Model ...... 16 Assumptions ...... 17 Study Aims ...... 18 Research Questions ...... 18 Study Hypotheses ...... 18
2- Review of the Literature ...... 20 Insomnia ...... 21 Causes of Insomnia ...... 24 Risk Factors of Insomnia ...... 25 Consequences Of Insomnia ...... 26 Stressors and Insomnia ...... 28 Insomnia and IPV ...... 29 Intimate Partner Violence (IPV) ...... 30 What is IPV? ...... 30 Types of IPV ...... 31 Severity of IPV ...... 32 Multiple IPV Experience ...... 34 Risk Factors of IPV ...... 35 Consequences of IPV ...... 36 vi
Social Support ...... 38 Insomnia in Thailand ...... 41 IPV in Thailand ...... 41 Gaps in the Thai Literature ...... 47 Summary ...... 47
3- Methodology ...... 49 Data Source ...... 49 Study Design ...... 51 Analytic Sample ...... 52 Determination of Sample Size...... 53 Study Variables ...... 54 Outcome Variable ...... 55 Independent Variables ...... 57 Moderating Factor ...... 60 Confounding Variables ...... 61 Demographic Variables ...... 61 Data Management and Analysis ...... 62 Data Screening ...... 62 Testing Statistical Assumptions ...... 63 Statistical Analysis ...... 64
4- Results ...... 67 Data Screening ...... 67 Missing Data ...... 67 Outliers ...... 67 Testing of the Assumptions ...... 70 Demographic Characteristics ...... 70 Study Variables Description...... 71 Psychometric Properties (Reliability) ...... 72 Research Questions ...... 73 Research Question (1) ...... 73 Research Question (2) ...... 75 Research Question (3) ...... 77 Summary ...... 79
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5- Discussion ...... 81 Research Question (1) ...... 82 Research Question (2) ...... 86 Research Question (3) ...... 89 Nursing Implications ...... 90 Nursing Knowledge and Practice ...... 90 Nursing Education ...... 92 Theory Development ...... 92 Health Policy ...... 93 Dissemination ...... 94 Limitations and Recommendations ...... 94 Future Research ...... 95 Conclusion ...... 96
References ...... 98
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List of Figures
Figure Page
Figure 1. Transactional model of stress and coping ...... 13
Figure 2. Substruction model ...... 14
Figure 3. Study model ...... 17
Figure 4. Mahalanobis distance ...... 68
Figure 5. Perceived severity of physical abuse outliers ...... 69
Figure 6. Perceived severity of sexual abuse outliers...... 69
Figure 7. Perceived severity of psychological abuse outliers...... 69
Figure 8. Social support outliers ...... 70
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List of Tables
Table Page
Table 1. Variables and Tools of the Primary Study ...... 50
Table 2. Variables and Tools of the Proposed Study ...... 54
Table 3. Participants’ Demographic Characteristics ...... 71
Table 4. Variables Characteristics ...... 72
Table 5. Pearson r Correlations ...... 74
Table 6. Hierarchical Regression Analysis Output ...... 76
Table 7. Comparing Hierarchical Regression between Friends Support and Family Support .... 78
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Running head: INSOMNIA AMONG THAI WOMEN 1
Chapter 1
Introduction
Sleep is a physiological need essential for optimal body function; it is an indicator for overall health (National Sleep Association, 2018). Sufficient sleep is important in maintaining human cognitive, psychological, and physical health (Fernandez-Mendoza &
Vgontzas, 2013; Pun, 2016). According to the National Sleep Association (2018), adults require seven to nine hours of sleep per day. Even though they are likely aware of the benefits, some people still cannot attain adequate sleep since they have a problem initiating sleep, which is called insomnia. Insomnia is the most common type of sleep problem (American Psychiatric Association [APA], 2017) that contributes to negative health outcomes. Actually, insomnia is comorbid with depression and chronic physical health issues (Sivertsen et al., 2014). If experienced for an extended time, insomnia can influence a person’s daily function and cause substantial impairments in quality of life
(Wagener, 2016). The American population spends about $100 billion annually in medical costs, ramifications of accidents, and reduced productivity due to absenteeism and decreased work efficiency, attributable to insufficient sleep (Attarian & Perlis, 2010).
Many factors can influence sleep patterns, generally, and insomnia in particular. These factors can be related to internal bodily function or behavior, or factors related to the external environment. One external factor that can affect sleep patterns, specifically, is a threat from others (Dimitriou, Le Cornu Knight, & Milton, 2015; Rogojanski, Carney, &
Monson, 2013). Violence is a threat that often affects sleep patterns, thereby causing
INSOMNIA AMONG THAI WOMEN 2
insomnia (Rogojanski et al., 2013).
Violence against women is a major threat that affects their health, well-being, and self-determination (World Health Organization [WHO], 2013). This problem is not considered a culture-bound problem; women of different ages, cultures, levels of education, races, and religions experience violence (WHO, 2016). Violence (also referred to as “abuse”) is defined as using force and power intentionally to threaten another person, group, or community, which can result in injury, deprivation, psychological harm, maldevelopment, or death (WHO, 2016). The most common source of violence toward women comes from spouses; in this case, it is called Intimate Partner
Violence (IPV).
In general, IPV is categorized by physical, sexual, and psychological (also referred to as “emotional” or “mental”) abuse. The severity and frequency of each type of IPV range along a continuum (Breiding et al., 2011, Centers for Disease Control and
Prevention [CDC], 2013). All types of abuse can impact a woman’s health and well- being, leading to poor physical, mental, social, and/or behavioral health problems (Asadi,
Mirghafourvand, Yavarikia, Alizadeh-Charandabi, & Nikan, 2016; Breiding, Chen, &
Black, 2014; Costa et al., 2015; Montakarn & Usaneya, 2014; Ross, Stidham, Saenyakul,
& Creswell, 2015; Saito, Creedy, Cooke, & Chaboyer, 2012; Tracy, 2017). The more intense degrees of abuse can negatively effect health consequences such as insomnia
(Montakarn & Usaneya, 2014).
Insomnia and its consequences on the body can become important motivators for seeking protection and intervention strategies (Troxel, Buysse, Monk, Begley, & Hall,
INSOMNIA AMONG THAI WOMEN 3
2010). Accessing social support is one strategy that has some proven effectiveness in buffering insomnia (Troxel et al., 2010). Social support is defined as either support that has already been received or support that the victim believes to be accessible and available (Lee, Pomeroy, & Bohman, 2007). The relationship between sleep and social support, however, remains unclear. Some studies have maintained that social support is an interpersonal factor that improves sleep quality and decreases sleep problems (Chung,
2017; Nordin, Westerholm, Alfredsson, & Akerstedt, 2012; Stafford, Bendayan,
Tymoszuk, & Kuh, 2017). Conversely, other studies have not identified social support as a factor affecting the improvement of insomnia (Jarrin, Chen, Ivers, & Morin, 2014;
Kamen et al, 2017; Kim & Suh, 2017).
Social support is a protective factor against IPV that reduces negative health consequences by protecting victims from its adverse physical and mental effects (Carlos,
Ferriani, Esteves, Silva, & Scatena, 2014; Herrenkohl et al, 2016; Jose & Novaco, 2016;
Sigalla et al., 2017; Silva, Padoin, & Vianna, 2015; Wright, 2015). Some evidence in the literature showed that social support impacts insomnia, while other evidence showed its impact on IPV. Despite this, limited studies have investigated the relationships between these three variables in one study, namely IPV, insomnia, and social support. The connections between them are logically supported, but theoretical and empirical evidence to support these relationships is needed. Therefore, this study was conducted to determine the relationships between these variables.
INSOMNIA AMONG THAI WOMEN 4
Background and Significance
Worldwide Prevalence and Significance of Insomnia
Sleep disorders, in general, are becoming a significant and growing epidemic in the United States (U.S.). According to the CDC (2014), more than 50 million Americans complain of sleep disorders such as insomnia. Approximately 10 million Americans use sleep aids (Sowder, 2018). For insomnia, in particular, up to 22% of the American population has insomnia every day of the week. Women are more likely to experience insomnia at a rate of 1.3 times more than men. People over age 65 are more likely to experience insomnia at a rate of 1.5 times more than younger people. Divorced, widowed, and separated people are more likely to have insomnia than married people
(National Sleep Foundation, 2013). Approximately 35% of people with insomnia have a family history of insomnia. Moreover, 90% of people with depression experience insomnia (Sowder, 2018).
The significance of insomnia lies in the cost of its effect. The direct costs are more than $14 billion among the U.S. population (Wade, 2011). These expenses involve treating insomnia, including doctor visits and hospital admissions. The annual indirect costs of insomnia are approximately $35 billion, and the annual cost of lost productivity, attributable to insomnia, is approximately $18 billion (Gradisar et al., 2013).
Further, sleep issues are a worldwide problem. A study conducted by Warwick
Medical School in the United Kingdom (UK) (2012) concerning sleep problems in pan-
Africans and Asians concluded that an estimated 150 million adults across the developing world have sleep-related problems. The percentage of sleep problems is not significantly
INSOMNIA AMONG THAI WOMEN 5
different between the populations of developed (20%) and developing (17%) countries
(Breus, 2012). This indicates that sleep problems appear in countries and cultures for a variety of reasons. A survey of 910 doctors indicated that 20% of their patients ask for sleeping pills (Bhalla, 2016).
Worldwide Prevalence of IPV
The significance of IPV as a global health problem across cultures is becoming more widely recognized. IPV occurs in most countries around the world (WHO, 2013) and affects 20-25% of adolescent and adult women in the U.S. (Coyle, Shuping,
Speckhard, & Brightup, 2015). It causes more than 1.5 million deaths per year in the world and 20% of deaths in Southeast Asia (WHO, 2014). In 2005, the WHO conducted a survey of 24,000 women from ten countries. The survey findings revealed a substantial prevalence of all types of abuse toward women: physical abuse ranged from 13–61%; emotional abuse was 20–75%; and sexual abuse occurred with 6–59% of this population
(WHO, 2005). In the U.S., the prevalence rates for IPV showed that 17% of women were sexually abused, 24% experienced physical abuse, and close to half of the women, 48%, experienced psychological abuse from their partners (CDC, 2014). In Arab countries, the prevalence of IPV is increasing. In Egypt, for instance, the prevalence of abuse against women, in general, is 62% among women aged 18-50, and 90% among unmarried women (WHO, 2013). Other studies conducted in Sudan and Jordan reported that abuse against women is a public health problem since it has a hazardous impact on women’s health (WHO, 2013). A global database of violence against women reported that the prevalence of IPV in Jordan was 24% in 2016 (United Nation of Women, 2016). In
INSOMNIA AMONG THAI WOMEN 6
Saudi Arabia, the prevalence of overall abuse against women in 2010 was 33%, mental abuse 29%, physical abuse 23%, and sexual abuse was 12% (Afifi, Al-Muhaideb, Hadish,
Ismail, & Al-Qeamy, 2011).
Significance of Social Support
Social support is one of the protective factors shown to effectively decrease or prevent stress (Gutowski, White, Liang, Diamonti, & Berado, 2017; Shavitt et al., 2016).
Emotional support from a partner is important in improving mental health, and one study found that emotional support from partner decreased by 60% among those using mental health services (Maulik, Eaton, & Bradshaw, 2011). A study conducted by Brigham
Young University and the University of North Carolina revealed that people with illnesses who received social support were 50% less likely to die from those illnesses than those who did not have social support (Blue, 2010). Given its confirmed importance, many people, especially Americans, now access formal as well as informal support when they do not have a valuable source of social support. Seventy percent of people accessing mental health services seek emotional support to talk about their problems or to get help in making difficult decisions (APA, 2016).
Prevalence of Insomnia in Thailand
Insomnia and night waking are common problems among the Thai population
(Udomratn, 2008). The total prevalence of insomnia in healthy Thai adults and elderly people is 41% and 52%, respectively (Apidechkul, 2011; Udomratn, 2008). Elderly Thai people are more likely to have insomnia than younger people, as insomnia tends to increase with age (Miyata et al., 2013). Thai women are more likely to have insomnia
INSOMNIA AMONG THAI WOMEN 7
than men, and educated people are less likely to have insomnia than non-educated people
(Assantachai, Aekplakorn, Pattara-Archachai, & Porapakkham, 2010). Socio-economic status is another factor associated with insomnia; poor people are more likely to have insomnia than those with higher economic status (Assantachai et al., 2010). Poor self- care, depression, and poor self-perceived health are other factors that increase the prevalence of insomnia in the Thai population (Assantachai et al., 2010).
Prevalence of IPV in Thailand
Recent studies in Thailand have investigated IPV to assess the extent of the problem and seek solutions. Thailand was one of the ten countries included in the WHO study to investigate IPV against women. The results revealed that the prevalence of physical abuse against women in urban areas was 22.9%, while 29.9% reported sexual violence and 41.1% reported physical or sexual violence, or both. On the contrary, in rural areas, physical abuse against women was 33.8%, sexual abuse was 28.9%, and the rate of physical or sexual violence, or both was 47.4% (WHO, 2005). As reported, substantial abuse against women in Thailand occurs in both rural and urban areas, indicating that geographic characteristics do not correlate to occurrence of abuse against women in Thailand. Additional studies conducted report the prevalence of IPV in
Thailand. In 2006, the rates of physical, sexual, and psychological IPV among pregnant women during their pregnancy were 26.6%, 53.7%, and 19.2%, respectively (Sricamsuk,
2006). The statistics also revealed that up to 47% of women suffer exposure to IPV
(Saito et al., 2012). In 2014, One Stop Crisis Centre (OSCC) in Bangkok reported that more than 70% of Thai women were exposed to violence more than once (Chuemchit &
INSOMNIA AMONG THAI WOMEN 8
Perngparn, 2014). Another study in 2014 reported the prevalence of IPV was 22.1%, with 20.5% from a previous partner and 6.7% from a current partner (Fernbrant,
Emmelin, Essén, Östergren, & Cantor-Graae, 2014); incidentally, that study investigated
Thai women in Sweden. In 2015, Ross and others reported that the IPV rate in Thaliand has reached almost 90%. This rapidly-rising rate of IPV among Thai women has put
Thailand on the alert for identifying IPV as an important public health issue (Ross et al.,
2015). In 2018, Chuemchit and others reported that 15% of the study sample experienced
IPV in the last 12 months. Psychological abuse was reported as the highest form of abuse
(60–68%), followed by sexual violence (62–63%) and then physical violence (52–65%).
IPV thus contributes to the overall burden of disease in women’s health in several regards
(Thananowan & Vongsirimas, 2014a). As such, Thai women are at risk for immediate and long-term health problems.
Problem Statement
People everywhere are often exposed to life stressors (e.g., sexual abuse, physical abuse, witnessing or victimization of domestic violence, natural and human-made disasters, or suicides). Sleep disturbances commonly occur after experiencing stressful events (Colvonen et al., 2015; Grønli et al., 2017) that include sleep onset insomnia, sleep maintenance insomnia, recurrent nightmares, and sleep-related respiratory disturbances.
Exposure to violence is a stressor that threatens women’s lives, and many women experience insomnia and sleep problems related to fear from this threat (Grønli et al.,
2017).
In general, IPV leads to negative physical or mental health outcomes. Still, little
INSOMNIA AMONG THAI WOMEN 9
evidence supports a relationship between IPV and sleep disturbances, such as insomnia.
Insomnia is one of the most important sleep disturbances, and long-term insomnia usually negatively affects a person’s health (Pun, 2016). It remains important to understand insomnia and the factors that can cause insomnia among women who have experienced
IPV in order to extend help to such women. Social support is a potential alleviating factor to help the victim decrease the negative outcomes of IPV. Previous evidence supports the positive role of social support on IPV and health. The present study examined whether social support also affects insomnia in Thai women.
In the primary study on which this secondary analysis is based, the researchers examined social support from family, friends, and spouses as a mediating factor between the IPV types and women’s health outcomes. The results of the primary study showed that social support provided a minimal mediating effect between IPV and health outcomes. This weak mediating effect can likely be explained by the inclusion of the spouse in the social support, since the primary study population was women who experienced violence from spouses or partners. The weakness might also be attributed to examining the mediating effect rather than moderating effect. A mediating effect would be evident if an improved relationship between IPV and health outcomes was achieved solely through social support. More often, social support serves as a buffering or moderating variable in IPV relationships (Bang, 2012; Bakasa, 2007; Forrest, 2013;
Sanguanklin et al., 2014).
Finally, the findings of this secondary analysis study add significant empirical evidence to the current insomnia literature addressing the Thai population. The findings
INSOMNIA AMONG THAI WOMEN 10
also add new information about the correlation between two significant problems: IPV and insomnia; a potentially logical connection exists between them, but they have lacked empirical evidence to support their correlation. It is difficult to collect data from subjects about a hidden social problem with stigma, such as IPV. The findings of social support in this study were compared to findings generated from the primary study.
Theoretical Framework
The transactional model of stress and coping guided this study (see Figure 1)
(Lazarus & Folkman, 1984). This figure shows the relationships among the model constructs. The transactional model of stress and coping has been proposed to emphasize appraisal to evaluate threat or stressors, which results in the process of coping with stressful events (Lazarus & Folkman, 1984). The model also assumes that stress results from an imbalance between environmental demand and personal resources. The transaction appears in managing this imbalance (Lazarus & Folkman, 1984). The main constructs of the model are stressors, appraisal, and coping, along with adaptation outcomes.
Construct Definitions and Theoretical Correlations
Stressors are defined as “a particular relationship between the person and his/her environment that is appraised by the person as taxing or exceeding his or her resources and endangering his/her well-being” (Lazarus & Folkman, 1984, p. 19). A person evaluates stressors during the appraisal phase (Lazarus & Folkman, 1984). Appraisal is
“an evaluation process that determines why and to what extent a particular transaction or series of transactions between the person and the environment is stressful” (Lazarus &
INSOMNIA AMONG THAI WOMEN 11
Folkman, 1984, p. 19). The person conducting the appraisal detects what he or she can do in the current situation. Individuals react differently to stressors, based on sensitivity, vulnerability, and interpretation of stressors (Lazarus & Folkman, 1984). For the same situation, one person could react to the situation with depression or anger, while another person ignores it, since that person considers the situation as insignificant. The appraisal appears in two levels, primary and secondary (Lazarus & Cohen, 1977). In primary appraisal, the person faces a stressor; she/he evaluates the potential threat of the stressor, meaning the person ranks or evaluates whether the situation is a stressor, has positive significance, or is irrelevant (Lazarus & Folkman, 1984). The secondary appraisal is a social or cultural evaluation of the stressors, meaning an assessment of the individual’s coping resources and options (Cohen, 1984; Lazarus & Folkman, 1984).
Coping is another construct of this model that occurs between stressors and adaptation. Lazarus and Folkman (1984) explained coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (p. 141). Coping takes two general forms: emotional regulation and problem management (Folkman & Lazarus,
1980). Emotional regulation focuses on coping strategies that deal with internal stressors that trigger an emotional response, rather than external stressors. Emotional regulation alters the emotional well-being aspect of adaptation as an outcome (Folkman & Lazarus,
1980). Problem management coping occurs when the person believes someone can do something to manage or remove the stressors (Folkman & Lazarus, 1980). Problem management includes strategies such as learning new skills, problem solving, planning,
INSOMNIA AMONG THAI WOMEN 12
and developing a new standard of behavior. Some coping strategies affect both emotional regulation and problem management, such as social support and dispositional coping style (Vitaliano, Maiuro, Russo, & Becker, 1987). Social support is defined as
“constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person”
(Lazarus & Folkman, 1984, p. 141). Dispositional coping style is a stable coping strategy used by a person to cope with different threats (Donnellan, Hevey, Hickey, & O’Neill,
2006).
Adaptation is an outcome of the model conceptualized by positive application of coping strategies that affect an individual’s health (Robinson, 2003). Adaptation, as used by Lazarus and Folkman (1984), includes the processes used to manage environmental demands. Adaptation can be explained as a result of sequences of responses that yield outcomes (Lazarus & Folkman, 1984). Outcomes can be either positive or negative as a result of effective or ineffective coping. Then, adaptation is a positive result of using coping strategies, whereas maladaptation is a negative or ineffective use of coping strategies. The main categories of adaptation are emotional well-being, functional status, and health behavior aspects (Lazarus & Folkman, 1984).
INSOMNIA AMONG THAI WOMEN 13
Primary Appraisal: Perceived sustainability, Perceived severity, Motivational relevance, Causal focus
Coping: Adaptation: Stressor Problem focused - Emotional well-being, Emotional regulation Function status, Health behaviors
Secondary Appraisal: Perceived control over outcomes, Perceived control over emotions, Self-efficacy
Dispositional coping style. Social support
Figure 1. Transactional model of stress and coping (Lazarus and Folkman, 1984).
Substruction Framework
This study has been built on the relationships between three constructs and one moderator of the transactional model of stress and coping (Lazarus & Folkman, 1984).
The constructs consist of 1) stressors, as represented by number of IPV types experienced, 2) primary appraisal, as repsented by perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse, and 3) adaptation (functional status), as represented by insomnia as an outcome. The moderator is social support, which is represented by the social support variable (see Figure 2).
INSOMNIA AMONG THAI WOMEN 14
Figure 2. Substruction model.
Relationships between Constructs and Study Variables
Number of IPV incidents experienced is considered to be a stressful element from the external environment that leads to a personal evaluation of the severity of this stressful situation. According to Lazarus and Folkman (1984), stress results from an imbalance between an individual’s perceived personal demands and perceived personal resources. Perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse are represented by a primary appraisal of the stressful situation. Primary appraisal is defined as an evaluation of the significance of a stressor (Lazarus & Folkman, 1984) that can take one of four forms: perceived susceptibility; perceived severity; motivational relevance; or causal focus. Severity of
IPV is a subjective evaluation of the abusive action, which depends on how women
INSOMNIA AMONG THAI WOMEN 15
evaluate the degree of the abusive action. One woman can appraise the action as non- abuse, while another could evaluate it as an abusive action to a high degree.
Accessing social support is one strategy used to help in coping with stressors
(Lazarus & Folkman, 1984). It comes after the appraisal process as a coping strategy that can help in adapting to stressors. In the current study, social support was hypothesized as a moderator on the relationships between perceived severity of physical, sexual, and psychological abuses, number of IPV types experienced, and insomnia. The previous empirical studies that used this model to guide other studies have likewise made use of social support as a moderator (Bang, 2012; Bakasa, 2007; Forrest, 2013; Sanguanklin et al., 2014).
Adaptation is an outcome of the model conceptualized by positive application of coping strategies that affect an individual’s health (Robinson, 2003). It includes emotional well-being, function status, and health behavior. Using coping strategies leads to either adaptation or maladaptation. Adaptation results when the coping strategy proved effective and helped a person to maintain emotional, functional, or behavioral health status. Maladaptation can result when a person remains unable to adapt to stressors or uses ineffective coping strategies. Insomnia is a part of functional status. Severity of IPV can affect sleep, which alters the body’s functional status. Effective coping strategies can improve sleep, whereas ineffective coping strategies can make insomnia worse, or persist.
Throughout this study, the transactional model of stress and coping (Lazarus & Folkman,
1984) was deemed appropriate, as it represents all of the study concepts and variables and it draws on their relationships.
INSOMNIA AMONG THAI WOMEN 16
Study Model
The study model (Figure 3) of this current study was adapted from the transactional model of stress and coping (Lazarus & Folkman, 1984). The dependent variable of this study was insomnia. Age, education level, and income presented themselves as confounding factors that affect insomnia (Assantachai et al., 2010; Miyata et al., 2013). The independent variables of this study consisted of number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse. Empirical evidence revealed that the severity of the sexual, physical, and emotional abuse correlated with adult health, particularly when the abuse was chronic and severe (Greenfield, 2010; Herrenkohl et al, 2016).
Women experiencing highly severe IPV are more likely to have poor health than women who perceived their experience of IPV as less severe (Vives-Cases et al., 2011).
Moreover, experiencing multiple types of IPV potentially leads to worse health outcomes than experiencing one type of IPV (Sabri, Huerta, Alexander, St.Vil, Campbell, &
Callwood, 2015; Young-Wolff et al., 2013).
The moderating role of social support has been identified in the current literature using the transactional model of stress and coping (Bang, 2012; Bakasa, 2007; Forrest,
2013; Sanguanklin et al., 2014). In 2012, Fortin, Guay, Lavoie, Boisvert, and Beaudry found that social support had a positive buffering effect on the distress of women who experienced physical and psychological abuse. Other studies indicated that the buffering effects of social support appeared strongest at lower levels of abuse against women
(Beeble, Bybee, Sullivan, & Adams, 2009; Schönbucher, Maier, Mohler-Kuo, Schnyder,
INSOMNIA AMONG THAI WOMEN 17
& Landolt, 2014). The literature mentioned that higher social support demonstrates significant affect in reducing the risk of poor mental and physical health (Coker et al.,
2002).
Social Support: -Friends Support -Family Support
Number of IPV Types Experienced
Perceived Severity of Insomnia Physica l Abuse
Perceived Severity of Sexual Abuse
-Age -Education level Perceived Severity of -Income Psychological Abuse
Figure 3. Study model.
Assumptions
Based on the study model, the assumptions of this study were as follows:
1. Perceived severity of IPV is a self-evaluation concept.
2. IPV affects women’s insomnia.
3. Social support is a buffering factor in alleviating IPV health consequences.
INSOMNIA AMONG THAI WOMEN 18
Study Aims
The first aim of this study sought to examine the relationship between number of
IPV types experienced, perceived severity of types of IPV (physical, sexual, and psychological abuse), social support, and insomnia. Guided by the transactional model of stress and coping (Lazarus & Folkman, 1984), the second aim sought to examine the moderating effect of social support on the relationships between number of IPV types experienced, perceived severity of IPV types, and insomnia after controlling for age, education level, and income. The third aim endeavored to determine which social support form was more effective: family support or friends support.
Research Questions
In Thai women:
1. Is there a relationship among number of IPV types experienced, perceived
severity of physical abuse, perceived severity of sexual abuse, perceived severity
of psychological abuse, social support, and insomnia?
2. Does social support have a moderating effect on the relationships between
number of IPV types experienced, perceived severity of physical abuse, perceived
severity of sexual abuse, perceived severity of psychological abuse, and insomnia
after controlling for age, education level, and income?
3. Which is the more effective social support form: friends support or family
support?
Study Hypotheses
1. There is a relationship between number of IPV types experienced, perceived
INSOMNIA AMONG THAI WOMEN 19
severities of physical, sexual, psychological abuse, social support, and insomnia.
2. Social support has a moderating effect on the relationship between number of IPV
types experienced, perceived severity of physical, perceived severity of sexual
abuse, and perceived severity of psychological abuse, and insomnia, after
controlling for age, education level, and income.
3. Friends support is more effective than family support.
INSOMNIA AMONG THAI WOMEN 20
Chapter 2
Review of the Literature
This chapter delves deeply into the literature to discover what is known about insomnia, IPV, and social support as well as what has been found in the existing literature about the relationships between them, if they are each present. Insomnia was addressed in most literature as a concept hidden within sleep problems or disturbances. This section clearly discusses how the available literature defines insomnia and its associated factors and health consequences.
A large body of scholarly literature about IPV from the U.S. and other countries has begun to emerge. This has increased the awareness of IPV toward women and its negative consequences on their health, families, and communities. Still, some factors that affect the nature of this issue make it appear as a private family matter. These factors could include a lack of women’s awareness to identify the abusive action as IPV, general acceptance of abusive actions that come from partner or other family members, and altogether denial of IPV (Brodus, 2008).
Public awareness in recognizing IPV as a serious issue began during the 1960s and 1970s. This recognition combined with the international women’s movement to play an important role in the development of their societies (Mazzotta, 2014; Toussaint-Green,
2016). Further recognition and focus on the IPV issue has been needed to understand the consequences of this problem and how it affects women physically, psychologically, or both. Until recently, IPV has been somewhat obscured because most people consider it to be a private problem.
INSOMNIA AMONG THAI WOMEN 21
Insomnia
Why sleep is important?
As mentioned previously, sleep is essential for healthy body function (National
Sleep Association, 2018) and sleep increases well-being that improves quality of life
(Ngante, 2016; Nguyen, 2014). During high quality sleep, the body heals damaged cells, boosting the immune system, and saves energy by decreasing blood pressure, heart rate, breathing, and body temperature, before entering a rest period (Hirshkowitz et al; 2015;
Mindell, Meltzer, Carskadon, & Chervin, 2009). These changes during sleep lead the body to conserve and replenish energy for a new day. The number of adequate sleep hours is an indicator for potentially improving a person’s productivity and quality of life
(Ngante, 2016).
Stages of Sleep
Sleep progresses through five stages. The first four stages are categorized as non-
Rapid Eye Movement (non-REM) sleep, while in the 5th stage, an individual enters Rapid
Eye Movement (REM) sleep (National Sleep Foundation, 2016a, Ngante, 2016). Each stage of non-REM sleep lasts from 5 to 15 minutes, progressing gradually from stage 1 to stage 4 into deep sleep. The heart rate and breathing become slow, which decreases use of energy (National Sleep Foundation, 2016a). In non-REM sleep, the body also repairs and grows tissues, thereby boosting the immune system and building bone and muscle
(Vyazovskiy & Delogu, 2014).
REM happens after approximately 90 minutes of uninterrupted sleep. REM also has stages of deep sleep. The first stage lasts approximately 10 minutes. Other stages
INSOMNIA AMONG THAI WOMEN 22
take longer, and the last stage lasts up to one hour. In this stage, the heart rate and breathing increase, thereby increasing brain activity. Intense dreams also occur in this stage of REM sleep (National Sleep Foundation, 2016a).
Sleep Disorders
Changes in an individual’s sleep pattern often cause sleep disorders, regardless of the reasons, which then affect overall life. Sleep disorders can impact individual safety through decreasing concentration (Ngante, 2016). Many different types of sleep disorder categories exists, based on natural sleep-wake cycles, breathing problems, or difficulty sleeping (Sateia, 2014). The most common sleep disorders are insomnia (difficulty falling asleep), sleep apnea (difficulty breathing during sleep), restless leg syndrome (an uncomfortable sensation causing the legs to move while falling asleep), and narcolepsy
(falling asleep suddenly during the day) (American Academy of Sleep Medicine, 2016;
Chervin, 2013; Sateia, 2014; National Sleep Foundation, 2016b).
What is Insomnia
Insomnia is the most common sleep disorder and the second most common complaint, after pain, reported in primary care visits. The primary care records revealed that up to 50% of adult clients in primary care reported a sleep disorder per year (Attarian
& Perlis, 2010). Insomnia is characterized by the inability to initiate and/or, maintain sleep, and the inability to attain sufficient duration or quality of sleep (Attarian & Perlis,
2010; Mazzotta, 2014). In some cases, persons sleeping 9 to 10 hours a day can wake up feeling unrefreshed or lacking energy, due to frequent wakefulness at night. Insomnia might also be manifested by awakening several hours early without being able to resume
INSOMNIA AMONG THAI WOMEN 23
sleep (Nguyen, 2014). Insomnia influences daytime function with excessive daytime sleepiness. Functional impairment includes fatigue, poor concentration, excessive sleepiness, or excessive arousal (APA, 2000; Nguyen, 2014).
It is common for approximately 30% of American adults to have insomnia, as noted in Chapter 1 (Mazzotta, 2014). Some factors associated with insomnia are gender, age, education, employment, and socioeconomic status (Smagula, Stone, Fabio, &
Cauley, 2016; Zhang, Lam, & Li, 2012). Women are more likely to have insomnia symptoms and daytime consequences than men (Hershner & Chervin, 2014), and aging people are more likely to have insomnia than younger people (Ogunbode, Adebusoye,
Olowookere, Owolabi, & Ogunniyi, 2014). Insomnia occurs more frequently in separated, divorced, or widowed people (Canivet, Nilsson, Lindeberg, Karasek, &
Ostergren, 2014; Basta, Chrousos, Vela-Bueno, & Vgontzas, 2007). Education and employment serve as other significant factors associated with increased prevalence of insomnia. Insomnia is more frequent in people who have a lower educational level and who are unemployed (Basta et al., 2007).
Types of insomnia
Insomnia is classified into multiple types according to length of time and co- occurrence with other factors. There are three predominant classifications of insomnia:
(1) Acute insomnia is a brief episode affected by life events, such as threats, stressors, travel, bad news, etc. that disappears without treatment (Attarian & Perlis, 2010, National
Sleep Foundation, 2018); (2) Chronic insomnia is a long-term issue evident when a person has trouble falling asleep at least three nights a week for a month or longer
INSOMNIA AMONG THAI WOMEN 24
(Attarian & Perlis, 2010); and (3) Comorbid insomnia occurs concurrently with another condition. It can occur with anxiety, depression, or certain medical conditions that make a person uncomfortable at night (Reddy & Chakrabarty, 2011).
In 2005, the National Institutes of Health (NIH) also classified insomnia into two major categories - primary insomnia and secondary insomnia. In primary insomnia, the inability to initiate or get sufficient sleep is not related to other health conditions.
Secondary insomnia is a sleep disorder related to underlying health conditions such as depression, anxiety, arthritis, cancer, pain, medication, or alcohol abuse.
Causes of Insomnia
Previously, healthcare professionals thought that psychiatric or psychological disorders were the underlying causes of insomnia. Recent studies have refuted this myth and have discovered others reasons for insomnia (Attarian & Perlis, 2010). The common causes consist of physiological, psychological, and environmental factors (American
Sleep Association, 2017; Attarian & Perlis, 2010; University of Maryland Medical
Center, 2017).
Physiological factors relate to changes in body functions due to asthma, high blood pressure, discomfort, hormonal changes, and prescribed medications. Some medications often interfere with sleep and cause insomnia. Psychological factors include emotional discomfort, depression, anxiety, and stress (Attarian & Perlis, 2010; University of Maryland Medical Center, 2017). Stress is the most common cause of acute insomnia.
Violence is considered as a stressful situation that changes a person’s emotion and places the human mind in a fight status, which can in turn lead to insomnia (Hall et al., 2015;
INSOMNIA AMONG THAI WOMEN 25
Jansson & Linton, 2006). Other stressful events that can lead to insomnia include job loss, the death of a loved one, divorce/separation, and moving (American Sleep
Association, 2017; Attarian & Perlis, 2010; University of Maryland Medical Center,
2017). Environmental factors that interfere with sleep include noise, light, extreme temperatures, jet lag, threats from other people, or eating late in the evening (Attarian &
Perlis, 2010). IPV is considered as an external threat that can interfere with sleep.
Diagnosis of Insomnia
Insomnia is a subjective complaint confirmed by conducting an interview to investigate the medical and sleep history. In this step, a nurse has the responsibility to make a deep assessment to determine the type of insomnia and its underlying cause(s). A physical assessment is also performed to confirm the diagnosis of insomnia (Attarian &
Perlis, 2010; National Sleep Foundation, 2018). Keeping a daily sleep diary might be required for a week or more (National Sleep Foundation, 2018). In some cases, special tests for insomnia performed at a sleep center are required. In special cases, the bed partner can be interviewed to collect further data about an individual's sleep (Ngante,
2016).
Risk Factors of Insomnia
Risk factors increase a person’s susceptibility to insomnia. These factors are common to most of the investigated populations: age; gender; education; and socioeconomic status. People over 60 years of age, female, with low education, and poor people are more likely to have insomnia than others (Amaral, de Figueiredo Pereira, Silva
Martins, Delgado Nunes de Serpa, & Sakellarides, 2013; Mayo Clinic, 2016; Ohayon,
INSOMNIA AMONG THAI WOMEN 26
Riemann, Morin, & Reynolds, 2012; Zhang et al., 2012). Other risk factors include having an irregular sleep schedule, experiencing stressful times and events, working different shifts, coffee and alcohol consumption, living alone, taking hormonal replacement therapy, and co-existing medical and psychiatric disorders (Amaral et al.,
2013; Mayo Clinic, 2016; Morin & Jarrin, 2013).
Consequences of Insomnia
As mentioned above, during periods of sleep the body repairs damaged tissues, restores energy, boosts the immune system, and rests the cardiovascular and respiratory systems (Hirshkowitz et al; 2015; Mindell, Meltzer, Carskadon, & Chervin, 2009).
Insomnia deprives the human body of those benefits, and the negative consequences of insomnia become evident. The negative health consequences can be physical, psychological, and social and are associated with elevated use of health care resources
(National Institutes of Health, 2005).
Physical Consequences. Generally, insomnia can affect all physical activities, since it decreases human energy and increases feelings of fatigue for activities of daily living (Pigeon, Cerulli, Richards, He, Perlis, & Caine, 2011; Steine et al., 2012).
Insomnia decreases appetite, which results in weight loss and, with long-term insomnia, nutritional deficiency. Another consequence of long-erm insomnia is developmental problems, since sleep helps grow and regenerate the body cells. Sensory problems are another consequence of insomnia. Since sleep plays a critical role in rebuilding and renewing brain cells, changes in sleep can affect the brain and the sensory system
(Attarian & Perlis, 2010; Nelega, 2012). Lowe, Humphreys, and Williams (2007)
INSOMNIA AMONG THAI WOMEN 27
investigated adverse consequences among women who have sleep difficulties. They reported that a lack of sleep led to many physical health problems, such as feeling “run down,” aching all over, having migraines and/or headaches, suffering from elevated blood pressure, and encountering digestive problems (Lowe et al., 2007).
Psychological consequences. Insomnia leads to decreases in a person’s concentration and attention, which eventually leads to mood swings as well as an inability to make decisions. In some cases, people with insomnia are more susceptible to abusing controlled substances, such as heroin and cocaine, than people with normal sleep
(Dolse & Harvey, 2017). Previous studies have supported that long-term insomnia results in depression and impaired memory (Nelega, 2012; Riemann, 2018). In 2015,
Farrell-Carnahan and colleagues found a significant relationship between depression, anxiety, and insomnia. In 2013, Fernandez-Mendoza and Vgontzas reported that insomnia impacts mental health and contributes to some mental disorders such as depressed mood, anxiety, intrusive thoughts, and poor coping (Fernandez-Mendoza &
Vgontzas, 2013). Furthermore, Walker, Shannon and Logan (2011) examined the mental health consequences of sleep disturbance in a sample of IPV victims who had sought court intervention. The study revealed that sleep disturbance negatively affects a victim’s insight and awareness, and it likewise influences one’s ability to solve problems and plan for safety (Walker et al., 2011).
Social consequences. Insomnia can restrain relationships with others, contributing to loneliness and an inability to maintain close personal relationships.
Inadequate sleep makes an individual more irritable and creates difficulties in interpreting
INSOMNIA AMONG THAI WOMEN 28
facial expressions (Mindy, 2014). Misreading facial expressions can introduce conflict with others. Moreover, individuals with insomnia react negatively to stressful situations
(Kayser, Mainwaring, Yue, & Sehgal, 2015).
Stressors and Insomnia
Stress is commonly described as an important risk factor for sleep disturbances, including insomnia (American Sleep Association, 2017; Attarian & Perlis, 2010). The existing literature holds that a person with stress is more likely to have insomnia than a person without stress (Hall et al., 2015; Jansson & Linton, 2006; Jarrin et al., 2014).
Some studies investigated general stressors without distinguishing between internal or external stressors. Hall and others (2015), for instance, evaluated whether levels of upsetting life events predict sleep outcomes in middle-aged women. The study found that women who have high chronic stress experience lower sleep quality were more likely to report insomnia and wakefulness after sleeping for brief periods (Hall et al., 2015). To the contrary, some studies examined specific types of stressors. A study conducted by
Jansson and Linton (2006) examined whether psychosocial work stressors relate to the development and persistence of insomnia. The results of that study indicated that perceived work stressors do relate to the development and maintenance of insomnia
(Jansson & Linton, 2006). Similarly, another study supported the relationship between exposure to psychosocial stressors and insomnia, showing that exposure to a psychosocial stress is the strongest predictor of insomnia over time (Slopen & Williams, 2014).
Largely, stressors have two basic sources, internal or external. Internal stressors originate within the individual and challenge the body’s ability to manage them (Alsentali
INSOMNIA AMONG THAI WOMEN 29
& Anshel, 2015). Internal stress-inducing factors or stressors can be attitudes, thoughts, feelings of anger, fear and worry, overall health levels, the presence of illness, or emotional well-being. External stressors originate from the surrounding environment, such as noise, trauma, injury, or relationships with others (Alsentali & Anshel, 2015).
External stress is sometimes related to workplace stress, interpersonal conflicts, and relational or marital stress (Alsentali & Anshel, 2015). As indicated, conflict in a marital or partner relationship is an external stressor. IPV is a conflict that occurs within a partner relationship that has negative effects on a woman’s life, which can in turn cause sleep disorders such as insomnia.
Insomnia and IPV
Limited research has established that sleep problems are a health issue related to
IPV. Most of these studies have emerged from the U.S, Spain, and Norway (Pigeon et al., 2011; Mazzotta, 2014; Steine et al., 2012). These studies investigated whether sleep disturbance serves as a predictor of current IPV. The results of these studies supported the relationship between sleep disturbance and IPV; women who reported sleep problems had concurrent experience with IPV (Mazzotta, 2014; Lalley-Chareczko, Segal, Perlis,
Nowakowski, Tal, & Grandner, 2017; Pigeon et al., 2011). Steine and others (2012) examined the role of perceived social support and abuse characteristics in sleep disturbance among Norwegian sexual abuse victims. The findings of that study revealed that higher levels of perceived social support significantly lowered levels of sleep disturbance (Steine et al., 2012).
Some evidence has justified the occurrence of sleep problems for abused women
INSOMNIA AMONG THAI WOMEN 30
attempting to sleep in an unsafe environment concurrent with the site of abusive action, which is generally the home (Pigeon et al., 2011). Insomnia remains a concept hidden within sleep disturbance problems. Insomnia warrants investigation as an isolated concept due to its impact on health consequences in an individual’s life, and, in particular, an IPV victim’s life. Few studies have focused on insomnia as a concept.
Because of this, the nursing field needs more studies to clarify insomnia’s relationship to
IPV.
Intimate Partner Violence (IPV)
What is IPV?
The WHO generally defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (WHO, 2002, p. 211). This definition includes all types and forms of abuse that occur among people in any relationship. One of these types is domestic violence. Domestic violence transpires when one person hurts another either physically or emotionally, where both the victim and the aggressor are in a close relationship (Toussaint-Green, 2016). “Domestic violence” or “intimate partner violence” appear interchangeably to indicate the same phenomenon, since it occurs between a woman and her husband, ex-husband, boyfriend, or ex-boyfriend, or between a man and his wife, girlfriend, or ex-girlfriend (Toussaint-
Green, 2016). For this study, the focus will be on domestic violence or IPV against women. Abuse against women is defined as any act based on gender that causes
INSOMNIA AMONG THAI WOMEN 31
physical, sexual, or emotional harm (Bekmuratova, 2012). Three types of domestic violence against women have been identified: physical abuse; sexual abuse; and psychological or emotional abuse (Breiding et al., 2011; Toussaint-Green, 2016).
Types of IPV
Physical abuse. Physical abuse is the most commonly recognized type of abuse, since it has visible effects (Lacey, McPherson, Samuel, Sears, & Head, 2013). As indicated by its name, it involves the use of physical force and includes any action that causes physical harm. This could include scratching, pushing, punching, hitting, burning, shoving, throwing, grabbing, hair-pulling, slapping, biting, choking, shaking, use of a weapon, use of restraints, or intentionally using any object to cause harm toward a woman (CDC, 2015a; Toussaint-Green, 2016). Physical abuse sometimes results in an injury that needs medical attention. Sometimes, however, physical abuse threatens the overall health status of victims, causing them to seek care at hospitals or urgent care units
(Toussaint-Green, 2016).
Sexual Abuse. Sexual abuse is another type of IPV against women. It refers to unwanted or undesirable sexual actions, or forcing a woman to engage in sexual activities without her consent (CDC, 2014; Toussaint-Green, 2016). Sexual abuse comes in two major forms: sexual assault, which includes coercing sexual contact, rape, prostitution, and any unwanted sexual behavior; and sexual harassment, which is treating woman in a sexually humiliating manner (CDC, 2014; Toussaint-Green, 2016).
Psychological/emotional abuse. Psychological abuse is another form of IPV that involves trauma caused by verbal abuse, acts, threats of acts, or coercive tactics.
INSOMNIA AMONG THAI WOMEN 32
Psychological abuse is used to control, terrorize, and denigrate victims (Toussaint-Green,
2016). Psychological abuse usually happens prior to or concurrent with physical or sexual abuse (CDC, 2015a; Toussaint-Green, 2016).
Psychological abuse humiliates the victim. It can also consist of controlling what the victim can or cannot do, hiding information from the victim, intentionally doing something to keep the victim diminished, isolating the victim from her friends or family, controlling the victim’s access to money or other basic resources, stalking, belittling the victim in public or in private, or decreasing the victim’s confidence or self-worth
(O’Leary & Mairuo, 2005; Rogers & Follingstad, 2014; Toussaint-Green, 2016).
A number of studies have concluded that psychological abuse causes long-term harm to a victim’s mental health. Psychological abuse often leads to depression, suicidal ideation, low self-esteem, post-traumatic stress disorder, postpartum depression, eating disorders, and difficulty trusting others (Lacey et al., 2013; Rogers & Follingstad, 2014).
Among psychologically abused women, seven in ten show symptoms of PTSD or depression (Wong, Tiwari, Fong, Humphreys, & Bullock, 2011). Women who have experienced psychological abuse are significantly more likely to have poor physical and mental health (Hegarty et al., 2013). The literature also indicates that psychological abuse is a stronger predictor of PTSD than physical abuse among women (Wong et al.,
2011).
Severity of IPV
Severity of violence is another dimension of IPV. Severity of IPV relates to health problems and the severity of these problems. The literature reveals that increasing
INSOMNIA AMONG THAI WOMEN 33
severity of IPV leads to increased mental health symptoms, such as more severe PTSD symptoms and greater levels of depression (Devries et al., 2013; Lalley-Chareczko et al.,
2017; Loeb et al., 2014). Another study analyzed whether the socio-demographic status of victims varies correlatively to the severity of IPV. The study reported that women who experienced low severity IPV and those experiencing high severity IPV have a similar socio-demographic status. The study also reported that women with highly severe
IPV suffered from poorer health than those who reported less severe IPV (Vives-Cases et al., 2011).
As mentioned before, IPV includes physical abuse, sexual abuse, and psychological abuse. The severity of each type differs according to its manifestations.
Physical abuse can leave scars on the body of a victim, depending on its severity. As such, physical abuse is the one most reported of all three IPV types (Folami, 2013;
Nwabunike & Tenkorang, 2015), while sexual abuse and psychological abuse remain highly underreported (Folami, 2013). Victims of sexual abuse are often unable to disclose their experiences. Emotional abuse is likewise difficult to disclose (Tenkorang,
Owusu, Yeboah, & Bannerman, 2013). The disclosure or nondisclosure of IPV symptoms influences where and how women seek help (Folami, 2013; Nwabunike &
Tenkorang, 2015). Women suffering physical abuse can seek and receive assistance more readily than women suffering sexual and emotional abuse, due to high levels of disclosure. Highly severe sexual and psychological abuse induces victims to ask for help from trusted friends, family members, or formal support organizations (Tenkorang,
Sedziafa, & Owusu, 2017). Influenced by such data, the current study examined each
INSOMNIA AMONG THAI WOMEN 34
type of IPV as an individual concept. This means the independent variables consisted of severity of physical abuse, severity of sexual abuse, and severity of psychological abuse.
Multiple IPV Experiences
Multiple IPV indicates that more than one or more types of abusive actions - physical, sexual, or psychological - have been experienced (Sabri et al., 2015; Young-
Wolff et al., 2013). Very little literature has addressed multiple types of IPV experienced by victims and how their health is affected. Three studies were found in the literature focusing on the number of IPV types and health. Among black women in Baltimore, women with multiple types of IPV were less likely to have access to community resources to help them manage their abuse. They were also less likely to use health care resources, social resources or religious resources than women experiencing no or one type of IPV (Sabri et al., 2015). Another study investigated whether exposure to multiple types of IPV influences women’s resource utilization. That study also examined whether women’s resource utilization associated with different occurrence patterns of victimization described as current IPV, past IPV, and childhood events. Resource utilization differed based on women’s exposure to past and current victimization.
Women who experienced more types of IPV appeared more likely to use resources, experience more posttraumatic stress and depression symptoms, and suffer drug problems than women who experienced fewer IPV types (Young-Wolff et al., 2013). In 2017,
Lalley-Chareczko and colleagues conducted a study to investigate whether frequency of
IPV associates with current sleep disturbance in men and women. Their study showed a significant relationship between the frequency of IPV and self-reported poor sleep.
INSOMNIA AMONG THAI WOMEN 35
Risk Factors of IPV
Researchers have started to look at all potential indicators in order to identify women at risk for abuse (Brem, Florimbio, Elmquist, Shorey, & Stuart, 2017; Øverup,
Hadden, Raymond Knee, & Rodriguez, 2017). Recent studies have endeavored to identify women at highest risk for IPV (Dery & Diedong, 2014; Ebenezer & Agbemafle,
2016; Fageeh, 2014), considering such factors as age, socioeconomic status, education level, and employment (Brodus, 2008). Women who are older, with low-education, low- socioeconomic status, and who are unemployed are more likely to experience IPV than younger, highly-educated, and employed women with higher socioeconomic status
(Brodus, 2008). Ethnicity and level of wealth also serve as indicators for both physical and sexual abuse (Tenkorang et al., 2013; Dery & Diedong, 2014). In 2016, Ebenezer and Agbemafle indicated that women whose husbands had ever witnessed their fathers beating their mothers experienced higher rates of abuse themselves. Interestingly, women whose own mothers had ever been beaten by their fathers also found themselves at a higher risk to experience abuse. Their study also revealed that 48% of women whose husbands have only a secondary education had an increased risk of experiencing domestic violence than women whose husbands have higher education. Women married to alcoholic husbands were more likely to experience abuse than women with non- alcoholic husbands (Ebenezer & Agbemafle, 2016).
In Saudi Arabia, women from an urban area whose husbands have issues such as problems with police, smoking, exposure to abuse in childhood, seeing their mothers abused, or who do not spend enough time with their families are more likely to be
INSOMNIA AMONG THAI WOMEN 36
subjected to abuse (Afifi et al., 2011; Fageeh, 2014). Previous studies found that women with social anxiety are more likely to be victims of IPV than women without social anxiety (Hanby, Fales, Nangle, Serwik, & Hedrich, 2012; Graham, 2012).
Consequences of IPV
Overall, women subjected to frequent abuse over time find themselves more likely to experience serious consequences, including poor health, and higher healthcare utilization compared to women with one occurrence or who have never been abused
(CDC, 2015b; Montero, 2013). Most health conditions that arise from abuse are the result of physical abuse (Black, 2011; CDC, 2015b). Seeing this, the most obvious negative health consequences that appear in a victim of IPV are physical injuries (Black,
2011). Health consequences can also include psychological consequences, such as suicide and depression (Ansara & Hindin, 2011).
Physical health effects of IPV. Physical injuries derived from IPV range from minor injuries to defects, physical deformities, disabilities, or death (Black, 2011). IPV has a significant effect on victims’ health, safety, and quality of life (Sugg, 2015;
Montero, 2013). Race, sexual orientation, or socioeconomic status does not impact IPV incidence; rather, IPV is a common worldwide issue regardless of these factors (Sugg,
2015).
In 2015, Lukasik and others conducted a study among Polish women, focusing on somatic complaints other than direct somatic consequences. They found abused women to be at risk to develop many medical complications, including peptic ulcers and ischemic heart disease. They were also more likely to use medical services, utilize emergency
INSOMNIA AMONG THAI WOMEN 37
departments, and seek treatment from a specialist, such as neurologist, cardiologist, gastroenterologist, psychiatrist, endocrinologist, or pulmonologist (Lukasik et al., 2015).
Physical injuries lead to the frequent use of healthcare services (Dillon, Hussain,
Loxton, & Rahman, 2013; Montero, 2013). Abused women have short-term symptoms, which include headache, back pain, vaginal bleeding, pelvic pain, sexually transmitted diseases, vaginal infection, urinary tract infection, painful intercourse, stomach pain, joint pain, neck pain, abdominal pain, loss of appetite, and digestive problems (Dillon et al.,
2013). Long-term symptoms include increased risk for cardiovascular disease, respiratory problems, sleeping problems, allergies, hearing and sight problems, and malnutrition (Dillon et al., 2013). Abuse against women also contributes to poor reproductive health (Silverman & Raj, 2014). Negative reproductive health outcomes such as abortion, unintended pregnancy, and infant and maternal mortality remain dominant among women subjected to abuse (Makayoto, Omolo, Kamweya, Harder, &
Mutai, 2013; Pallitto et al., 2013; Silverman & Raj, 2014).
A study by Dillon and colleagues (2013) focused on pain and use of analgesic or pain medication for treatment. The literature reported a relationship between IPV and use of analgesic or non-steroidal, anti-inflammatory drugs (Dillon et al., 2013). Additional studies have also found that a relationship exists between HIV and women who have experienced IPV (Dillon et al., 2013; Hampanda, 2016; Wilson et al; 2016). This relationship explains that women exposed to violence might not be able to ask their partners to use sexual protection aids, such as condoms, during intercourse (Dillon et al.,
2013; Wilson et al; 2016). To the contrary, some previous studies could not support a
INSOMNIA AMONG THAI WOMEN 38
relationship between women who have experienced IPV and HIV risks. These studies took place in Kenya, Tanzania, Haiti, India, Kenya, Liberia, Malawi, Mali, Rwanda,
Zambia, and Zimbabwe (Harling, Msisha, & Subramanian, 2010; Prabhu et al., 2011).
This contrary result might be attributed to differences in demographic and social factors, seeing that these studies were conducted in 11 developing countries.
Mental health effects of IPV. IPV victims also experience negative psychological and mental health consequences (Machisa, Christofides, & Jewkes, 2017) such as post-traumatic stress disorder, depression, anxiety, substance abuse, and, often, suicidal ideation (CDC, 2010; Sugg, 2015). Such consequences are less detectable because of their invisibility. Researchers and health care providers have thus begun to direct their attention to the mental and psychological consequences of IPV. Interventions to reduce the occurrence of IPV can help to prevent and treat mental illness among women who have experienced IPV (Machisa et al, 2017).
Stress and fear could further result from frequent exposure to abuse. Recurrent abuses also affect victims’ thoughts, feelings, and behaviors. As a result, such negative psychological consequences inevitably influence a victim’s mental stability (CDC, 2010;
Sugg, 2015). Additionally, those women find themselves at more risk for suicidal attempts and substance abuse (Ansara & Hindin, 2011; Deribe et al., 2012; Sugg, 2015).
Social Support
Social support consists of “interpersonal transactions that include one or more of the following”circumstances: “the expression of a positive effect of one person toward another, the affirmation or endorsement of another person's behavior, perceptions or
INSOMNIA AMONG THAI WOMEN 39
expressed views; and giving symbolic or material aids to one another” (Kahn &
Antonucci, 1980, p. 173). Environment and social setting around individuals influence their daily choices, understandings, visions, and general behavior (Wright, 2015).
Support in general has many forms and sources; it could be monetary support, advice, praise, and/or emotional support. Typically, social support can come from family, friends, romantic partners, pets, community ties, or coworkers (Taylor, 2011).
Social support plays an effective role in sleep improvement (Chung, 2017; Nordin et al., 2012; Stafford et al., 2017), including improved sleep quality, sleep efficiency, total sleep time, and night-to-night total sleep time variability among midlife adults in the
U.S. (Chung, 2017). Social support can appear in two dimensions: network social support and emotional social support; both of these sources or dimensions promote human sleep in general (Nordin et al., 2012). Close partner support was investigated to substantiate that support from the closest persons improves sleep quality (Stafford et al.,
2017). Social support also effectively moderates the relationship between stress from occupation and sleep quality; people with low social support appeared to have poorer sleep quality (Pow, 2015).
Conversely, some studies found that social support does not have any significant or moderating effects on health outcomes (Jarrin et al., 2014; Kamen et al, 2017; Kim &
Suh, 2017). Moderating effects of social support and coping style did not demonstrate significance in sleep reactivity or risk of incidence and persistent insomnia, after controlling for prior sleep history, depressive symptoms, arousal predisposition, stressful life events, and perceived impact (Jarrin et al., 2014). Another study examined social
INSOMNIA AMONG THAI WOMEN 40
support as a potential protective factor for sleep among older people with insomnia; however, that study revealed no significant effect on insomnia (Troxel et al., 2010).
Moreover, this social support finding did not demonstrate a distinction between adults and the elderly (Gafarov, Gagulin, Gromova, Panov, & Gafarova, 2015).
In IPV victims, accessing social support from people close to the victim is recognized as an important and protective measure or intervention to treat abuse (Wright,
2015). Social support can be provided in two major forms. It can either be found in informal groups, such as family, neighbors, or friends, or it can come from formal organizations such as shelters, hotlines, and advocacy groups (Cowling, 2011). Some studies addressed the role of social support in decreasing IPV occurrence (Kamimura,
Parekh, & Olson, 2013; Wright, 2015). They reported that women surrounded with supportive family and friends are less likely to experience IPV than women without support from family or friends (Kamimura et al., 2013; Wright, 2015). These studies also revealed that poor social support had a negative effect on the mental and physical health of abused women. Thereafter, such women often need to enroll in short- and long-term advocacy programs (Kamimura et al., 2013; Ngujede, 2017; Sigalla et al., 2017). In some cases, informal social support proves more effective than community services to support abused women. Some cultures consider seeking these services to be a shameful action. In such cases, informal support is preferred over community services (Kamimura et al., 2013). This inconsistency regarding the role of social support and its relationship to insomnia is reflected in the current literature that contributes little knowledge on this subject. A better understanding of the role of social support should help to improve
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treatment of insomnia among victims of IPV.
Insomnia in Thailand
Insomnia is highly prevalent in Thailand, especially among the elderly
(Awirutworakul, Sukying, & Udomsubpayakul, 2015; Aunjitsakul, Pitanupong,
Werachattawan, & Anantapong, 2017; Manjavong, Limpawattana, Mairiang, &
Anutrakulchai, 2017). Though the literature in Thailand has documented rates of insomnia and its consequences, limited studies address this problem in a satisfying manner. The prevalence of insomnia among adult and elderly populations has been well- documented. The consequences of insomnia among elderly Thai people consist of daytime dysfunction, requiring a sedative drug, depression, joint pain, and impaired attention (Assantachai et al., 2010; Awirutworakul et al., 2015; Manjavong et al., 2017).
Another study investigated sleep problems among a wider range of people, ages 20 to 78 years old. Researchers conducted the study to assess sleep problems in outpatient clinics.
Ninety-nine percent of participating patients suffered from short sleep duration, 62% from poor sleep efficiency, and 52% from daytime dysfunction (Aunjitsakul et al.,
2017).
IPV in Thailand
Thailand is a traditional society, differing from other countries in its rules and norms. These rules and norms emphasize family privacy and gender role expectations.
In traditional Thai culture, the role of women is to take care of their children and homes, while men are leaders, responsible for working outside the home. Modern Thai women have more freedom and opportunities to get education or to work outside their homes.
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Even with this development in Thailand, Thai society still retains some of the old cultural beliefs that give men more power and privileges than women (Lim, 2011; Ross & Ross,
2012).
Presence of extended family is also a dominant norm in Thailand (Punsomreung,
2012). Currently, some Thai people are moving from the countryside to large cities for jobs or education. This fosters changes in culture that force families to live in nuclear families instead of extended families. This factor might also contribute to increasing IPV in Thailand (Thananowan & Heidrich, 2008). Women being subjected to abuse from their partners is considered a family matter in Thailand (Chuemchit & Perngparn, 2014;
Sroisong, Triamchaisri, Kongsakon, Bennett, & Ross, 2017). Most Thai women have learned that it is not appropriate to inform an outsider about family matters (Chuemchit &
Perngparn, 2014; Ross et al., 2015). Women`s perception is generally that fighting between partners is normal and physical fighting sometimes happens to reunite their relationships (Ross et al., 2015). As a result, the vast majority of IPV cases in Thailand go unrecognized and unreported, hidden within family borders as a private issue
(Archavanitkul, Kanchanachitra, Imem, & Lerdsrisuntad, 2005; Peltzer & Pengpid,
2018). Because of this, the reported statistics of IPV in Thailand are still underestimated
(Chuemchit et al., 2018; Sroisong, Triamchaisri, Kongsakon, Bennett, & Ross, 2017).
Government Organizations (GOs) and Non-Government Organizations (NGOs) such as the OSCC are the most reliable sources of IPV statistics (Chuemchit et al., 2018). In
2015, the OSCC and Ministry of Public Health records showed that 23,977 Thai women had made use of their services, and 460 cases of IPV were reported by police (The
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Women's Affairs and Family Development, 2015).
An increase in the statistical rates of IPV have dramatically developed. Thai governmental awareness drew attention to this issue in order to decrease the side effects on the Thai population. Before 2007, victims of domestic violence were not legally protected. In 2007, the government legislated the “Domestic Violence Victim Protection
Act, Buddhist Era 2550 (2007)” (Bhumibol, 2014). This Act, which focuses on violence within families, has 18 sections, most of which legally protect the spouses from violence, including sexual abuse. Thus, this Act makes the perpetrator of abuse legally liable
(Bhumibol, 2014; Chuemchit et al., 2018).
As indicated previously, the number of abused Thai women has increased despite the government’s effort to protect them (Thananowan & Vongsirimas, 2014a). Other factors have been found to be associated with IPV in Thailand. Studies have reported a significant relationship between abuse and low educational level, low income, unmarried status, unemployment, number of children, partner’s alcohol consumption, living in a small family, high level of stress, depressive symptoms, and self-esteem among Thai women (Ross et al., 2015; Thananowan, 2013; Thananowan & Vongsirimas, 2014a).
Previous studies in Thailand have addressed the mental and psychological consequences of IPV. In 2014, Fernbrant and others concluded that current and previous IPV (all types: physical, sexual, or psychological abuse) associated significantly with poor mental health, and they found that women who have had a previous IPV experience are at risk for repeated IPV more than women without a history of IPV. Another study reported that abused women are more likely to have depressive symptoms than non-abused women
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(Thananowan & Heidrich, 2008). Thananowan and Vongsirimas (2014a) reported that sexual abuse is associated with more stress and depression than other types of IPV, and it is associated with less self-esteem and less social support than physical and psychological abuse. In addition, they found that having experienced three types of IPV puts them at greatest risk for mental illness. Thananowan and Vongsirimas (2014b) conducted a second study that examined the relationship between IPV and depression among women with gynecological problems. The findings were consistent with the first study in verifying a relationship between experience of IPV and depressive symptoms. Some IPV studies conducted among pregnant Thai women (Boonnate et al., 2015; Pengpid, Peltzer,
McFarlane, & Puckpinyo, 2016; Saito et al., 2012) have established that the prevalence of
IPV against pregnant women is higher than in non-pregnant women. Further, pregnant women suffer exposure to physical abuse more than other types of abuse (Boonnate et al.,
2015).
Social Support in Thailand
The concept of social support is dominant among Thais, since it emerges from
Thai cultural beliefs. Family support in conjunction with Buddhism is an essential source of strength in Thailand (Ross & Ross, 2012). Internal spiritual strength helps people to be strong and live with peace in all aspects of life, one of which is health. Parents are obliged to take a care of their children and extended family members, including support for pregnant family members (Ross & Ross, 2012). Social support has been examined in studies conducted in the Thai population (Thananowan & Vongsirimas, 2014b; Ross et al., 2005; Ross et al., 2015) and correlates with decreasing health problems, such as
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depression, among Thai women. Researchers specifically identied social support as a factor that decreases depression symptoms (Liabsuetrakul, Vittayanont, & Pitanupong,
2007; Ross et al., 2009). Social support also plays a role in helping Thai women with cancer to adapt to their condition and leads to improvement in their well-being and their survival rates (Dumrongpanapakorn & Liamputtong, 2017; Suwankhong & Liamputtong,
2015). But few studies in Thailand have addressed insomnia and social support together.
Meanwhile, some studies were conducted to show the role of social support in the occurrence of IPV in Thailand (Thananowan & Vongsirimas, 2014b, Ross et al, 2015;
Sroisong et al., 2017). Presence of social support is negatively associated with IPV, meaning that social support, either in perception or actual support, works as a protective mechanism in decreasing IPV. Social support gives a victim more empowerment and strengthens self-esteem (Thananowan & Vongsirimas, 2014b). Less social support can lead to more abuse against women, particularly during pregnancy (Thananowan &
Kaesornsamut, 2010).
In 2017, Sroisong and others explored the experience of Thai women who survived IPV. The study revealed that help from friends and parents was sought by study participants to stop IPV. Help was given in the forms of emotional support, gifts of money, or provision of a safe place. In addition, women turned to friends or family for advice, inspiration, protection of their children, and encouragement. Those women who survived with social support had feelings of psychological well-being and higher self- esteem. Women without children asked for help from health services providers, police, or even lawyers to help them obtain a divorce. Women with children asked for help from
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friends and family, since they were concerned about the psychological statuses of their children (Sroisong et al., 2017).
In contrast, traditional Thai cultural beliefs still influence women’s perceptions that exposure to abuse within the partner relationship is a personal matter, so it remains unacceptable to make it known to the public (Archavanitkul et al., 2003). In order to protect their privacy, women suffering from abuse therefore might not ask for help from their family or friends (Saito Creedy, Cooke, & Chaboyer, 2013). Ross and others (2015) found a weak mediating effect of social support on IPV and health outcomes (quality of life, depression, and physical symptoms).
The government in Thailand has created some agencies to help and support abused women and to report cases of IPV (Saito et al., 2013). One of these agencies is
OSCC, which is administratively affiliated with the Ministry of Public Health. The
OSCC has established a unit in all government hospitals designated to support victims of violent situations referred from police stations, NGOs, and shelters (Chuemchit et al.,
2018).
Providing nursing support through counseling is recognized in Thailand as a way to help abused women. Counseling from nurses has demonstrated significance in increasing self-esteem and improving general health among Northeast Thai women who have experienced IPV (Sawangchareon et al., 2013). Abused women with high self- esteem show less avoidance of coping styles. Low self-esteem in abused women leads to less effort to master their environment, overcome negative criticism from others, and less reliance on internal coping mechanisms (Sawangchareon et al., 2013).
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Gaps in the Thai Literature
In Thailand, most of the existing literature about insomnia concerns the elderly population because it is common among these people. The Thai literature lacks studies about insomnia specifically among women, which is peculiar, since women are more likely to suffer from insomnia than men. Conversely, many studies in Thailand are devoted to IPV. Nonetheless, limited studies have addressed the relationship between types of IPV and insomnia or examined the effect of social support on abusive relationships. With the rising prevalence of abuse toward women, increasing numbers of women suffering from health problems as a consequence of abuse have emerged.
Moreover, the perception of the severity of IPV did not appear as a concept in the Thai literature, likely affected by cultural norms and beliefs. Male dominance prevails in Thai culture, and some aggressive behaviors toward women are not perceived as abusive
(Brodus, 2008). Seeing this, the current study fills gaps in the Thai literature by addressing the relationship between number of IPV types experienced, perceived severity of types of IPV, and insomnia as well as the buffering effect of social support on these relationships. The literature has shown that insomnia might be influenced by age, educational level, and/or income, so these characteristics served as control variables in this study.
Summary
Insomnia and IPV are major worldwide health problems. Insomnia is commonly recognized as a significant health problem; the literature has addressed the dimensions of this problem, such as causes, prevalence, risk factors, and consequences. Many studies
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have also emerged to understand IPV. Public alarm is emerging, recognizing that IPV against women is a serious problem as its prevalence increases in many countries. Views toward IPV, however, vary from one culture to another, depending on social norms.
Thailand is one country that has begun to recognize IPV as a serious issue that needs more investigation. The number of abused women is significant, and greater awareness by the Thai government and healthcare providers is needed due to the negative health consequences on victims of IPV. Even though the importance of negative health consequences has been identified, most studies investigating IPV have focused on identifying the risk to women. Little is known about insomnia in IPV victims in all existing literature, especially Thai literature. Consequently, the intent of this study is to fill these gaps in the Thai literature by examining the relationship between number of IPV types experienced, perceived severity of IPV types, and insomnia and the moderating effect of social support on these relationships.
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Chapter 3
Methodology
This study sought to examine the relationship between number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, and insomnia as well as the moderating effect of social support from friends and family on the relationships between independent variables and insomnia among Thai women. This chapter discusses the methods used in this secondary analysis of an available dataset to achieve the study aims. It includes discussion about the data source, study design, analytical sample, study variables and their measures, data management, and statistical tests used in this study.
Data Source
The data for the current study was taken from “Intimate Partner Violence,
Emotional Support and Health Outcomes among Thai Women: A Mixed Methods Study”
(Ross et al., 2015). The mixed-method study was based on a convenience sample of women 18 years of age or older who received care at a hospital and who wrote and read in Thai. The primary study examined several predictors of IPV: the association between
IPV and health outcomes which are depression, quality of life, and physical symptoms; the effect of social support as a mediator in the relationship between IPV and health outcomes; and IPV experience among Thai women. The study used a convergent mixed method with a correctional cross-sectional method in the quantitative part. The total sample consisted of 284 Thai women from a large hospital in northeast Thailand. The power analysis for the primary study estimated that the sample size could be 284, based
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on a recommendation of five to 20 subjects for each parameter in the Structural Equation
Model (SEM). Frequency, percentage, mean, standard deviation, and SEM were used to answer the research questions in the quantitative section. The study used valid and reliable instruments for the study variables, and reported a good Cronbach’s α for each measure. Table 1 displays the variables and assessment tools used in the quantitative part of the primary study.
Table 1.
Variables and Tools of the Primary Study.
Variables Measures Cronbach’s α
Emotional violence Psychological Maltreatment of .90 Women Inventory
Physical violence Severity of Violence against .96 Women Scale: Physical
Sexual violence Severity of Violence against .84 Women Scale: Sexual
Family support Multidimensional Scale of .89 Perceived Social Support (MSPSS)-Family subscale
Friend support MSPSS-Friends subscale .93
Spousal support MSPSS-Spouse subscale .89
Depression Thai Depression Inventory .88
Physical symptoms Patient Health Questionnaire .84 (PHQ)
Quality of life World Health Organization .87 Quality of Life (WHOQOL- BREEF)
Emotional violence was measured using the Psychological Maltreatment of
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Women Inventory. The assessment of physical violence was based on the Severity of
Violence against Women Scale: Physical subscale. Measures of sexual violence were generated using the Severity of Violence against Women Scale: Sexual subscale. Family support was assessed with the MSPSS - Family subscale. Friend support was measured with the MSPSS-Friends subscale. Finally, measurement of spousal support was based on the MSPSS: Spouse subscale. The outcomes of the primary study appeared in three variables: depression, measured by the Thai Depression Inventory; physical symptoms, which was calculated using PHQ; and quality of life, which was assessed using the
WHOQOL.
In the qualitative section of the mixed method study, the researcher posed open- ended questions. The questions consisted of whether the victim had told anyone about the abuse and what was shared, what the reasons were for concealing the violence, discussing her plan to avoid repeated violence, and discussing what kind of support or help the victim would like to have in order to solve the problem of violence.
The results of the primary study revealed that family income, spouse’s drug use, alcohol use, and gambling behavior served as predictors of IPV. Depression, physical symptoms, and quality of life were significantly associated with IPV. The study also showed a weak mediating effect of emotional support on IPV and health outcomes.
Qualitative results provided more insights into antecedent factors of IPV, reasons for disclosure and nondisclosure, and perceptions of the role of social support in IPV cases.
Study Design
A secondary data analysis with a correlational and non-experimental design was
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used to examine the relationship between number of IPV types experienced, perceived severity of IPV types, and insomnia, and to test the moderating effect of social support on these relationships. In general, using an existing data set has two approaches, the
“research question-driven” approach and the “data-driven” approach. In the approach driven by the research question, researchers pose their own questions and hypotheses.
Next, they search existing data sets that can answer their research questions (Cheng &
Phillips, 2014). In the data-driven approach, researchers already have data, and they look to the available data to view variables in the existing data. Based on the existing data, researchers start to consider what kinds of questions can be answered by the available data (Cheng & Phillips, 2014).
This study possesses the criteria of the data-driven approach. Questions were formulated based on the available data. The existing data included all study variables, and the data set provided answers to the study questions. Using this existing data was not intended to serve as a replication of Thai IPV science. On the contrary, this study produces new knowledge and contributions to IPV science by using acceptable and pertinent data with an appropriate theoretical framework.
Analytic Sample
For this study, data from 284 women from a large hospital in northeast Thailand comprised the sample. The eligible criteria consisted of women 18 years of age and older receiving care in the obstetrics and gynecology unit, who could read and write in Thai.
Data from all subjects in the primary study were eligible to be included in this study.
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Determination of Sample Size
The estimated sample size was calculated using power analysis, G*power 3.1 software (Faul, Erdfelde, Buchner, & Lang, 2009) for multiple regression of eight predictors (five predictors and three confounding variables): number of IPV types experienced; perceived severity of physical abuse; perceived severity of sexual abuse; perceived severity of psychological abuse; social support; age; education; and income.
Based on a medium effect size of .15, alpha level of .05, and power of .80, the estimated sample size was 103 subjects. A probability of .80 for true effect is acceptable in the social sciences (Van Voorhis & Morgan, 2007). A medium effect size of .15 was used in this study, based on a previous study that reported a medium effect size using the hierarchical linear regression to examine the relationship between three predictors
(prevalence of sleep pattern, sleep duration, and daytime sleepiness) and sleep pattern
(Weiner, 2013). Effect size varies from one study to another, based on the severity of illness or effect of outcome (Cohen, 1988). Here, the effect of insomnia was evaluated to determine that the .15 effect size was adequate to this study type with herarchial multiple regression as a statistical analysis.
The actual sample size in this study that underwent analysis was 284 subjects, since the data from all participants in the primary study were eligible to be included. In addition, collecting data about a sensitive issue such as IPV is not easy; participants expose part of their private lives to others outside of their partner relationships. Thus, using 284 participants meant collecting more data about an accessible population and making the sample more representative to the entire population.
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Study Variables
Table 2 shows the study variables and assessment instruments.
Table 2.
Variables and Tools of the Proposed Study.
The Study Scales Cronbach's α at Psychometric Properties at Level of Variables (Ross et al., 2015) Literature Measurement Insomnia During the past 6 months, how - - Interval much have you been bothered by Insomnia? From PHQ/15 items (Kroenke, Spitzer, & Williams, 2002) Number of IPV Numeric scale from 0-3. (0) Non- - - Ratio types experienced IPV; (1) Experienced experienced one type of IPV; (2) Experienced two types of IPV; and (3) Experienced three types of IPV Perceived Severity of Violence against .96 α =.92 to .96 in female Interval severity of Women Scale: Physical/40 items college students, α = .89 to physical abuse (Marshall, 1992). .96 in community women (Marshall, 1992). Perceived Severity of Violence against .84 α =.92 to .96 in female Interval severity of Women Scale: Sexual/6 items college students, α = .89 to Sexual abuse (Marshall, 1992). .96 in community women (Marshall, 1992).
Perceived Psychological Maltreatment of .90 Thai α =.80 (Saito et al., Interval severity of Women Inventory/14 items 2012). Good construct psychological (Tolman, 1989). validity was reported with abuse Conflict Tactics Scale, Index of Marital Satisfaction, Index of Spouse Abuse, and Brief Symptom Inventory (Tolman, 1999).
Social support MSPSS/4 items for Friends .93 for Friend The MSPSS has been Interval Support and 4 items for Family scale reported reliability and Support (Zimet et al., 1988) .89 for Family validity (Zimet et al., scale 1988). The MSPSS has demonstrated strong factorial validity in its three subscales (Zimet et al., 1990).
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Outcome Variable
Insomnia. Insomnia is defined as difficulty in falling asleep or maintaining sleep
(Mazzotta, 2014). Insomnia was measured using one item from the Patient Health
Questionnaire (PHQ), which asked women about their insomnia. The question was,
“During the past 6 months, how much have you been bothered by an insomnia problem?”
The responses for this item were rated on a 5-point Likert scale: “1 = None of the time, 2
= A little of the time, 3 = Some of the time, 4 = Most of the time, and 5 = All of the time.” A higher score indicated more frequent insomnia, while lower scores indicated less-frequent insomnia experienced by the participants.
The 15-item PHQ (PHQ-15) has demonstrated to be a valid and reliable scale for assessing somatic symptoms. The Cronbach’s α was .82 among 8008 participants from the general German population (Kocalevent, Hinz, & Brahler, 2013). Construct validity was supported by calculating the correlation between the PHQ-15 total score and the
PHQ-9 depression scale. The result supported the inter-correlation of the PHQ-15 with the PHQ-9 Depression Scale (r = .65 - .75), the SF-12 Quality of Life Scale (r(s) = −.68-
−.53), and the Life Satisfaction Scale (r = −.37) (Kocalevent et al., 2013).
Singnificance of using a single measure of insomnia. Few studies have used a single item to measure insomnia. Single items have been used effectively to assess quality of life (Zimmerman et al., 2006), life satisfaction (Schimmack & Oishi, 2005), job satisfaction (Wanous, Reichers, & Hudy, 1997), self-esteem (Robins, Hendin, &
Trzesniewski, 2001), religious orientation (Hettler & Cohen, 1998), readiness to change
(Williams, Horton, Samet, & Saitz, 2007), and functional status in patients with chronic
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conditions (Stewart et al., 1989). Hoddes, Zarcone, Smythe, Phillips, and Dement (1973) have used the one-item Stanford Sleepiness Scale to assess sleep deprivation and examine the impact of sleep deprivation on memory and vigilance.
Generally, a single item measure is used for an unambiguous phenomenon
(Wanous, Reichers, & Hudy, 1997). It is beneficial in providing valuable data about personal perceptions with a holistic view of the concept under study. Holistic perceptions are used to study a subject’s appraisal of quality of life, general health status, personal satisfaction, or symptom intensity (Youngblut & Casper, 1993). A single item measure is more efficient and more easily applied than multiple item measures, since using a single item saves time, shortens the length of a survey, and reduces survey costs (Hoeppner,
Kelly, Urbanoski, & Slaymaker, 2011). A single item measure is more convenient to use with a busy or ill population (Moss, 2016). The choice to use a single item measure in research is based also on ethical preference to reduce burden on the participants (research subjects). Additionally, it is easier to develop and more adaptable to different populations than multiple item measures (Hoeppner et al., 2011).
Single item measures can take more than one form: (a) self-reported facts, such as education and age; (b) psychological constructs, such as job satisfaction; (c) visual analog scale; (d) Likert scale; and (e) graphic presentation (Moss, 2016; Wanous et al.,
1997). Single-item measures have shown strong psychometric properties in some studies
(Youngblut & Casper, 1993; Zimmerman et al., 2006). Psychosocial functioning and quality-of-life items have reported test-retest reliability (Zimmerman et al., 2006). Single item measures for symptom severity, psychosocial functioning, and quality of life have
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had significant evidence of validity, shown in the correlation between single item scores and the total scores of multiple item measures for the same constructs (Zimmerman et al.,
2006). In 1993, Youngblut and Casper showed that single item measures of a mother’s choice and satisfaction with an employment decision have demonstrated strong validity and reliability. Moreover, a single visual analogue scale for depression, anxiety, and distress has demonstrated validity through a strong correlation with the Beck Depression
Inventory (r = .58), the Spielberger State Anxiety Inventory (r = .52), and with the
Perceived Stress Scale (r = .63) (Cella & Perry, 1986).
All this evidence provides a rationale for using a single item to measure insomnia for the current study, which asked women to rate their holistic perception of insomnia.
Using a single item demonstrated to be feasible in this study. The study participants
(research subjects) were patients from the obstetrics and gynecology unit at one hospital.
Since some of them were ill or busy, using this measure saved them time. Findings of the current study are applicable for nurses in clinical practice, as a nurse can assess insomnia in a short time. Since clinical nurses have mulitple duties to perform with their patients during interviews, using a single-item instrument to collect valuable information about insomnia is minimally intrusive.
Independent Variables
Number of IPV types experienced. Number of IPV types experienced was defined as being subjected to one, two, or all three types of abusive actions - physical, sexual, and psychological (Sabri et al., 2015). The number of IPV types experienced was recoded using the Severity of Abuse against Women Scale: Physical and Sexual
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subscales, and the Psychological Maltreatment of Women Inventory. The number of IPV types experienced was measured with a numeric scale from 0-3, “(0) Non-experienced
IPV; (1) Experienced one type of IPV; (2) Experienced two types of IPV; and (3)
Experienced three types of IPV.” In this study, the women who have not experienced
IPV were scored in category (0); women who experienced just one type of IPV were in category (1); women who experienced physical and sexual, or sexual and psychological abuse, or physical and psychological abuse fell into category (2); and women who experienced all three types (physical, sexual, and psychological abuse) appeared in category (3).
Perceived severity of physical abuse. Perceived severity of physical abuse is defined as an individual’s perception about the degree of physical abuse that resulted from physical force against a woman (Fiorillo-Ponte, 1999). For this study, it was measured using the summed score of Severity of Abuse against Women Scale: Physical subscale containing 46 items, developed to evaluate men’s abuse against women
(Marshall, 1992a). It is a self-report questionnaire. The severity of physical abuse was measured using the first 40 items of this scale. Some of the partners’ abusive actions are described as “threw an object at me,” “shook fist against me,” “punched me,” “pushed or shoved me,” “beat me up,” “acted like he would kill me,” and “other actions.” The women were asked about how often these behaviors might have been perpetrated against them, and each item appeared on a 4-point Likert scale, “1 = Never, 2 = Once, 3 = A few times, and 4 = Many times.” Scores on this summed scale ranged from 40 to 160, with higher scores indicating greater experience of physical abuse within the relationship. The
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scale has been reported as having strong psychometrics. The reliability coefficient was
.96 in the primary study (Ross et al., 2015). Internal consistency ranged between .92 to
.96 among female college students and .89 to .96 among community women (Marshall,
1992a; Marshall, 1992b). Other studies reported the reliability index by dividing the results into two dimensions, namely, “threat of violence” and “actual violence”
(McFarlane, Willson, Malecha, & Lemmey, 2000). The threat of violence dimension reported a coefficient alpha = .97 while the actual violence dimension reported a coefficient alpha = .92 (McFarlane et al., 2000). The scale demonstrated good construct validity using explanatory factor analysis. The results were presented in four major categories, symbolic violence, threats of physical violence, actual physical violence, and sexual violence (Marshall, 1992a).
Perceived severity of sexual abuse. Perceived severity of sexual abuse is defined as an individual’s perception about degree of a sexual action against a woman without her consent. Perceived severity of sexual abuse was measured using the Severity of Abuse against Women Scale: Sexual subscale. Six items were employed to measure perceived severity of sexual abuse by an intimate partner (e.g., made you have oral sex against your will). The items were arranged according to the perceived severity of actions. Each item is measured on a 4-point Likert scale, including “1 = Never, 2 = Once,
3 = A few times, and 4 = Many times.” Item scores were coded and summed to calculate a total score ranging from 4 to 24, with higher scores indicating greater experience of sexual abuse within the relationship, and having a reliability coefficient of .84 in the primary study (Ross et al., 2015).
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Perceived severity of psychological abuse. Perceived severity of psychological abuse was defined as an individual’s perception about degree of intention to cause mental or emotional harm to a victim using verbal and non-verbal communication. The 14-item
Psychological Maltreatment of Women Inventory (Tolman, 1989; Tolman, 1999) measured this variable. A sample question is, “My partner yelled and screamed at me.”
The scale is a 5-point Likert scale, “1 = Never, 2 = Rarely, 3 = Sometimes, 4 =
Frequently, and 5 = Very frequently.” The summed total scores ranged from 14 to 70 with higher scores indicating greater psychological abuse.
The Psychological Maltreatment of Women Inventory was reported as having good validity and internal consistency. It was reported as having a reliability coefficient of .90 in the primary study (Ross et al., 2015), and Cronbach’s α of .80 in the Thai version (Saito et al., 2012). The Psychological Maltreatment of Women Inventory has demonstrated good construct validity (Conflict Tactics Scale, Index of Marital
Satisfaction, Index of Spouse Abuse, and Brief Symptom Inventory) tested with 100 women in three sub-groups. It was correlated with the short subscales derived from it, and it also highly correlated with the Physical Abuse Scale in the Index of Spouse Abuse and the Physical Abuse subscale in the Conflict Tactics Scale (Tolman, 1999).
Moderating Factor
Social support. Social support was defined as an individual’s perception about availability of people to provide help and act in a caring and protecting role (Fleury,
Keller, & Perez, 2009; Langeland & Olff, 2008). An individual’s perception of support from family, friends, and significant other was measured using the 12-item MSPSS
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(Zimet, Dahlem, Zimet, & Farley, 1988). In the primary study, three subscales - perceived family support, perceived friend support, and perceived spouse support - were used to measure this variable. In this study, only the subscales of perceived family support and perceived friend support were used. The perceived spouse support subscale was excluded because a woman’s spouse is the source of IPV abuse and its inclusion in the primary study might explain the weak score for the mediating role of social support.
The two subscales include eight items, four items for each scale. These eight items referred to how participants perceived support from family and friends, such as
“My family really tries to help me” or “My friends really try to help me.” Responses were recorded on a 7-point Likert scale consisting of “1 = Very strongly disagree, 2 =
Strongly disagree, 3 = Mildly disagree, 4 = Neutral, 5 = Mildly agree, 6 = Strongly agree, and 7 = Very strongly agree.” The total of the summed scores ranged from 8 to 56.
Higher scores meant women perceived greater social support, whereas lower scores indicated that women perceived less social support. The reliability coefficients for the
Family and Friend Support subscales in the primary study were .93 and .89, respectively
(Ross et al., 2015). The MSPSS has demonstrated good internal reliability with pregnant women, adolescents living abroad, pediatric residents, and undergraduate students (Zime et al., 1988; Zimet, Powell, Farley, Werkman, & Berkoff, 1990). The tool showed strong factorial validity in the three subscales of the MSPSS, namely Family, Friends, and
Significant other (Zimet et al., 1990).
Confounding Variables
Demographic variables. Age, education, and income status served as covariate
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variables in this study, since the literature supports the relationships between these variables and insomnia. They were measured using a background information questionnaire that collected data about age, education, income, marital status, and pregnancy status (Ross et al., 2015). Age was measured using a numeric scale.
Education level was measured using three categories under the question, “What is your highest education level? (1) Grade 6 or below, (2) High school, (3) Diploma or more.”
The final covariate variable was income. The women were asked, “What is your family monthly income?” The response comprised “(1) 5,000 baht or less, (2) 5,001-20,000 baht, and (3) more than 20,000 baht.”
Data Management and Analysis
Data Screening
The Statistical Package for the Social Sciences (SPSS) 24 was used for data analysis. The data were inspected to check for any blank responses. Descriptive analysis was used to ensure that the values were within possible values. Incorrectly coded data was examined using the means and standard deviations. Data were also screened for outliers and missing data to verify the data’s readiness for analysis. Missing data were screened using frequencies and the pattern of missing data was detected, whether it appeared at random or in a systematic pattern. Then, an appropriate strategy was used to deal with the missing data. Generally, if missing data are under 10% of total data, the researcher ignores it if the total cases with no missing data are sufficient to run the appropriate analysis test (Hair, Black, Babin, & Anderson, 2010). When the missing data appears in a non-random manner, it needs an imputation technique (Hair et al., 2010).
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Outliers were screened using Mahalanobis distance for multivariate outliers and boxplots for univariate outliers. Outliers were assessed as to whether they appeared due to an incorrect data entry or if they appeared in a legitimate manner, meaning that cases with outliers experienced extreme score values. The researcher planned to include legitimate outliers that appeared within its score values in the analysis, whereas outliers exceeding the lower or upper score values were to be excluded.
Testing Statistical Assumptions
Multiple regression assumptions were evaluated before performing the analysis.
The assumptions of the multiple regression analysis are normality, linearity, collinearity, and homoscedasticity (Tabachnick & Fidell, 2013). Normality means that variables have normal distribution, and data normality was tested by using a histogram, the Shapiro
Wilks test, and the Kolmogorov-Smirnova test (Tabachnick & Fidell, 2013). Linearity means that the dependent variables are in a linear relationship with the independent variables (Tabachnick & Fidell, 2013). Residual plots were used to show whether the linearity assumption had been violated or not (Tabachnick & Fidell, 2013).
Collinearity was tested by tolerance and use of the Variance Inflation Factor
(VIF) (Munro, 2013). Most commonly, tolerance is ≥ 0.1, and VIF is ≤ 10 in un-violated collinearity cases (Munro, 2013). Violation of collinearity assumption is called multicollinearity. The continuous variables were centered by moving the mean to 0 and subtracting the mean from the variable (Field, 2013). The biggest advantage of centering variables in test moderation is in being able to avoid multicollinearity and increase the interpretability of the regression coefficient (Afshartous & Preston, 2011).
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Homoscedasticity means that the variance of errors is the same across each value of independent variables (Keith, 2006). The homoscedasticity was tested by using the
Mahalanobis distance graph or the Chi-Square critical values table with a criterion of degree of freedom (df) equal to the number of independent variables to detect the critical value (Tabachnick & Fidell, 2013). All values greater than the critical value are regarded as extreme cases that violate the assumption of homoscedasticity (Tabachnick & Fidell,
2013). Mahalanobis distance assessed by graphing must be in a regular shape around the line of regression using standardized residuals. In general, if violation of assumptions appears, it could be possible to address the problem by using bootstrapping (Filed, 2013).
Statistical Analysis
The research questions were as follows: (1) Is there a relationship among number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, social support, and insomnia?;
(2) Does social support have a moderating effect on the relationships between number of
IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, and insomnia after controlling for age, education level, and income?; and (3) Which is the more effective social support form: friends support or family support?
Hierarchical multiple regression served as the appropriate statistical analysis to answer each research question. Multiple regression outputs also included an output box of Pearson r correlations between variables that provided an answer to the first research question. Hierarchical multiple regression was used in this study to examine whether the
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interaction effect between independent variables (number of IPV types experienced; perceived severity of physical abuse; perceived severity of sexual abuse; and perceived severity of psychological abuse) and social support predicts insomnia after controlling for age, education, and income.
A five-stage hierarchical multiple regression was conducted with insomnia as an outcome. Entering variables into the regression model was dependent on the theoretical substraction order using the transactional model of stress and coping (Lazarus &
Folkman, 1984). Age, educational level, and income were entered at stage one of the regression as controlling variables. The number of IPV types experienced was entered at stage two. Perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse were entered at stage three. Social support was entered at stage four. The interactions between social support with number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse were entered at stage five. Bootstrapping was used in analysis as a step within the regression analysis. It demonstrated the best option for this study with questionable assumptions of normality and homoscedasticity. The researcher applied 1000 bootstrap samples and 95% bias-corrected confidence intervals.
Bootstrapping is a technique based on estimating the statistical sampling distribution by drawing repeated samples (with replacement) from the data set.
Bootstrapping can be an alternative method when violation of the assumptions occurs
(Field, 2013). The standard error of the statistics is estimated as the standard deviation of the sampling distribution created from the bootstrap samples. Confidence interval and
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significance tests were also computed (Field, 2013). Again, the principle of the bootstrapping method is built on a sampling distribution for a statistic by drawing a large number of re-sampling statistics from the available dataset (Field, 2013). In this study analysis, the original sample size included in the study was 284 subjects; however, after using pairwise deletion cases in herarchial multiple regression, the sample who underwent herarchial multiple regression concsited of 278 subjects. Bootstrap samples were taken from the dataset of N = 278, and the bootstrap sample was repeated 1000 times. In each instance of multiple bootstrap samples, new estimators were generated with each new set of observations from the dataset; thus, slightly different estimations in each new set of observations could exist. In the end, the estimations of all samples together allowed for making inferences across all bootstrap samples.
To answer the third research question, the hierarchical multiple regression was performed twice. The first time entailed the same previous steps, but interactions of the friend support with the study’s independent variables (number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse) were entered at the fourth stage. For the second time, the test took place with interactions of family support with other predictors at the fourth stage. The bootstrap technique was employed both times. Then, adjusted R2 and beta weight values in family support outputs were compared with adjusted R2 and beta weight values in friend support outputs to see which one contributed more to predicting insomnia.
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Chapter 4 Results
The study endeavored to examine the relationship between the number of IPV types experienced, the perceived severity of (physical, sexual, and psychological) abuse, and insomnia as well as the moderating effect of social support on the relationships between insomnia and other study variables among Thai women. This chapter details the study results. The first section includes missing data and outlier screening results, the statistical assumption results, the descriptive statistics of the sample, and descriptive statistics of the variables. The second section includes the answers to the research questions.
Data screening
Missing data
The frequency test detected the missing values. The amount of missing values was quite small and data were missing completely at random. The missing values consisted of 5 values in age and 1 value in level of education. Pairwise deletion of cases was used when eligible during the statistical analysis.
Outliers
Outliers were detected in the study variables. Multivariate outliers were detected using the Mahalanobis distance, shown in Figure 4. It indicates the existence of extreme values in the data. Box plotting was also used to detect univariate outliers in perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, and social support. Twenty-eight outliers were detected in the
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perceived severity of physical abuse variable. All outliers fell within the range of the measured scores. Perceived severity of physical abuse outliers appear in Figure 5.
Twenty-seven univariate outliers were detected in the perceived severity of sexual abuse variable, as shown in Figure 6. Figure 7 explains the outliers in the perceived severity of psychological abuse. Fourteen outliers were identified in this variable. Nine univariate outliers were also detected on the social support variable, as shown in Figure 8.
All outlier values were checked to see whether or not they were within the respective score values. As they were found to be legitimately within the score values, all outliers were included in the analysis. The decision to include the outliers was based on the meaning of the extreme values in IPV cases. Removing outliers from an analysis of a sensitive issue like IPV would mean discarding the data from subjects reporting the most extreme abuse, which affects the generalizability of the study results. This is especially important because some study variables (physical and sexual abuse) revealed that the overwhelming majority of subjects reported extreme abuse.
Figure 4. Mahalanobis distance.
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Figure 5. Perceived severity of physical abuse outliers.
Figure 6. Perceived severity of sexual abuse outliers.
Figure 7. Perceived severity of psychological abuse outliers.
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Figure 8. Social support outliers.
Testing the Assumptions
The tests revealed that no variables were normally distributed. The Shapiro Wilks test and the Kolmogorov-Smirnova test results were significant (p < .05), indicating a violation of normality. As to the linearity assumption, residual plots show that all of the relationships between insomnia and predictors were linear. Multicollinearity was not detected in the relationships between the variables. Tolerance of all variables after centering was ≥ 0.1, and all of IVF was ≤ 10.
Homoscedasticity was violated, as shown by the Mahalanobis distance in Figure
4. The upper range of Mahalanobis distance was 98, and the critical point according to df was 26.17. Thereafter, all of the Mahalanobis distance values above this point were outliers. Using bootstrap was the solution when assumptions were violated. After using the bootstrapping technique, the residual values fell within a range of -3 and 3. The actual upper and lower values were between -1.7 and 2.8 (M = .00, SD = .74).
Demographic Characteristics
The total sample was 284 women. The age of participants ranged from 18 to 58
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years, the mean age was 36 years (SD = 9.11). The majority of the participants were married (85%) and approximately 80% of the participants were not pregnant. The majority of the participants (43%) had obtained a high school diploma or higher education, and 38% of participants had completed high school, while 18% of participants had no education beyond elementary school. Approximatily, half of the participants reported that their income ranged from 5,001 to 20,000 Baht per month (47%), while
25% of the sample reported that their incomes were more than 20,000 Baht, and 28% of the participants revealed monthly incomes of 5,000 Baht or less. Table 3 describes the sample characteristics.
Table 3.
Participants’ Demographic Characteristics (N =284).
n % M (SD) Min Max Age (years) 279 36.03 (9.11) 18 58 Marital status Married 242 85 Separate, divorced, or widowed 13 5 Difficult relationship 29 10 Pregnancy Yes 57 20 No 227 80 Education Grade 6 or less 51 18 High School 109 38 Diploma or more 123 43 Monthly income 5,000 Baht or less 78 28 5,001-20,000 Baht 134 47 More than 20,000 Baht 72 25 Note: M: Mean; SD: Standard Deviation; Max: Maximum; Min: Minimum; n: Number of participants.
Study Variables Description
Descriptive statistics of insomnia reported a mean of 2.37 (SD = .77). For
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independent variables, the mean of number of IPV types experienced was 2.00 (SD =
.91). The range of perceived severity of physical abuse scores was from 40 to 133 (M =
47.97, SD = 15.37). Perceived severity of sexual abuse scores ranged from 6 to 24 (M
=7.10, SD = 2.59). Perceived severity of psychological abuse scores ranged from 14 to
62 (M = 22.56, SD = 8.89). The social support scores ranged from 8 to 56 (M = 42.73,
SD = 9.38). The mean of family support was 23.02 (SD = 5.07), while the mean of friends support was 19.72 (SD = 5.37). Descriptive statistics of variables appear in Table
4.
Table 4.
Variables Characteristics (N=284).
Variables M (SD) Min Max
Insomnia 2.37 (.77) 1 5 Number of IPV types experienced 2.00 (.91) 0 3 Perceived severity of physical abuse 47.97 (15.37) 40 133 Perceived severity of sexual abuse 7.10 (2.59) 6 24 Perceived severity of psychological 22.56 (8.89) 14 62 abuse Social support 42.73 (9.38) 8 56 Family support 23.02 (5.07) 4 28 Friends Support 19.72 (5.37) 4 28 Note: M: Mean; SD: Standard Deviation; Min: Minimum; Max: Maximum.
Psychometric Properties (Reliability)
Internal consistency was assessed to determine the reliability of the study scales since only a single sample of data was needed to measure it. Internal consistency measured the relationships between items in a specific instrument (Waltz, Strickland, &
Lenz, 2010). Different manners exist to measure internal consistency, but it is described most often using Cronbach’s alpha for the continuous scale (Waltz et al, 2010).
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All of the study scales reported good Cronbach’s alpha values. For Severity of
Violence against Women Scale: Physical subscale, the Cronbach’s alpha was .97; in
Severity of Violence against Women Scale: Sexual subscale, the Cronbach’s alpha was
.83; in Psychological Maltreatment of Women Inventory, the Cronbach’s alpha was .90; and in MSPSS: Friends and Family subscales, the Cronbach’s alpha was .92. In MSPSS:
Family subscale, the Cronbach’s alpha was .90; and in MSPSS: Friends, Cronbach’s alpha was .93.
Research Questions
Research Question (1)
Is there a relationship among number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, social support and insomnia? Pearson r measured the relationships between the variables. The test showed small (Cohn, 1988) and significant relationships between insomnia and number of IPV types experienced, r(278) = .23, p <.001; insomnia and perceived severity of physical abuse, r(278) = .11, p = .03; insomnia and perceived severity of sexual abuse, r(278) = .17, p = .002; insomnia and perceived severity of psychological abuse, r(278) = .14, p =. 01; and insomnia and social support, r(278) = -
.17, p = .003.
The results described a large and significant relationship between perceived severity of physical abuse and perceived severity of psychological abuse, r(278) = .70, p
<.001; a moderately significant relationship between perceived severity of psychological abuse and perceived severity of sexual abuse, r(278) = .41, p <.001; a large significant
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relationship between perceived severity of psychological abuse and number of IPV types experienced, r(278) = .53, p <.001; and a small significant relationship between perceived severity of psychological abuse and social support, r(278) = -.15, p =.007. The perceived severity of physical abuse has a large significant correlation with perceived severity of sexual abuse, r(278) = .56, p <.001, a moderate correlation with number of
IPV types experienced, r(278) = .46, p <.001, and a small correlation with social support, r(278) = -.11, p < .036. Perceived severity of sexual abuse revealed a large significant relationship with the number of IPV types experienced, r(278) = .54, p <.001. The relationship between number of IPV types experienced and social support was small and significant, r(278) = -.18, p = .001. Table 5 displays Pearson r correlations between the study variables.
Table 5.
Pearson r Correlations.
Insomnia Number of Perceived Perceived Perceived Social IPV types Severity of Severity of Severity of support experienced physical sexual abuse psychological abuse abuse Insomnia 1 Number of IPV types .23*** 1 experienced Perceived Severity of .11* .46*** 1 physical abuse Perceived Severity of .17** .54*** .56*** 1 sexual abuse Perceived Severity of .14* .53*** .70*** .41*** 1 psychological abuse Social support -.17** -.18** -.11* -.01 -.15** 1 Notes: * p < .05, ** p < .01, *** p < .001, N= 278.
As displayed, all the relationships were positive, except those between social
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support and other variables that came out as negative. This means that the presence of social support is associated with less insomnia, number of IPV types experienced, perceived severity of physical abuse, and perceived severity of psychological abuse.
Research question (2)
Does social support have a moderating effect on the relationships between number of IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse, and insomnia after controlling for age, education level, and income? Hierarchical multiple regression was used to answer this question. The hierarchical multiple regression revealed that at stage one, neither age, educational level, nor income significantly contributed to the regression model (R2 = .003, F (3,274) = .32, p = .810), and contributed to .3% of the variation in insomnia. Adding number of IPV types experienced to the regression model at stage 2 explained the 5.5% variation in insomnia, and the R2 change was significant in this stage
(R2 =.059, F (1, 273) = 16.06, p = .000). Perceived severity of psychological abuse, physical abuse, and sexual abuse variables explained an additional .4% variation in insomnia, and this change in R2 was not significant (R2 = .063, F (3,270) = .38, p = .768).
Adding social support to the regression model accounted for an additional 1.7% of the variation in insomnia, and this change in R2 was significant (R2 = .080, F (1,269) = 4.99, p = .026). Finally, social support did not significantly moderate the effects of number of
IPV types experienced, perceived severity of physical abuse, perceived severity of sexual abuse, or perceived severity of psychological abuse on insomnia. The addition of interaction terms between social support and other predictors to the regression model
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only explained an additional .1% of the variation in insomnia; this change in R2 was not significant (R2 = .081, F (4,265) = .10, p =.984). Table 6 displays an overview summary of the models.
Table 6.
Hierarchical Regression Analysis Output.
Predictors R² Adjusted R² R² Change β b 95% CI
Step 1 .003 -.007 .003 Age .05 .00 [-.008, .017] Education .01 .01 [-.163, .176] Income -.04 -.05 [-.198, .108] Step 2 .059 .045 .055** Number of IPV types .24** .20 [.112, .283] experienced Step 3 .063 .039 .004 Perceived severity of -.06 .00 [-.010, .003] physical abuse Perceived severity of .08 .02 [-.014, .061] sexual abuse Perceived severity of .04 .00 [-.011, .018] psychological abuse
Step 4 .080 .053 .017* Social Support -.14* -.01 [-.022, -.002]
Step 5 .081 .040 .001 Social support x .01 .00 [-.016, .025] Number of IPV types experienced Social support x .01 .00 [-.001, .001] Perceived severity of physical abuse Social support x -.01 .00 [-.005, .003] Perceived severity of sexual abuse Social support x .03 .00 [-.002, .002] Perceived severity of psychological abuse Note: *p < .05, **p < .01, β: beta, b: bootstrap coefficient.
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In all five variables (number of IPV types experienced; perceived severity of physical abuse; perceived severity of sexual abuse; perceived severity of psychological abuse; and social support), the number of IPV types experienced and social support are the only significant predictors of insomnia as to coefficient regression output and bootstrap coefficients output. As for coefficient output, the number of IPV types experienced showed a significant β weight (β = .24, t(7) = 4.00, p =.000), and social support resulted in a significant β weight (β = -.14, t(7) = -2.23, p =.026). In the bootstrap coefficient output, the number of IPV types experienced reported (b = .20,
95%Cl [.112, .283]), and social support reported (b = -.01, 95%Cl [-.022, -.002]).
Perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse did not serve as significant predictors of insomnia, even as far as the significance of the entire model.
In terms of interaction, all interactions between social support and predictors
(number of IPV types experienced; perceived severity of physical abuse; perceived severity of sexual abuse; or perceived severity of psychological abuse) were not significant in predicting insomnia; p values were >.05, and all confidence intervals were
95% Cl ranges included the 0 value; if a zero value is included in the confidence interval range, then the null hypothesis has not been rejected (Warner, 2013). For the most part, the conclusion was that social support did not serve as a significant moderating effect between study predictors and insomnia, which fails to reject the null hypothesis and rejects the alternative hypothesis.
Research question (3)
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Which is the more effective social support form: friends support or family support? The test results of stage 5 revealed that the change in R2 for friends interactions was .004 while the R2 change in family interactions was .007. The p value for both was not significant; p > .05. Nevertheless, the difference between friends and family support was not equal to 0; it was quite small but it still existed. In non-interaction terms, when entering friend support and family support to the models in stage 4 as predictors, friend support showed significant in predicting reduced insomnia (β = -.171, t(7) =-2.85, p=
.005), (b = -.025, 95%Cl [-.043, -.007]), while family support was not a significant predictor of reducing insomnia (β = -.065, t(7) = -1.08, p = .283), (b = -.010, 95%Cl [-
.028, .008]). Therefore, friends support was more effective as a predictor of less insomnia compared to family support, but not as a moderator. Table 7 explains the models’ summary of support from friends and family.
Table 7.
Comparing Hierarchical Regression between Friends Support and Family Support.
Model Stage R2 Adjusted R2 R2 Change Sig. F β b 95% CI Change Step 4. .090 .063 .027 .005 Friends support Friends support -.171** -.025 [-.043, -.007]
Step 5. .094 .053 .004 .878 Friends support interactions stage Friends support x .002 .000 [-.023, .029] Number of IPV types experienced Friends support x .086 .001 [-.001, .003] Perceived severity of physical abuse
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Cont. Model Stage R2 Adjusted R2 R2 Change Sig. F β b 95% CI Change Fiends support x -.023 -.001 [-.010, .007] Perceived severity of sexual abuse Friends support x -.170 .000 [-.004,.003] Perceived severity of psychological abuse Step 4. .067 .039 .004 .286 Family support Family Support -.065 -.010 [-.028, .008] Step 5. .073 .032 .007 .759 Family support interactions stage Family support x .022 .004 [-.026, .037] Number of IPV types experienced Family support x -.097 -.001 [-.003, .001] Perceived severity of physical abuse Family support x .021 .002 [-.007, .014] Perceived severity of sexual abuse Family support x .098 .002 [-.002, .005] Perceived severity of psychological abuse Note: **p < .01, β: Beta, b: bootstrap coefficient.
Summary
In the first resech question, Pearson r was used to measure the relationships between the study variables. The results indicated significant relationships between the study variables, except for the relationship between perceived severity of sexual abuse and social support, which was not significant. In the second research question, hierarchical multiple regression was used to answer the second research question. The
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results indicated that social support did not have a moderating effect between independents variable and insomnia, since results reported a non-significant R2 change in insomnia variance when adding the interaction terms of social support with other variables to the regression model. In the third research question, outputs of friends support and family support were compared. Neither friends nor family support were significant as moderators between study variables. Even so, friends support was significant as a predictor of reduced insomnia while family support was not.
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Chapter 5
Discussion
This chapter includes a discussion of the study’s findings, implications, dissemination, limitations and recommendations, future research suggestions, and the conclusion. This secondary data analysis examined the relationship between number of
IPV types experienced, perceived severity of types of IPV (physical, sexual, and psychological abuse), and insomnia. Further, the study also examined the moderating effect of social support on the relationships between number of IPV types experienced, perceived severity of IPV, and insomnia after controlling for age, education level, and income. The study also examined which type of social support was more effective: support from family or friends. Existing data from 284 Thai women who attended obstetrics and gynecology units at a large hospital in northeast Thailand in 2010 comprised the study group (Ross et al., 2015). The results of this study remain current and important for Thai women, despite the data having been collected in 2010, since this data is not easy to collect from the affected population based on its potential hazard for victims’ social image and family safety.
The current study was built on new conceptual and theoretical models, which made it distinct from the primary study. At the same time, it was complementary to the primary study since it added new information to the Thai literature on insomnia as well as
IPV. The difference between the two studies appeared in the outcomes. The primary study investigated QOL, depression, and physical symptom outcomes, whereas the current study examined the outcome of insomnia, which was one of the physical
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symptom items in the primary study. The findings of insomnia in this study are more practical and applicable to the Thai clinical area than the primary study, since it is the major outcome of this study.
Research Question (1)
Number of IPV Types Experienced
The study results indicated that experiencing multiple types of IPV increases insomnia. As a result, women with one type of IPV are less likely to have insomnia than women with two or three types. The number of IPV types experienced by women also correlated significantly with all the other variables. It was the strongest predictor of insomnia in the regression model. This study added a new idea to the literature, which is that exposure to multiple types of IPV leads to worse insomnia. Previous studies failed to address insomnia as a health problem or insomnia’s relationship with IPV, even though the findings of this study were consistent with other studies that addressed the experience of multiple types of IPV. As in the study by Kamimura and others (2017) mentioned above, this study likewise revealed that women subjected to multiple types of IPV were likely to have more health problems than those who experienced one type of IPV. They were also more likely to report risky behaviors than victims of one type of IPV.
Sabri and others (2015) examined the relationship between experiencing multiple types of IPV and using health care services. The study was conducted on black women exposed to multiple types of IPV. They reported that these women lacked knowledge and access to treatment, and they did not use community resources such as health care facilities, domestic violence services, and other resources. Interestingly, another study
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indicated that women who experienced multiple IPV were more likely to use resources than women who experienced fewer IPV types, since exposure to multiple types of IPV leads to more negative health consequences such as posttraumatic stress, depression symptoms, and drug problems (Young-Wolff et al., 2013). The negative health consequences cause women to seek care from health resources. The current study results remain consistent with both studies. Women who experience insomnia related to IPV might not seek health care, since they know the cause of their insomnia. They are not able to seek assistance from domestic violence services, influenced by the Thai cultural images and norms that prevent them from asking for help with IPV issues. But if the insomnia causes serious physical consequences, then women might seek health care from the available resources.
Perceived Severity of Physical, Sexual, and Psychological Abuse
The current study results showed that increasing perceived severity of physical abuse, perceived severity of sexual abuse, and perceived severity of psychological abuse correlate with experiencing more insomnia. The study results remained consistent with the study results from Pigeon et al. (2011). They reported that sleep disturbances occurred more prevalently among women experiencing IPV. Moreover, the current study reported positive correlations between each pair of perceived severity of abuses variables.
Perceived severity of abuses variables also correlated positively with the number of IPV types experienced; this correlation was expected, since the number of IPV types experienced variable was generated from those variables. Among all of the study variables, perceived severity of physical abuse has the highest relationship with perceived
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severity of psychological abuse. Perceived severity of sexual abuse has a high correlation with perceived severity of physical abuse. Looking at the results, percieved severity of physical abuse was the only variable that correlated highly with other types of abuse; this could reflect the importance of this variable in discovering the other types of abuse.
Physical injuries related to physical abuse often result in the victim seeking health care, which makes it the most-reported among other IPV types, and it is the starting point for reporting the other abuses (Toussaint-Green, 2016).
The study findings support the literature regarding the inter-correlations between the IPV types, and they reinforce that the manifestation of physical symptoms is the most-reported type of IPV, depending on the nature of this type (Toussaint-Green, 2016).
The study results also indicated consistent with a study conducted on 219 women from
Gujarat, India. That study reported that more than 60% of participants experienced one type of IPV. Physical abuse ranked as having the highest prevalence among IPV types.
Psychological abuse could appear concurrently with an extended experience of physical and/or sexual abuse (Kamimura, Ganta, Myers, & Thomas, 2017).
Social Support
The study found that participants who perceived poor social support from family and friends were more likely to have insomnia than participants with good social support.
The results of this study supported previous studies that reported persons who perceived more social support showed less likely to have insomnia than persons with minimal social support (Chung, 2017; Nordin et al., 2012; Stafford et al., 2017). Glenn, Enwerem,
Odeyemi, Mehari, and Gillum (2015) also tested the hypothesis that sleep disorders co-
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occur more frequently with social isolation than by chance. They found that low social support associated significantly with sleep disturbance and short sleep duration. In contrast, the study results concerning social support were not consistent with a study by
Troxel and colleagues (2010), which reported no significant effect on insomnia from social support. This inconsistency could be related to the differences in group’s age since young women comprised the subjects in the current study, while Troxel et al.’s study concerned elderly people.
As to IPV exposure, the study results showed that women with social support have less perceived severity of physical abuse as well as less perceived severity of psychological abuse. In the literature, accessing social support is considered to be a protective measure or intervention to treat abuse (Wright, 2015). Previous studies similarly revealed that lack of social support had a negative impact on the mental and physical health of abused women (Kamimura et al., 2013; Ngujede, 2017; Sigalla et al.,
2017). Johnson and colleagues (2011) reported that informal social support gives women a sense of well-being more than psychological treatment for the IPV. The current study reported a non-significant relationship between social support and perceived severity of sexual abuse. This result could be related to the nature of sexual abuse, differentiating whether it comes from the partner or husband who lives at the same place with victim, and women regard sexual relationships within the home as a private matter. This explanation is consistent with results of a study conducted by Littleton (2010), which found that social support and negative disclosure of sexual abuse play a significant role in post-trauma adjustment. Negative disclosure of sexual abuse leads to more health
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problems. Hiding sexual abuse often results in women continuing to suffer from psychological post-trauma effects without support from the people closest to them. Still, few studies have addressed the relationship between sexual abuse and social support in the context of IPV. As a result, this relationship needs more investigation, warranting future studies.
Research Question (2)
The second research question examined the moderating effect of social support between the study’s independent variables and insomnia as an outcome, after controlling for age, education level, and income. The results reveal that age, education level, and income were not significant in the insomnia variance. For age, insomnia increases as age increases; the majority of participants in this study were younger. The results of the age variable supported previous studies that have established the increasing prevalence of insomnia as people age (Amaral et al., 2013; Manjavong, Limpawattana, Mairiang, &
Anutrakulchai, 2016; Ohayon et al., 2012). As to education level and income, the majority of participants were educated beyond high school, with moderate income.
These factors remained consistent with previous literature in predicting insomnia, indicating that educated people who are not poor have less insomnia (Morin & Jarrin,
2013; Zhang et al., 2012).
Number of IPV types experienced was a significant predictor of insomnia, while adding perceived severity of physical abuse, perceived severity of sexual abuse, perceived severity of psychological abuse served as non-significant predictors of insomnia in this study. Adding the interaction of social support to those variables did not
INSOMNIA AMONG THAI WOMEN 87
add any significance in the variance of insomnia. Seeing this, the study results failed to support the alternative hypothesis and the researcher accepts the null hypothesis as to the moderating effect of social support. The suggested reason for non-significant findings in the interaction terms is due to cultural beliefs and women`s perceptions that they are unable to ask for help from others concerning abuse issues within their partner relationship, since this means disclosing a family matter that they are bound to keep private. These women also perceived the abusive actions to be normal within the partner relationship and not serious enough to warrant seeking assistance (Archavanitkul et al.,
2003; Saito et al., 2013; Ross et al., 2015). Feeling shame is another reason that prevents abused women to ask for help from others (Archavanitkul et al., 2003). Based on Ross et al., (2015), families of abused women view abusive action as a normal family occurrence, and this family perception makes abused women feel worse, so they cease asking for help from their families. Women might also stop seeking support from friends, perhaps due to being shamed for damaging their husbands’ images. In addition, some studies in
Thailand found that abused Thai women might adapt to the abusive relationship by staying with the partner, keeping silent and patient, feeling inferior, or terminating the abusive relationship by committing suicide (Archavanitkul et al., 2003; Tanopas, 2005).
Social support is important in protecting IPV victims from further abuse or in decreasing the recurrence of abuse (Cowling, 2011). Social support can also be effective depending on the reason for insomnia, such as IPV experience. Social support is initially required to remove the IPV threat, after which it can help enable the victims to sleep.
Since sleep usually occurs in a safe environment, the presence of threats around the
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victim is a reason to stay awake, despite the presence of social support.
The debate about the role of social support as a moderator in health problems is described in the literature. The current study results showed consistency with a previous study conducted in 2014 by Jarrin and others that examined the moderating effect of social support on the relationship between sleep reactivity and incidence of insomnia.
The results revealed that there was no moderating effect by social support on this relationship. The current study results were inconsistent with a previous study conducted by Van Schalkwijk and others (2015) to examine the main and moderating effects of social support in the relationship between stress and sleep. They reported that social support was a significant moderator between stress and sleep, and it also improved sleep quality. Moderating effects of social support appeared stronger in periods of high stress
(Van Schalkwijk, Blessinga, Willemen, Van Der Werf, & Schuengel, 2015). Further, they examined the moderating interaction of social support with anxiety and health outcomes (Stanton & Campbell, 2014). The study reported that more anxiety led to poorer health, even when perceived social support was high (Stanton & Campbell, 2014).
The transactional model of stress and coping guided this study (Lazarus &
Folkman, 1984). Other studies have used this model to investigate the moderating effect of social support (Bakasa, 2007; Sanguanklin et al., 2014). Bakasa (2007) conducted one of those studies to examine the relationship between stress, coping, and social support, as well as physical and mental health in family caregivers of HIV patients in Zimbabwe.
The results revealed no moderating effect by social support on the relationship between caregiver stress and mental health after controlling for demographic variables. These
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results corroborated the current study’s findings that no moderating effect from social support exists. Conversely, Sanguanklin and others (2014) used the transactional model of stress and coping (Lazarus & Folkman, 1984) to examine the moderating effect of social support on the relationship between job strain and psychological distress. Their results did not support the current study results, indicating, rather, that the moderating effect of social support between job strain and psychological distress was significant
(Sanguanklin et al., 2014).
Research Question (3)
The current study strove to explore which type of social support is more effective in decreasing insomnia. Neither friend support nor family support has a moderating effect on the relationships between the study’s independent variables and insomnia. Still, the study results indicated that friends support is more effective in predicting reduced insomnia than family support. Nonetheless, limited studies have differentiated the effectiveness of type of social support on insomnia cases. This result stands in opposition to those found in the IPV literature; one study asserts that family support is more effective than friend support in IPV cases, and that family plays an important role in providing social support to women experiencing abuse by decreasing repeated exposure to violence (Sigalla et al., 2017). Wright (2015) conducted a study to examine the effect of family support and friend support on IPV; he found that social support from family showed significance in reducing the prevalence and frequency of IPV, whereas social support from friends was associated with increased frequencies of IPV (Wright, 2015).
One study focused on family support for Mexican females suffering IPV, and the
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majority of these victims suggested that family members fail to serve as a good source of support (Frías & Carolina-Agoff, 2015). In Mexican culture, disclosing partner abuse contradicts core familial values in preserving children and family relations. The family, thus, cannot provide help in avoiding violence (Frías & Carolina-Agoff, 2015). That is consistent with this study regarding the non-significance of family support. The Mexican study was partly consistent with the primary study’s result in the qualitative section, showing the importance of social support that some victims sought from their families
(Ross et al, 2015). Other participants mentioned that some family members made them feel worse, which led to them to stop seeking social support (Ross et al, 2015). This could render an explanation for the study results that Thai women attempt to keep the
IPV and its health consequences hidden, possibly related to preserving personal and family safety from the abuser as well as trying to keep the family intact.
Nursing Implications
Nursing Knowledge and Practice
Among the sleep studies that have been conducted, very little data focus on insomnia and its associated factors related to IPV. Limited studies have been conducted in Thailand using similar study variables; the results of this study, therefore, make a significant contribution to nursing knowledge about insomnia. The study results aid in better identifying the associated factors of insomnia among Thai women. The findings of this study have clinical implications in nursing practice by using a single item to assess insomnia. Simplicity, time saving, economic cost saving, and ease of administering are factors considered in the decision to use a single-item measure of insomnia. Assessing
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insomnia, IPV, and general health conditions helps nurses to determine the cause of insomnia. IPV is a sensitive issue, so it is not easy to discover and solve insomnia related to IPV victims. Victims are mostly not able to talk about the abusive actions within partner relationships since they are fear reprisal from their partners if those partners knew that the abused disclosed abuse to others (Lowe et al., 2007). The role of nurses is to perform a comprehensive assessment to explore the underlying factors associated with insomnia; a nurse can use the SATELLITE Guide developed by Ross, Roller, Rusk,
Martsolf, and Draucker (2009) for this assessment. This is an appropriate tool for nurses to use since it provides guidelines regarding how to initiate a discussion about IPV in the home and the appropriate actions to take when abuse is revealed. This tool saves time in clinical settings, as it provides assessment and intervention to the nurse in one screening tool. Advocacy is another important role of nurses in insomnia cases associated with
IPV. Nurses can provide education about available resources and community agencies in
Thailand, such as OSCC (Chuemchit et al., 2018). Advocacy by a nurse can protect the victim from abuse and protect her children if they, too, are affected by the abuse. Nurses also have a responsibility to report cases of IPV. The primary study results gave important attention to the need for nurses and other health caregivers to provide support when family and friends did not prove effective in treating abused women’s insomnia
(Ross et al., 2015).
In insomnia cases not associated with IPV, one of the nurse’s intervention options for helping women improving their sleep, based on this study`s results, is to use available social support from friends. Each woman should be considered individually using a
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social environment assessment to determine who the woman’s closest friends are and how they can provide support to improve a woman`s sleep.
Nursing Education
More attention to insomnia related to IPV should be embedded in nursing education. The nursing curriculum can include the definition of insomnia and its causes.
There needs to be more education about insomnia related to IPV, including the definition of IPV types, effects of cultural values on women’s perception of IPV, related negative outcomes, and how persistent insomnia affects body functions and quality of life. Thai women have a cultural perception about the domination of their spouses in the family.
Staying passive and silent might be the Thai woman’s choice to protect her children and family from further conflicts. If this is the case, health education for Thai women is needed to increase their awareness about IPV and provide information about available resources to address instances of IPV. Nursing education can include referrals to organizations in Thailand that focus on women’s issues.
Theory Development
Theory and research converge to form a complementary process (Kim, 2010).
Research uses theories mostly to test a certain theory or to guide studies. At the same time, research is used to develop theories (Kim, 2010). This study was guided by the transactional model of stress and coping (Lazarus & Folkman, 1984), which helped establish the validity of the study results and give it more value for nursing knowledge and practice. The study results supported a section from the transactional model of stress and coping (Lazarus & Folkman, 1984). The study results supported the relationships
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between stressors, primary appraisal, and adaptation, while the study failed to support the moderating effect of social support as a coping strategy on the relationship between stressor, primary appraisal, and adaptation. The recognized inability to confirm the role of social support on the transactional model of stress and coping (Lazarus & Folkman,
1984) might be related to cultural beliefs. Thai cultural beliefs might influence women’s perception of their partners’ abusive actions. Considering fights within a partner relationship is a private matter, which often limits women’s inclination to seek social support.
The study results could make a substantial contribution in the future by refining the theory according to the effect of coping strategies on the model. Further research is needed to test this theory, which should add more empirical evidence about the relationships between the constructs. Conducting studies that use the same variables and the same theoretical model in other cultures is recommended to further distinguish the relationships between the theory constructs and social support.
Health Policy
This study provides substantial empirical evidence about the relationships between IPV, social support, and insomnia. With this, the study results can be used to support the formation and advancement of a health policy in Thai clinics that women who have insomnia should undergo a screening focused on insomnia and its underlying causes. This policy could help to detect related factors or predisposing factors of insomnia.
The study results can also contribute to supporting a health policy about screening
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each woman who visits a health care facility for indicators of physical abuse by using the
SATELLITE Guide (Ross et al., 2009). This initial assessment is important since it could reveal additional types of abuse. The proposed policy would help identify women who have experienced abuse (or women at risk of abuse) and increase the number of reported
IPV cases.
Dissemination
The study results will be disseminated via poster or oral presentations at nursing conferences. The Midwest Nursing Research Society (MNRS) is an annual nursing conference. The plan is to make an oral presentation at the MNRS conference during the upcoming academic year, 2018-2019. The manuscript will be prepared for publication in a scholarly nursing journal such as the American Journal of Nursing. Aggression and
Violent Behavior: A Review Journal will also be contacted, even though it is not a nursing journal, since the content is closely related. Thai nursing journals will likewise be contacted to explore the possibility of publishing the study in Thailand.
Limitations and Recommendations
Despite the significance of the study, some limitations remain. For instance, this study uses a single item measure to measure insomnia. Using a single item measure has advantages in clinical area. However, insomnia measure asked using time, which was
“During the past 6 months, how much have you been bothered by an insomnia problem?”
Other variables were measured without time limit. This might affect the interpretation of results.
The study represents a specific geographic population in the northeast region of
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Thailand. This affects the generalizability of the study’s results for all Thai women. In essence, the study cannot be generalized since the sample was a convenience sample. As a result, these limitations somewhat affect the study’s external validity. The primary researcher attempted to manage threats to validity and make the study results more feasible by using valid and reliable tools. The result is still not generalizable, but the result remains valuable.
Using a correlational study (with a singular time of data collection) demonstrated an inadequacy in exploring the causal relationship between the variables; if the exposures and the outcome of this study underwent concurrent measurement, then no evidence of a temporal relationship between exposures and outcome exists. Using self-reporting reveals another limitation in this study. Even though self-reporting is an objective method, it is not sufficient to explore deeply into Thai women’s experiences with insomnia and IPV. In IPV cases, open-ended questions are more useful for exploring the victim’s experience, feelings, beliefs, and perception of abusive actions as well as identifying more effective and available resources to help victims to sleep.
Future Research
Many future studies are recommended based on this study’s limitations. A mixed-method study focusing on the insomnia phenomenon is recommended; the qualitative part is extremely important in addition to the quantitative part. In studies that address sleep problems related to IPV, participants need to express their thoughts, including disclosing some facts about their relationships with partners during the dialogue and discussion, which was missing from the quantitative studies. Discussion of
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social support resources and participants’ expectations from social support, in addition to identifying which forms of social support the participant prefers, is likely to be more feasible using qualitative methods than quantitative methods. Nurses would then be able to develop an individual intervention for each case based on collected qualitative data.
A longitudinal study is recommended to follow the participants over time and explore the reasons for insomnia. Hence, a longitudinal study would be used to confirm the causal relationship between the study variables, and it would be helpful in resolving insomnia. Future research is recommended to assess the psychometric properties of insomnia with a single-item measure. Testing and retesting can also be used in future studies to assess reliability. The correlation between an insomnia single-item with PHQ-
15 can be examined to assess the validity of the insomnia single-item measure.
Future comparative studies are recommended using two groups of women suffering from insomnia. One group would be women with IPV and the second group would be women who never experienced IPV. Insomnia would be measured for both groups. The purpose would be to differentiate between the characteristics of insomnia that relate to IPV and insomnia with other causes. Such research can help to develop an intervention for this target group because sleeping medications and hygiene measures that promote sleep are not practical in women with IPV.
Conclusion
Insomnia is a common sleep problem that remains understudied. It is a complicated health problem since the treatment plan depends on its causes. Each insomnia case is unique and warrants thorough investigation. Limited studies in Thailand
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have thus far focused on insomnia among adult women. The current study is important, since it contributes to filling gaps in the pertinent literature. Nurses and other health care providers in Thailand can use the study findings while dealing with insomnia cases to develop the most accurate assessments. Assessment strategies based on the study findings can then be created to cover all related factors or predisposing reasons.
Consequently, nurses can formulate interventions to minimize insomnia and sleep problems in general.
INSOMNIA AMONG THAI WOMEN 98
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