Beyond Bruises and Broken Bones: the Joint Effects of Stress and Injuries on Battered Women’S Health1

Home , Bones (season 3), Bones (season 4)

P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

American Journal of Community Psychology, Vol. 30, No. 5, October 2002 (C 2002)

Beyond Bruises and Broken Bones: The Joint Effects of Stress and Injuries on Battered Women’s Health1

Cheryl A. Sutherland, Deborah I. Bybee, and Cris M. Sullivan2 Michigan State University

We investigated the joint mediating effects of injuries and stress on the relationship between abuse and women’s health. A community sample of 397 women, half of whom had been assaulted by an intimate partner within the prior 6 months, was interviewed about their experience of intimate partner violence, injuries, stress, income, depression, and physical health problems. Structural equation modeling techniques conﬁrmed the complex model of hypothesized indirect effects of abuse on women’s physical health problems through injuries, stress, and depression. Stress accounted for 80% of the indirect effect of abuse on women’s physical health. Its direct effect on physical health was somewhat larger than its indirect effect through depression, but both processes played a key role in determining the effect of abuse on women’s physical health problems. Furthermore, abuse was a stronger predictor of women’s stress than was poverty. Implication and future research are discussed. KEY WORDS: domestic violence; battered women; physical abuse; physical health; women’s health; stress; structural equation modeling.

Intimate partner violence is a pervasive social problem that compromises the personal health and safety of millions of women each year (Bachman & Saltzman, 1995; National Coalition Against Domestic Violence, 1995; Plichta, 1996). Cross-sectional and longitudinal investigations of women

1This research was supported by National Institute of Mental Health Grant R01 MH44849. 2To whom correspondence should be addressed at Psychology Department, 135 Snyder Hall, Michigan State University, East Lansing, Michigan 48824-1117; e-mail: sulliv22@msu. edu.

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from domestic violence shelter programs, emergency rooms, and primary health clinic settings consistently demonstrate that intimate partner violence places women at risk for physical and psychological health problems (Abbott, Johnson, Kozoil-McLain, & Lowenstein, 1995; Eby, 1996; Follingstad, Brennan, Hause, Polek, & Rutledge, 1991; Sutherland, Bybee, & Sullivan, 1998). Compared to nonbattered women, survivors of physical abuse are more likely to suffer multiple physical health symptoms (Council on Scientific Affairs, 1992; Eby, 1996; Follingstad et al., 1991; Hamberger, 1994), chronic health problems (Drossman, Talley, Leserman, Olden, & Barreiro, 1995; Talley, Fett, & Zinsmeister, 1995), depression (Campbell, Kub, Belknap, & Templin, 1997), and suicide ideation (Eby, 1996; Gleason, 1993; Orava, McLeod, & Sharpe, 1996). Women who experience more frequent and severe physical abuse are also more likely to report higher rates of health problems than are women who experience less violence (Bergman & Brismar, 1991; Campbell et al., 1997; Campbell, Sullivan, & Davidson, 1995; Eby, 1996; Follingstad et al., 1991; Khan, Welch, & Zillmer, 1993; Sutherland et al., 1998). Furthermore, prior research has shown that survivors’ rates of physical health problems, depression, and anxiety intensify as a partner’s physical violence continues, but gradually decrease with subsequent reductions in violence (Campbell et al., 1995; Follingstad et al., 1991; Sutherland et al., 1998). The psychological abuse women experience can be as devastating, if not more so, than the physical violence. Although research is limited with respect to its independent effects on women’s health, there is some evidence to suggest that psychological abuse lowers self-esteem and increases symptoms of depression and posttraumatic stress disorder among battered women (Aguilar & Nightengale, 1994; Arias & Pape, 1999; Follingstad, Rutledge, Berg, Hause, & Polek, 1990). Despite the recent advances in our knowledge about the harmful effects of abuse, we know little about the process by which intimate partner violence places women at risk for long-term health problems. Few researchers have investigated how intimate partner violence jeopardizes women’s health (exceptions include Campbell & Soeken, 1998; Eby, 1996; Sutherland et al., 1998). Clarifying the process by which abuse compromises women’s health may improve communities’ response to the needs of battered women. It may, for example, improve the ability of health care providers to identify and treat battered women. Physicians typically identify battered women on the basis of the types of injuries they present, yet frequently note that battered women suffer numerous health symptoms that do not necessar- ily relate to any specific injury or predisposing health problem. Showing how abuse predisposes women to complex health problems may encourage P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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health care providers to adopt innovative strategies for treating more than injuries.

FACTORS MEDIATING THE EFFECTS OF ABUSE ON WOMEN’S HEALTH

Injuries

Linked to serious health problems such as chronic pain, hearing and vi- sion loss, epilepsy, and arthritis (Goldberg & Tomlanovich, 1984; McCauley et al., 1995), injuries are the most visible and immediate consequences of physical and sexual violence. However, the extent to which abuse-related injuries lead to poor health outcomes is not well understood. Researchers have documented injuries as a way of generating prevalence rates of abuse, and have conﬁrmed that physical abuse is strongly related to increased levels of injuries. They have been less successful demonstrating that abuse- related injuries account for other less visible health problems. For example, Sutherland et al. (1998) found that abuse was strongly related to increased levels of injuries, whereas abuse-related injuries were not signiﬁcantly related to the physical health symptoms women reported. Moreover, injuries do not adequately explain the relationship between abuse and women’s risk for depression and suicide ideation.

Stress

Several researchers have proposed a stress-response theory of abuse, suggesting that it is the stress associated with surviving an intimate partner’s physical and verbal assaults that jeopardizes women’s health (Campbell et al., 1995, 1997; Dutton, Haywood, & EI-Bayoumi, 1992; Eby, 1996; Follingstad et al., 1990, 1991; Goodman, Koss, & Russo, 1993; Koss, 1990). Decades of rigorous research have demonstrated that stress can se- riously compromise physical and psychological well-being (see Adler & Mathews, 1994; Avison & Gotlib, 1994; Elliott, 1995, for reviews of relevant research). High levels of stress have been linked to various physical health conditions (Barnett, Davidson, & Marshall, 1991; DeLongis, Folkman, & Lazarus, 1988; Elliott, 1995) and to psychological distress symptoms such as depression (Amatea & Fong, 1991; Holahan & Moos, 1991; Kendler et al., 1995; Kuyken & Brewin, 1994; Stephens, Franks, & Townsend, 1994). Battered women experience more negative life events and daily hassles than do nonbattered women (Campbell et al., 1997; Eby, 1996; Jaffe, Wolfe, P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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Wilson, & Zak, 1986), and many of the health problems they report mir- ror those identified in stress studies. However, only a few researchers have empirically investigated the complex relationships among abuse, stress, and women’s health. Their findings indicate that stress is a substantial link between abuse and women’s health; high rates of negative life events and daily hassles among battered women significantly predicted levels of depression and physical health problems (Campbell et al., 1997; Jaffe et al., 1986). Eby (1996) demonstrated that stress mediated the effect of abuse on low-income women’s physical health and psychological health; experiences of stress explained nearly 100% of the effect of abuse on their physical health and 60% of the effect of abuse on their psychological health. These findings provide preliminary support for a stress-response theory of abuse. However, the re- liance on samples of low-income women has limited the generalizability of such research findings.

Poverty

Living in poverty places women at risk for numerous health problems, many of which parallel those reported by survivors of intimate partner violence. Low-income women are more likely to suffer higher levels of depression and anxiety (Hirschfeld & Cross, 1982; Lynch, Kaplan, & Shema, 1997; Murphy et al., 1991) and chronic physical health problems (Kington & Smith, 1997; Luepker et al., 1993; Lynch et al., 1997; Stronks, Van De Mheen, Van Den Bos, & Mackenbach, 1997) than are women with higher incomes. They endure unique stresses associated with living in poverty, such as income instability, frequent moves, lack of transportation, and poor housing conditions (Belle, 1990; Thoits, 1982). They experience a greater number of financial stressors (e.g., job losses, unpaid bills, inadequate housing) and have insufficient financial resources to address those and other undesirable events (e.g., frequent illness, legal problems) than do middle- or high-income women (McLeod & Kessler, 1990). Survivors of intimate partner violence report similar concerns: unem- ployment, lack of transportation, substandard housing, and financial issues (Eby, 1996; Sullivan, Basta, Tan, & Davidson, 1992). Because investigators have consistently relied on samples of low-income women, the extent to which these concerns are related to conditions of poverty versus intimate partner violence is unclear. Eby’s comparative study did indicate that the effects of abuse remain strong even when controlling for women’s low-income status; low-income “abused” women reported higher stress levels and poorer health outcomes than did the group of low-income “nonabused” women (Eby, 1996). However, without the inclusion of women from a broad range P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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of income levels, the extent to which poverty contributes to women’s stress and health remains inconclusive.

Relationship Between Psychological Health and Physical Health

Women’s psychological health may also influence the extent to which intimate partner violence affects their physical health status. Researchers have demonstrated a strong positive relationship between symptoms of depression and chronic health problems (Betrus, Elmore, & Hamilton, 1995; Hays, Wells, Sherbourne, Rogers, & Spritzer, 1995; Judd, Paulus, Wells, & Rapaport, 1996; Von Korff & Simon, 1996), suggesting that one’s physical health problems may be due, in part, to concomitant levels of psychological distress. Similar findings were generated from a recent investigation of the long-term effects of intimate partner violence. Results from the longitudinal study indicated symptoms of depression and anxiety exacerbated or at least partially explained women’s physical health symptoms (Sutherland et al., 1998). These findings highlight the importance of examining the complex relationships between psychological health and physical health as well as the effect of abuse on each outcome. In summary, although researchers have demonstrated that intimate partner violence places women at risk for numerous health problems, few have investigated the process by which abuse compromises women’s health. Severe abuse-related injuries may predispose some women to debilitating health problems, but injuries alone do not account for the complex array of physical health symptoms, chronic health problems, depression and anxiety survivors typically report. There has been preliminary support for a stress- response theory of abuse; battered women experience more daily hassles and negative life events than nonbattered women, and the stress they experience accounts for a significant portion of the relationship between abuse and health problems. However, in studies where stress was examined as a mediating variable (Eby, 1996) or as a contributing factor (Campbell & Soeken, 1999), the samples were primarily low-income women. The extent to which poverty affects the relationships among abuse, stress, and health remains unclear. Finally, previous researchers typically have treated psychological and physical health outcomes as isolated consequences of intimate partner violence, yet there is evidence indicating a strong relationship between them. Fully understanding the process by which intimate partner violence impacts women’s psychological health and physical health requires an examination of these complex relationships. This study investigated the relationships between and among women’s experiences of intimate partner violence, injuries, stress, income, depression, P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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Fig. 1. Conceptual model.

and physical health (i.e., physical health symptoms and general health status). A conceptual model of these hypothesized relationships is presented in Fig. 1. As can be seen in the conceptual model, six complex relationships were hypothesized. First, it was hypothesized that women’s recent experiences of abuse would be positively related to their levels of injuries and stress. Second, the effect of abuse on women’s physical health would be mediated by the injuries they sustained. Third, women’s levels of stress would mediate the effect of abuse on their levels of physical health and their levels of depression. Fourth, it was expected that women’s levels of depression would mediate the effect of stress on their levels of physical health symptoms and perceived general health status. Finally, it was hypothesized that women’s income level would have a direct negative effect on their experiences of stress.

METHOD

Participants were recruited primarily through newspaper advertisements (83%), although some women heard about the research project through a friend, relative, or service provider who had seen the advertise- ment (12%), or had themselves seen a ﬂyer (3%). Six women (2%) did not provide information about how they had learned about the study. Four consecutive advertisements were placed simultaneously in three local newspapers from August 1996 through June 1997. Two of the newspapers were delivered free of charge to households in the area. To increase the likelihood of including women from a range of income levels, each of the four P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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advertisements was specifically designed to attract women who fit a specific profile (e.g., middle-income women who had been physically harmed by an intimate partner). Women were considered eligible if they met the following criteria: (a) they were between 18 and 45 years of age and (b) they were current residents of the same midsized midwestern city. Each eligible woman was scheduled for a face-to-face interview at a time and location convenient for her. Interviews with trained female interview- ers took place in several different settings; most were scheduled at a local community organization, but some were conducted in women’s homes or at the local university. Of the 439 women who scheduled interviews, 397 (90%) completed them.

Research Participants

Seventy percent of the 397 participants identified themselves as White/Caucasian, 20% Black/African American, 6% multiple ethnicity, 5% Hispanic/Latina, 1% Asian Pacific, and 1% Native American. Generally, the participants were in their 30s (mean age = 34, SD = 7.68), employed at least part-time (66%), had some college experience (74%), and cared for two children (SD = 1.55). Thirty-nine percent were married or living with an intimate partner, 27% were in a serious relationship but not living together, and 34% were not involved in a serious relationship at the time of the interview. The majority of women (86%) owned or rented their homes, whereas the remaining 14% had temporary shelter arrangements with friends, relatives, or some other source. Despite the median household monthly income of $1,600 (SD = $1,616), 129 women (33%) were surviving on monthly incomes below the poverty threshold for the number of people supported by that income. In most households, the monthly income supported at least three people (68%), and in 5% of those homes, the income supported between six and nine people. Fifty-nine percent had private medical insurance, 22% received Medicaid or Medicare, and 19% were not insured. As expected, 52% of the participants reported that an intimate partner or expartner had physically harmed them within the 6 months prior to the interview. The demographic characteristics of this sample were generally repre- sentative of the midsized midwest community population. According to the 1990 Census data (Bureau of Census, 1990), the ethnic, educational, and employment distributions of the current sample were comparable to the city’s demographic characteristics. Women in this sample were as likely to have private health insurance or at least Medicaid or Medicare as were people living in the area in 1990 (Health Status Advisory Group, 1993). Despite the ap- parent similarities between this sample and the city’s population, the median P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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annual income of $18,000 was substantially less than the 1989 estimates of household income ($26,398; Bureau of Census, 1990).

Measures

Data were collected through face-to-face interviews using a structured questionnaire. The interview consisted of both an oral phase and a written phase, and assessed the following constructs: abuse, injuries, stress, income, physical health, and depression.

Abuse Experienced

Three different types of abuse were measured: physical, psychological, and sexual. Only women who were in an intimate relationship at the time of the interview or who had contact with a previously violent expartner during the 6 months prior to the interview were asked specific questions about abuse. The relationship was considered intimate if the participant indicated that the partner was at least a boyfriend or girlfriend (i.e., if a woman had been casually dating and didn’t consider the relationship intimate, she wasn’t probed further about threats or occurrence of physical, sexual, or psychological abuse). Of the 397 women interviewed, all except 53 (13%) women were asked about their partner’s or expartner’s abuse. Each type of abuse was measured with respect to its occurrence and frequency within 6 months prior to the interview. The 53 women who were not asked questions about abuse received scale scores of “0.” A 6-month time frame was chosen to be consistent with other scales’ time frames and to improve our confidence that women’s responses to questions about the frequency with which each form of abuse occurred were accurate. Physical abuse was conceptualized as any incident in which a person was physically harmed by an intimate partner or expartner. A modified 11-item version of the Conflict Tactics Scales (Straus, 1979) was used to assess experiences of physical abuse during the 6 months prior to the interview. For each item about a specific type of violent act (e.g., “kicked you”), responses ranged from 1 (never)to6(more than four times a week). Each participant’s scale score was calculated as the mean frequency rate with which they experienced the different forms of physical abuse. The internal consistency of the 11 items demonstrated high reliability ( = .93), with corrected item-total correlations ranging from .55 to .84. Because this variable was positively skewed (197 women received a score of 0 because they had not experienced physical abuse in the past 6 months), a log transformation was applied prior to structural equation modeling. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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Psychological abuse was measured with a shortened version of the 33-item Index of Psychological Abuse (IPA) Scale (Sullivan, Parisian, & Davidson, 1991). The IPA has demonstrated validity and reliability, and has been used successfully with other samples of battered women (O’Leary, 1999; Sullivan & Bybee, 1999). The 19-item version of the IPA asked women how often, in the past 6 months, they had been harassed, controlled, ridiculed, and criticized by an intimate partner or expartner. Responses to items about specific abusive acts (e.g., “How often has he/she tried to control your money?”) ranged from 0 (never) through 3 (often). Each participant’s scale score was calculated as the mean frequency rate with which they experienced the different forms of psychological abuse. Cronbach’s alpha for this measure was .94, with corrected item-total correlations ranging from .49 to .82. Sexual abuse was defined as any act or threat of sexual activity by an intimate partner or expartner that was unwanted or forced (Swett & Halpert, 1993; Winfield, George, Swartz, & Blazer, 1990). Four items were used to construct the Sexual Abuse Scale (SAS). The first item was measured as part of the psychological abuse scale: How many times in the last six months has ...used threats to try and have sex with you? The second item was measured as part of the physical abuse scale: How often in the past six months has ...forced any sexual activity you didn’t want to happen? The remaining two items were taken from the written section of the interview. For the first question, women were asked, How often have any of your partner(s) ever used threats to try and have sex with you in the past six months? For the second question, women were asked, How often have any of your partner(s) used physical force to have sex with you in the past six months? Both questions asked women to rate their experiences on a 5-point scale ranging from 0(never)to4(more than 20 times in the past 6 months). Although the third and fourth items of this scale repeated the first two questions, it was antic- ipated that some women would feel more comfortable responding to the written questions than to the oral ones. (Note: correlations between written and oral questions were moderate: physical force, r = .71; threat, r = .60.) Each participant’s standardized scale score was calculated as the mean frequency rate with which they experienced all four items. The internal consistency was .86 with corrected item-total correlations that ranged from .70 to .77. Because this variable was positively skewed, a log transformation was applied prior to structural equation modeling.

Injuries

The number of injuries sustained in the previous 6 months was derived from a checklist of 11 injury types (Sullivan, 1991; Sullivan & P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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Bybee, 1999) commonly associated with domestic violence (e.g., cuts, scrapes, and bruises, dislocated joints, broken bones, and knife and gunshot wounds). All 397 women (abused and nonabused) were asked about injuries they sustained during the 6 months prior to the interview. Cronbach’s alpha for this scale was .57, with item-total correlations ranging from .17 to .39. Individual scale scores were calculated as the total number of injuries reported.

Stress

The number of problematic situations or circumstances women experienced was derived from the 28-item Difﬁcult Life Circumstances (DLC) Scale (Barnard, 1989). The scale asked women to indicate whether or not they had experienced a particular situation (e.g., hospitalization in past year, problems with credit rating, and lack of privacy). Cronbach’s alpha for this scale was .68, with corrected item-total correlations from .00 to .40. Individual scale scores were calculated as the total number of difﬁcult life circumstances reported. The 50-item Life Event Checklist (Reischl, Eby, & Ramanathan, 1992) was used to assess women’s experiences of stressful life events. Although similar to other life event scales (Holmes & Masuda, 1974; Paykel, Prusoff, & Ulenhuth, 1971), this scale contains additional events that are typically associated with intimate partner violence (e.g., had new troubles with your boss or people at work, had trouble with your partner’s family members, had been a victim of a violent crime, such as rape or assault). Furthermore, it has been used successfully with low-income battered women (Eby, 1996). Participants were asked whether or not an event took place within the past 6 months, then to rate how stressful it was for them. Women rated their perceived stressfulness of the event on a 5-point scale that ranged from Not at all stressful to Extremely stressful. Cronbach’s alpha was .77, and corrected item-total correlations ranged from .01 to .43. Each participant’s mean stress score was calculated by summing their stressfulness ratings and dividing by the total number of stressors endorsed.

Income

Income level was operationalized as the extent to which adjusted annual household incomes were below, at, or above poverty level (i.e., “percent of poverty”). Annual household incomes were adjusted to account for the number of people supported by the income. The percent of poverty rates were calculated using a procedure based on the U.S. Census Poverty Threshold Index (Bureau of Census: Poverty P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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Thresholds, 1996). Each woman’s annual income was divided by the ap- propriate poverty threshold (i.e., highest allowable income considered at poverty level for the number of people supported by it), then multiplied by 100 to yield a continuous variable. One hundred percent poverty indicated the person’s annual income was at the poverty level. To be eligible for most government assistance (e.g., Medicaid, Food Stamps, Financial Aid), a person needs to demonstrate his/her annual income to be at or below 125% poverty. Therefore, for the purposes of this study, a participant was considered to have “low income” if her calculated percent poverty rate was at or below 125% poverty.

Depression

Three measures were used as indicators of depression. Feelings of depression were assessed through the Center for Epidemiological Studies— Depression Scale (CES-D; Radloff, 1977). Item responses ranged from 1(never or rarely bothered)to4(bothered most or all of the time). Inter- nal consistency was .93, with corrected item-total correlations ranging from .42 to .80. A widely used instrument, the CES-D is established as a reliable and valid measure of depression. Participants’ risk for suicide was assessed by the following two items: “How often have you thought about ending your life in the past 6 months?” and “Have you tried to end your life in the past 6 months?” If a woman indicated that she never thought about committing suicide in the past 6 months, she was not asked to answer the second question. Women’s responses to both questions were coded as follows: (0) no suicidal thoughts or attempts, (1) suicidal thoughts, no attempts, (2) suicidal thoughts and at least one attempt. Perceived quality of life was measured with a modiﬁed version of Andrews and Withey’s Quality of Life measure (Andrews & Withey, 1976). The adapted version of the original measure contained nine items. Partici- pants were asked to rate, on a 7-point scale, how they currently felt about various aspects of their lives (e.g., “How do you feel about what you’re ac- complishing in your life?”). Responses ranged from 1 (extremely pleased) to 7 (terrible). The internal consistency of this scale was .88 with corrected item-total correlations ranging from .41 to .78.

Physical Health Problems

Women’s general health status was assessed by one item, which asked women to rate their general health status on a four-point scale ranging from excellent to poor. This item was adopted from the National Health Interview P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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Survey (Centers for Disease Control and Prevention, National Center for Health Statistics, 1993). The frequency with which women were bothered by health problems was assessed through a modified version of the Cohen– Hoberman Inventory of Physical Symptoms (CHIPS; Cohen & Hoberman, 1983). The original scale was modified to include physical symptoms that are frequently reported by women with abusive partners, such as choking sen- sations, high blood pressure, and pelvic pain (Abbott et al., 1995; Campbell, 1989; Eby, Campbell, Sullivan, & Davidson, 1995). Participants were asked to rate how often in the past 6 months they had been bothered by each of 30 physical health symptoms. Their responses were rated on a 6-point scale ranging from 0 (never)to5(more than four times per week). Previous research has indicated that this modified version of CHIPS is a valid and reliable index of physical health symptomatology (Cohen & Hoberman, 1983) and has been used successfully with samples of battered and nonbattered women (Eby, 1996; Sutherland et al., 1998). The internal consistency of the 30-item scale was .91 with corrected item-total correlations ranging from .35 to .69.

Statistical Analysis

Structural equation modeling was used to examine hypothesized in- terrelationships among latent constructs. Maximum likelihood (ML) methods were used to estimate model parameters, as recommended by Hu and Bentler (1995). Analyses were conducted in Amos Version 3.6 (Arbuckle, 1997).

Assessment of Model Fit

Traditional ML chi-square ( 2) goodness-of-fit statistics were used to test the overall ability of the model to reproduce the observed data matrix; chi-square, Goodness-of-Fit Index (GFI), adjusted goodness of fit (AGFI), Normed Fit Index (NFI), Comparative Fit Index (CFI), Tuck–Lewis Index (TFI), and the root-mean-square error of approximation (RMSEA). Al- though the chi-square statistic was not expected to be significant, the large sample size and model complexity (degrees of freedom) may have increased the likelihood of detecting significant differences between the implied variance/covariance matrix and the observed matrix. Therefore, determi- nation of model fit was based on a comprehensive assessment of the other fit indices. Good model fit was considered achieved if the values of these fit indices exceeded .90 (GFI), .80 (AGFI), .90 (NFI), .90 (CFI), .90 (TLI) and if the value for RMSEA was less than .05 (Browne & Cudek, 1993). P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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Modeling Strategy

The path model of hypothesized relationships was tested using the two- step modeling approach recommended by Anderson and Gerbing (1988) and Schumacker and Lomax (1996): The measurement model was estimated ﬁrst, followed by the structural model. Conﬁrmatory factor analysis (CFA) was used to assess the hypothesized model of relationships between observed and latent variables. This step allowed for assessing both the convergent and discriminatory validity of the model. The second step involved testing the structural model; that is, the hypothesized relationships among the latent constructs. Additional analyses were conducted to assess the mediating effects of injuries, stress, and depression.

RESULTS

Two hundred and ﬁve (52%) participants met the criteria for inclusion into the abused group; that is, they had been physically assaulted by an intimate partner or expartner during the 6 months prior to the interview. Descriptive statistics of the abused and nonabused groups were generated for each of the scales assessing the latent variables (i.e., abuse, stress, injuries, physical health, depression, and income). Scale means, standard deviations, and response ranges for each construct are presented in Table I.

Table I. Summary of Scale Scores by Physical Abuse Status (N = 397) Abused (n = 205) Nonabused (n = 192) Latent constructs MSDM SD Abuse Physical abuse (CTS) 0.87 0.787 0.00 0.00 Index of psychological abuse (IPA) 1.43 0.574 0.28 0.429 Index of sexual abuse (ISA) 0.51 0.742 0.03 0.151 Injuries Injury checklist (IC) 3.43 1.78 2.40 1.33 Stress Difﬁcult life circumstances (DLC) 7.80 3.37 4.92 2.89 Stressful life events (SLE) 2.68 0.667 2.24 0.852 Physical health symptoms General health question (GHQ)a 2.60 0.867 2.06 0.710 Physical health symptoms (PHS) 1.56 0.834 0.96 0.575 Depression Depression (CES-D) 1.45 0.669 0.80 0.515 Quality of life (QOL)a 3.88 1.11 2.96 0.812 Suicide ideation scale (SIS) 0.69 0.633 0.33 0.505 Income Percent poverty (INC) 142 110 249 165 a Higher score indicates greater dissatisfaction. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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Experience of Abuse

Typically, women in the abused group reported between 3 and 8 different types of physical abuse (M = 5.52, SD = 2.97) and between 10 and 14 different types of psychological abuse (M = 12.2, SD = 3.60). Of the 205 women who had been physically assaulted, 66 (32%) had also been sexually assaulted. A woman’s partner or expartner was most likely to push, shove, or grab her (96%), throw something at her (61%), slap her with an open hand (57%), kick or punch her (56%), hit her or try to hit her with an object (55%), choke her (54%), and/or beat her up (50%). On average, women’s partners or expartners assaulted them two or three times a month. These ﬁndings coincide with reports from previous research on the number, severity, and frequency of physical assaults by intimate partners (Cascardi & O’Leary, 1992; Eby, 1996; Sato & Heiby, 1992; Sullivan & Bybee, 1999).

Injuries

All 397 women were asked to rate the frequency with which they sustained injuries during the 6 months prior to the interview. Overall, women sustained an average of three different types of injuries (M = 2.93, SD = 1.66), ranging from cuts, scrapes, and bruises (92%) to broken bones and fractures (11%) and gunshot or knife wounds (3%).

Stress

All 397 women were asked about their experiences of daily hassles (i.e., difficult life circumstances) and stressful life events. On average, women had experienced at least 6 out of 24 daily hassles. Four women (1%) reported no hassles, and 23 (6%) endorsed more than half of the items. The most commonly cited daily hassles were long-term debts (73%), problems with credit rating (51%), lack of privacy (41%), problems with a former spouse or partner (38%), and hospitalization due to accident or illness (38%). Women reported an average of eight stressful life events during the 6 months prior to the interview. Although no one endorsed more than half of the 50 items, 95% reported at least two items, and all but two of the women said they had experienced at least one of the events. The most common stressful life events evolved around financial matters such as having less money than usual (59%), relationship problems such as increased arguments with a spouse or partner (49%), and legal issues such as being involved in a lawsuit or legal action (33%). P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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Income

The sample’s household monthly incomes ranged from $0 to over $6,000. However, when accounting for family size, most women’s incomes fell within the low–middle-income ranges. On average, women reported household monthly incomes that were 194% of poverty; 43% were within the low- income range (125% poverty level or less), 19% were between low-income and middle-income range (up to 200% poverty level), and 37% were within the middle-income range (between 200 and 600% poverty level). The remaining 2% were above the middle-income range.

Depression

Sixty-three percent of the women were at least mildly depressed; 37% experienced no depression, 14% mild depression, 19% moderate depression, and 30% severe depression. Less than half of the participants had ever thought about committing suicide. Of those who had thought about it, 22 (6%) attempted to end their lives at least once during the 6 months prior to the interview. Two women said they had attempted suicide more than 10 times; both had been assaulted within the previous 6 months. Despite the high rate of depression and suicide ideation, women were generally pleased with their quality of life. Nearly 60% of the sample rated their quality of life as better than “equally satisﬁed and dissatisﬁed.”

Physical Health

When asked about their current health status, most women rated it as either fair (29%) or good (47%). On average, women endorsed 16 different health symptoms (M = 16, SD = 6.35) at least once a month or less. One in four women said they were bothered by at least 21 of the symptoms on the checklist. Most women reported symptoms indicative of pain and fatigue: feeling low in energy (93%), sleep problems (88%), headaches (84%), mus- cle tension or soreness (81%), back pain (80%), and fatigue (75%).

Correlations Among Observed Variables

The zero-order correlation estimates are presented in Table II.3 Moderate-to-high correlations represented relationships between indicators of the same construct or between indicators of constructs expected

3Correlation estimates were performed to examine effects of ethnicity on stress and health outcomes, but no signiﬁcant differences were found between samples of White and minority groups when we controlled for poverty. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

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Table II. Zero-Order Correlation Matrix of Observed Variables (Indicators; N = 397) CTS IPA ISA IC DLS SLE INC CESD QLS SIS GHQ PHS CTS — IPA .79 — ISA .59 .61 — IC .45 .41 .36 — DLS .40 .50 .30 .35 — SLE .30 .35 .22 .25 .38 — INC .28 .38 .25 .16 .31 .21 — CESD .51 .55 .34 .35 .54 .38 .29 — QLS .43 .45 .25 .28 .56 .40 .27 .70 — SIS .35 .31 .15 .29 .31 .24 .22 .48 .38 — GHQ .39 .34 .21 .29 .46 .27 .29 .48 .51 .34 — PHS .43 .46 .25 .49 .53 .42 .27 .59 .55 .38 .61 — Note. CTS = conflict tactics scale (physical abuse), IPA = index of psychological abuse, ISA = index of sexual abuse, IC = injury checklist, DLS = difficult life situations (stress), SLE = stressful life events (stress), INC = percent poverty (income), CESD = depression (psychological well-being), QLS = dissatisfaction with quality of life (psychological well- being), SIS = suicide ideation scale (psychological well-being), GHQ = general health question (physical health), PHS = physical health symptoms (physical health). p <.05, otherwise correlation is not significant.

to have a strong association (e.g., difﬁcult life circumstances and CES-D: r = .54, p <.05). Low correlations were found between indicators of different constructs not expected to have a strong relationship (e.g., injuries and income: r =.16, p <.05).

PATH MODEL OF HYPOTHESIZED RELATIONSHIPS

Assessment of Measurement Model

Table III presents a summary of the measurement model used in the analyses. With the exception of the injuries and income variables, each latent construct (abuse, stress, depression, and physical health) was associated with at least two observed measures. The proposed measurement model provided an adequate fit to the data. While the chi-square statistic suggested some lack of fit, 2(41, N = 397) = 95.70, p <.05, the other goodness of fit indices were more favorable; the GFI (.93), AGFI (.90), CFI (.95), and TLI (.94) were at or above the accepted value .90, and the RMSEA (.06) was slightly above the acceptable range .05.

Assessment of Structural Model

The structural model of the hypothesized relationships and correspond- ing path coefﬁcients is presented in Fig. 2. It should be noted that because P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style ﬁle version June 4th, 2002

Effects of Injuries and Stress on Battered Women’s Health 625

Table III. Measurement Model: Indicators and Their Factor Loadings (N = 397) Standardized measurement Latent construct coefﬁcient (factor loadings) Abuse Physical abuse (CTS)a .87 Psychological abuse (IPA) .91 Sexual abuse (ISA)a .67 Injuries Injury checklist (IC) NA Stress Difﬁcult life circumstances (DLC) .74 Stressful life events (SLE) .52 Depression Depression (CES-D) .85 Quality of life (QLS)b .82 Suicide ideation (SIS) .52 Physical health General health question (GHQ) .70 Physical health symptoms (PHS) .87 Income Percent poverty (INC) NA a To correct positive skew, a log transformation was applied to the physical and sexual abuse measures. bItems were reverse-scored so that a high scale score indicated high dissatisfaction with quality of life.

Fig. 2. Structural model. All path coefficients are significantly greater than 0 at p <.05. (Abuse and income were allowed to covary; r =.39, p <.05.) P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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of the significant negative correlation between abuse and income (r =.39, p <.05), they were allowed to covary throughout assessment of the structural model. When tested, the structural model demonstrated acceptable fit to the observed data; 2(48, N = 397) = 113.19, p = .00, RMSEA (.06), GFI (.96), AGFI (.93), CFI (.97), and TLI (.96). The combined indirect effects of abuse explained a significant portion of the variance in physical health symptoms (R2 = 71). Abuse explained a modest portion of variance in injuries (R2 = .25), and when joined with income, also explained a substantial portion of variance in stress (R2 = .52). Stress accounted for a large portion of the variance in women’s depression (R2 = .80).

Direct Effects

Women with higher rates of abuse reported higher levels of injuries (standardized direct effect = .50, p <.05) and stress (standardized direct effect = .65, p <.05) than did women with no or lower rates of abuse. Women with lower incomes reported signiﬁcantly more stress than did women with higher incomes (standardized direct effect =.14, p <.05). Although stress had a positive direct effect on both physical health and depression, it accounted for nearly twice as much variance in women’s levels of depression than it did for women’s physical health symptoms.

Mediating Effects

The mediating effects of stress, injuries, and depression were each tested separately using methods developed by Baron and Kenny (1986) and recommended by Brown (1997). Each analysis involved two major steps: (a) verify- ing the existence of a significant direct relationship between the independent and dependent variables that excludes the suspected mediator, and (b) ver- ifying the absence (or significant reduction) of the direct relationship in the presence of the mediating variable. Prior to testing the effects of each mediating variable, the indirect paths linking abuse, physical health, and any alternative mediators (i.e., stress and injuries, respectively) were set to zero. This was done to minimize the competing effect of the alternative mediator on the estimation of a direct relationship between abuse and physical health. Both stress and injuries significantly mediated the relationship between abuse and physical health; that is, the direct relationship between abuse and physical health (stress: = .21, CR = 4.26; injuries: = .15, CR = 2.83) be- came statistically indistinguishable from zero when estimated in the presence P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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of stress ( =.12, CR =1.33) and when estimated in the presence of injuries ( = .03, CR = 0.605). Similarly, the mediating effect of stress on the relationship between abuse and women’s rates of depression was significant. The direct relationship between abuse and depression ( = .66, CR = 12.76) was significantly indistinguishable from zero when estimated in the presence of stress ( = .06, CR = 0.568). Finally, depression was found to partially mediate the relationship between stress and physical health; although still significant, the magnitude of the direct relationship ( = .69, CR = 8.25) dropped substantially in the presence of the depression construct ( = .39, CR = 2.01). The standardized indirect effect of stress through depression was moderate (.33), and somewhat less than the direct effect of stress on physical health (.39), which indicates battered women’s levels of depression explained only some of what they experienced physically. Overall, stress accounted for 80% of the indirect effect of abuse on women’s physical health (total standardized indirect effect = .47). Its direct effect on physical health was somewhat larger than its indirect effect through depression (.39 and .33, respectively), but both processes played a key role in determining the effect of abuse on women’s physical health. Furthermore, women’s experiences of abuse explained 82% of the direct effect on stress, substantially more than what was accounted for by income.

DISCUSSION

The results of this study support a stress-response theory of abuse to explain the primary process through which intimate partner violence compromises women’s health. Women who reported higher rates of abuse had higher levels of stress, depression, and physical health symptoms compared with women who had no or lower rates of abuse. Subsequently, the stress women experienced significantly mediated the relationship between abuse and their physical health and the relationship between abuse and their level of depression. These findings corroborate Eby’s research with low- income women and demonstrate that women’s responses to the stress associated with surviving intimate partner violence are complex (Eby, 1996). Furthermore, women’s experiences of stress had both direct and indirect effects (i.e., through the intervening impact of depression) on their physical health. Research on the physiological mechanisms that directly link stress to health problems is still relatively new, yet there is evidence to suggest that ongoing stress decreases the immune system’s ability to fight infectious disease and other illnesses (see Adler & Matthews, 1994). Not surprising, these P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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physiologic responses to stress have been linked with long-term health problems such as myocardial ischemia, angina, and upper respiratory infections. The stress associated with intimate partner violence may magnify women’s susceptibility to chronic health problems, thus increasing the rate at which women experience various physical health symptoms. The relationship between stress and depression has been well- documented in the literature (Avison & Gotlib, 1994). Finding that women’s stress levels mediated the effect of abuse on their levels of depression further demonstrates that intimate partner violence permeates multiple facets of women’s lives. Much of what women identified as stressful did not specifically relate to the violence they experienced, but did relate to financial, relationship, and employment issues. A survivor’s psychological health is jeopardized by the detrimental impact violence has on various parts of her life—her financial security; her relationship with neighbors, friends, and family members; and her ability to secure employment. Subsequently, women’s levels of depression partially explained the relationship between their experiences of stress and physical health symptoms. This finding expands upon the results reported in Sutherland et al.’s longitudinal study—that depression and anxiety mediated the direct effect of abuse on physical health symptoms (Sutherland et al., 1998). Injuries provided another explanation for the relationship between abuse and physical health symptoms. Women who reported high rates of abuse reported a greater number of injuries than did women with no or lower rates of abuse. These findings are consistent with those found in previous research on battered women (Follingstad et al., 1991; Sutherland et al., 1998). Furthermore, we demonstrated that injuries did mediate the effects of abuse on women’s physical health symptoms, which supports common assumptions about the effects of abuse-related injuries on women’s physical health (Council on Scientific Affairs, AMA, 1992; McCauley et al., 1995). However, these findings should be interpreted with caution for several rea- sons. First, there is little evidence to suggest that the injuries women sustained were a direct result of physical violence; abuse accounted for only 25% of the variance in injuries. Second, the mediating impact of injuries was relatively small (standardized indirect effect = .12), especially when compared to that of stress (total standardized indirect effect = .47). Finally, these findings contradicts results from Sutherland et al.’s longitudinal research that abuse-related injuries were not significantly related to increased rates of physical health symptoms either within or across time points (Sutherland et al., 1998). This discrepancy in findings may be due to differences in the way injuries were assessed. In Sutherland et al.’s study, the range of scores on abuse and injuries was restricted because of inclusion of only women P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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who had been abused at Time 1 (Sutherland et al., 1998). All 397 women in this study were questioned about injuries sustained for any reason in the 6 months prior to their interview. Overall, the research findings helped to clarify the process through which intimate partner violence jeopardizes women’s psychological and physical health. Abuse was found to affect women’s physical health in three ways: (a) through injuries women experienced, (b) through the stress women experienced, and (c) through the combined effects of stress and depression. Although all three processes contributed to women’s experiences of physical health problems, the joint mediating effects of stress and depression accounted for more variance in physical health problems than did either injuries or stress alone. Another significant contribution of this study was that it differentiated the effects of poverty on women’s health from those due to abuse. Our final hypothesis was that women’s income level would have a direct negative effect on their experiences of stress. That is, women with higher income levels would report lower levels of stress. The results demonstrated that income level exerted a minimal impact on the relationship between intimate partner violence and women’s depression and physical health symptoms. While women with higher incomes reported significantly less stress than did women with lower incomes, the magnitude of the direct relationship between income and stress ( = .14) was relatively small, especially when compared to the effect of abuse on stress ( = .65). The effect of abuse on women’s stress levels clearly supercedes the effect of poverty on women’s stress. Although the study did improve upon previous research, it had several methodological limitations. First, the range of incomes was somewhat restricted. The overrepresentation of low-income women in the abused group limited our ability to generalize our findings to women with higher incomes and restricted our ability to confirm that specific stressors (e.g., long-term debts, having less money than usual, and increased arguments with partner) were due to the dynamics of intimate partner violence rather than low-income status. Similarly, the restricted range of incomes among minority women limited our ability to sufficiently examine the effects of intimate partner violence within the context of race and ethnic differences. Repli- cation of the study’s findings using more ethnically diverse women from a broader range of income levels would strengthen the generalizability of the results and clarify some of these issues. Basing the assessment of women’s physical health on self-report measures of physical health symptoms and general health presented another methodological limitation. Self-report measures of physical health symptoms are subjective and may not discriminate well between physical and P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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psychological health problems. In addition, although symptoms are an important dimension of a woman’s physical health, they are not a comprehensive indicator of women’s overall health status. Further research using multidimensional instruments to assess chronic health problems, physical functioning, and general health perceptions as well as symptoms is needed to capture the full impact of violence on women’s health. Measuring any injury women sustained, whether because of physical abuse or not, limited our ability to directly compare our results with previous research (especially Sutherland et al., 1998) and may have minimized the mediating effect of injuries on the relationship between abuse and health outcomes. Replicating the study’s findings using only abuse-related injuries is needed to fully understand how such injuries impact women’s health. Simi- larly, the potential confounding effects of prior abuse experiences, particu- larly childhood sexual and physical abuse, limited our ability to understand the full impact of intimate partner violence on women’s health. Further research examining women’s abuse history is needed to differentiate the effect of current and past abuse. Finally, the cross-sectional nature of the research design restricts our ability to assert causal direction among the relationships. Abuse had a strong impact on women’s stress levels, and stress was highly associated with both psychological and physical health problems, yet the extent to which intimate partner violence caused elevated stress levels and subsequent health problems remains unclear. Perhaps women’s stress levels were exacerbated by their health problems. It is also difficult to ascertain the extent to which women’s experiences of stress were directly caused by a partner’s violence, indirectly associated with abusive episodes, and/or exacerbated by the abuse. Clarification of these issues would require a longitudinal design. Despite these limitations, this study expands previous research efforts in several ways. First, half the sample had not experienced physical abuse within the 6 months prior to the study, which allowed for a more accurate estimation of the effects of abuse on women’s health. Second, women were recruited from the community rather than within a shelter or clinical setting, which increased the likelihood of assessing battered women’s experiences of abuse as well as their health status when they were not in a state of crisis. Third, by including women from a broad range of income levels, it was possi- ble to examine the extent to which poverty contributed to health problems. Finally, by using multiple indicators and structural equation modeling techniques, the relationships between abuse and health were examined without the confounding effects of measurement error. The results of this study have implications for intervention, policy, and future research. Finding that stress was the primary link between abuse and P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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women’s psychological and physical health underscores the importance of mobilizing community resources around survivors’ individual needs. Treat- ing abuse-related injuries is not enough. To curtail the health consequences of abuse, communities must also attend to the stress associated with domestic violence. Eliminating the violence from women’s lives is the most effective way to reduce their stress and subsequent health problems. This would involve coordinated efforts among law enforcement, courts, probation officers, and batterer intervention programs to consistently hold batterers accountable for their violence. Survivors of intimate partner violence may need affordable legal counsel, court advocacy programs, and other community services when trying to navigate the criminal justice system. The health care community is an important component of any comprehensive community approach to domestic violence (Campbell, 1998). Battered women often seek medical attention for abuse-related injuries as well as health problems that appear unrelated to any specific injury or predisposing health condition. In many cases, a physician or nurse may be the only person women feel comfortable talking to about their partner’s violence. This provides health care providers with a unique opportunity to identify and assist domestic violence survivors. Early identification of abuse is essential to eliminating violence and subsequent health problems from women’s lives. Universal screening pro- cedures may be the most effective way to identify battered women. The signs of abuse are not always visible, and if physicians rely on the presence of sus- picious injuries to ask women about violence, they may miss the chance to provide valuable assistance. Worse yet, they may misdiagnose the underly- ing cause of the health problems or provide treatment options that could further jeopardize women’s physical and psychological well-being (e.g., pre- scribing tranquilizers). Health care providers can increase the likelihood of early identification and intervention by implementing a universal screening procedure for all female patients. Such a procedure would entail sensitively asking women about their history of physical, emotional, and sexual abuse on a routine basis, but especially in cases where women present multiple health complaints in lieu of injuries. Several researchers and practitioners have outlined interventions health care providers can implement to assist survivors of intimate partner violence (Campbell & Lewandowski, 1997; Dutton et al., 1992). These interventions include providing emotional support and mental health counseling, safety planning, patient education, legal advocacy, referral to community services, and consistent documentation of abuse history. At the very least, medical professionals should validate women’s experiences by creating a P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

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nonjudgmental supportive atmosphere, and have information about local domestic violence services readily available. Our ﬁndings highlight the complex nature of intimate partner violence and its impact on women’s lives. In addition to eliminating the violence in women’s lives, coordinated community efforts are needed to ease the burden of securing affordable housing and childcare, employment, transportation, job training, ﬁnancial assistance, and health care (Shepard & Pence, 1999; Sullivan, 2000). Informal and formal support systems are needed to validate women’s experiences and reduce their isolation. While further research is required to fully understand the complex dynamics of intimate partner violence and its impact on women’s stress levels, a comprehensive community approach to assisting survivors of domestic violence represents one way of minimizing the effects of abuse on women’s health.

REFERENCES

Abbott, J., Johnson, R., Koziol-McLain, J., & Lowenstein, S. R. (1995). Domestic violence against women: Incidence and prevalence in an emergency department population. JAMA, 273(22), 1763–1767. Adler, N., & Matthews, K. (1994). Health Psychology: Why do some people get sick and some stay well? Annual Review of Psychology, 45, 229–259. Aguilar, R. J., & Nightengale, N. N. (1994). The impact of specific battering experiences on the self-esteem of abused women. Journal of Family Violence, 9, 35–45. Amatea, E. S., & Fong, M. F. (1991). The impact of role stressors and personal resources on the stress experience of professional women. Psychology of Women Quarterly, 15, 419– 430. Anderson, J. C., & Gerbing, D. W. (1988). Structural equation modeling in practice: A review and recommended two-step approach. Psychological Bulletin, 103, 411–423. Andrews, F., & Whithey, S. (1976). Social indicators of well-being: American’s perceptions of life quality. New York: Plenum. Arbuckle, J. L. (1997). Amos users’ guide: Version 3.6. Chicago: Smallwaters. Arias, I., & Pape, K. T. (1999). Psychological abuse: Implications for adjustment and commit- ment to leave violent partners. Violence and Victims, 14(1), 55–67. Avison, W. R., & Gotlib, I. H. (Eds.). (1994). Stress and mental health: Contemporary issues and prospects for the future. New York: Plenum. Bachman, R., & Saltzman, L. E. (1995). Violence against women: Estimates from the redesigned survey (NCJ-154348). Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. Barnard, K. (1989). DLC: Difficult life circumstances. A resource manual for professionals using the Difficult Life Circumstances Scale. Seattle, WA: NCAST. Barnett, R. C., Davidson, H., & Marshall, N. L. (1991). Physical symptoms and the interplay of work and family roles. Health Psychology, 10(2), 94–101. Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. Belle, D. (1990). Poverty and women’s mental health. American Psychologist, 45(3), 385– 389. Bergman, B., & Brismar, B. (1991). A 5-year follow-up study of 117 battered women. American Journal of Public Health, 81(11), 1486–1489. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

Effects of Injuries and Stress on Battered Women’s Health 633

Betrus, P.A., Elmore, S. K., & Hamilton, P.A. (1995). Women and somatization: Unrecognized depression. Health Care for Women International, 16, 287–297. Browne, M. W., & Cudek, R. (1993). Alternative ways of assessing fit. In K. A. Bollen & L. J. Long (Eds.), Testing structrual equation models. Newbury Park, CA: Sage. Brown, R. L. (1997). Assessing specific mediational effects in complex theoretical models. Structural Equation Modeling, 4(2), 142–156. Bureau of Census. (1990). Statistical abstract of the United States 1990. U.S. Department of Commerce, Bureau of Census. Campbell, J. C. (1989). A test of two explanatory models of women’s responses to battering. Nursing Research, 38(1), 18–24. Campbell, J. C. (1998). Making the health care system an empowerment zone for battered women: Health consequences, policy recommendations, introduction, and overview. In J. C. Campbell (Ed.), Empowering survivors of abuse: Health care for battered women and their children (pp. 3–22). Thousand Oaks, CA: Sage. Campbell, J. C., Kub, J., Belknap, R. A., & Templin, T. N. (1997). Predictors of depression in battered women. Violence Against Women, 3(3), 271–293. Campbell, J. C., & Lewandowski, L. A. (1997). Mental and physical health effects of intimate partner violence on women and children. Psychiatric Clinics of North America, 20(2), 353–374. Campbell, J. C., & Soeken, K. (1999). Women’s responses to battering over time: An analysis of change. Journal of Interpersonal Violence, 14(1), 21–40. Campbell, R., Sullivan, C. M., & Davidson, W. S., II. (1995). Women who use domestic violence shelters: Changes in depression over time. Psychology of Women Quarterly, 19, 237– 255. Cascardi, M., & O’Leary, K. D. (1992). Depressive symptomatology, self-esteem, and self-blame in battered women. Journal of Family Violence, 7(4), 249–259. Centers for Disease Control and Prevention, National Center for Health Statistics. (1993). Current estimates from the National Health Interview Survey, 1993 (Department of Health and Human Services Publication No. PHS 95-1518, Series 10, No. 190, 4-1639, Atlanta, GA: Centers for Disease Control and Prevention.). Cohen, S., & Hoberman, H. M. (1983). Positive events and social supports as buffers of life change stress. Journal of Applied Social Psychology, 13(2), 99–125. Council on Scientific Affairs, AMA. (1992). Violence against women: Relevance for medical practitioners. JAMA, 263(23), 3184–3189. DeLongis, A., Folkman, S., & Lazarus, R. S. (1988). The impact of daily stress on health and mood: Psychological and social resources as mediators. Journal of Personality and Social Psychology, 54(3), 486–495. Drossman, D. A., Talley, N. J., Leserman, J., Olden, W., & Barreiro, M. A. (1995). Sexual and physical abuse and gastrointestinal illness: Review and recommendations. Annals of Internal Medicine, 123, 782–794. Dutton, M. A., Haywood, Y., & El-Bayoumi, G. (1992). Impact of violence on women’s health. In S. J. Gallant, G. P.Keita, & R. Royak-Schaler (Eds.), Health care for women: Psychological, social, and behavioral influences (pp. 41–56). Washington, DC: American Psychological Association. Eby, K. K. (1996). Experiences of abuse and stress: A path model of their joint effects on women’s psychological and physical health. Unpublished doctoral dissertation, Michigan State University, East Lansing. Eby, K. K., Campbell, J. C., Sullivan, C. M., & Davidson, W. S., II. (1995). Health effects of experiences of sexual violence for women with abusive partners. Health Care for Women International, 16, 563–567. Elliott, S. J.(1995). Psychosocial stress, women, and heart health: A critical review. Social Science Medicine, 40(1), 105–115. Follingstad, D. R., Brennan, A. F., Hause, E. S., Polek, D. S., & Rutledge, L. L. (1991). Factors moderating physical and psychological symptoms of battered women. Journal of Family Violence, 6(1), 81–95. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

634 Sutherland, Bybee, and Sullivan

Follingstad, D. R., Rutledge, L. L., Berg, B. J., Hause, E. S., & Polek, D. S. (1990). The role of emotional abuse in physically abusive relationships. Journal of Family Violence, 5(2), 107–120. Gleason, W. J. (1993). Mental disorders in battered women: An empirical study. Violence and Victims, 8(1), 53–68. Goldberg, W. G., & Tomlanovich, M. C. (1984). Domestic violence victims in the emergency department: New findings. JAMA, 251(24), 3259–3264. Goodman, L. A., Koss, M. P., & Russo, N. F. (1993). Violence against women: Physical and mental health effects: I. Research findings. Applied and Preventive Psychology, 2, 79–89. Hamberger, L. K. (1994). The battered woman: Identification and intervention. The Female Patient, 19, 29–33. Hays, R. D., Wells, K. B., Sherbourne, C. D., Rogers, W., & Spritzer, K. (1995). Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Archives of General Psychiatry, 52, 11–19. Health Status Advisory Group. (1993). An assessment of the health status of the capital community (Brief report). Lansing, MI: Author. Hirschfeld, R. M. A., & Cross, C. K. (1982). Epidemiology of affective disorders: Psychosocial risk factors. Archives of General Psychiatry, 39, 35–46. Holahan, C. J., & Moos, R. H. (1991). Life stressors, personal and social resources, and depression: A 4-year structural model. Journal of Abnormal Psychology, 100(1), 31–38. Holmes, T. H., & Masuda, M. (1974). Life changes and illness susceptibility. In B. S. Dohrenwend & B. P. Dohrenwend (Eds.), Stressful life events: Their nature and effects (pp. 45–72). New York: Wiley. Hu, L., & Bentler, P. M. (1995). Evaluating model fit. In R. H. Hoyle (Ed.), Structural equation modeling: Concepts, issues, and applications (pp. 76–99). Thousand Oaks, CA: Sage. Jaffe, P., Wolfe, D. A., Wilson, S., & Zak, L. (1986). Emotional and physical health problems of battered women. Canadian Journal of Psychiatry, 31, 625–629. Judd, L. L., Paulus, M. P., Wells, K. B., & Rapaport, M. H. (1996). Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. American Journal of Psychiatry, 153(11), 1411–1417. Kendler, K. S., Kessler, R. C., Walters, E. E., MacLean, C., Neale, M. C., Health, A. C., et al. (1995). Stressful life events, genetic liability, and onset of an episode of major depression in women. American Journal of Psychiatry, 152(6), 833–842. Khan, F. I., Welch, T. L., & Zillmer, D. (1993). MMPI-2 profiles of battered women in transition. Journal of Personality Assessment, 60(1), 100–111. Kington, R. S., & Smith, J. P. (1997). Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health, 87(5), 805–810. Koss, M. (1990). The women’s mental health research agenda: Violence against women. American Psychologist, 45(3), 374–380. Kuyken, W., & Brewin, C. R. (1994). Stress and coping in depressed women. Cognitive Therapy and Research, 18(5), 403–412. Luepker, R. V., Rosamond, W. D., Murphy, R., Sprafka, J. M., Folsom, A. R., McGovern, P.G., et al. (1993). Socioeconomic status and coronary heart disease risk factor trends: The Minnesota Heart Survey. Circulation, 88(P. 1), 2172–2179. Lynch, J. W., Kaplan, G. A., & Shema, S. J. (1997). Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. New England Journal of Medicine, 337, 1889–1895. McCauley, J., Kern, D. E., Kolodner, K., Dill, L., Schroder, A. F., DeChant, H., et al. (1995). The “Battering Syndrome”: Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Annals of Internal Medicine, 123(110), 737– 746. McLeod, J. D., & Kessler, R. C. (1990). Socioeconomic status differences in vulnerability to undesirable life events. Journal of Health and Social Behavior, 1, 162–172. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

Effects of Injuries and Stress on Battered Women’s Health 635

Murphy, J. M., Olivier, D. C., Monson, R. R., Sobol, A. M., Federman, E. B., & Leighton, A. H. (1991). Depression and anxiety in relation to social status: A prospective epidemiologic study. Archives of General Psychiatry, 48, 223–229. National Coalition Against Domestic Violence. (1995). Voice. Washington, DC: Author. O’Leary, K. D. (1999). Psychological abuse: A variable deserving critical attention in domestic violence. Violence and Victims, 14(1), 3–23. Orava, T. A., McLeod, P. J., & Sharpe, D. (1996). Perceptions of control, depressive symptomatology, and self-esteem of women in transition from abusive relationships. Journal of Family Violence, 11(2), 167–186. Paykel, E. S., Prusoff, B. A., & Ulenhuth, E. H. (1971). Scaling of life events. Archives of General Psychiatry, 25, 340–347. Plichta, S. B. (1996). Violence and abuse: Implications for women’s health. In M. M. Falik & K. S. Collins (Eds.), Women’s health: The Commonwealth Fund survey (pp. 237–272). Baltimore: Johns Hopkins University Press. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Reischl, T., Eby, K., & Ramanathan, C. S. (1992). Life Events Checklist. Lansing: Michigan State University. Sato, R. A., & Heiby, E. M. (1992). Correlates of depressive symptoms among battered women. Journal of Family Violence, 7(3), 229–245. Schumaker, R. E., & Lomax, R. G. (1996). A beginner’s guide to structural equation modeling. Mahwah, NJ: Erlbaum. Shepard, M. F., & Pence, E. L. (1999). Coordinating community responses to domestic violence: Lessons from Duluth and beyond. Thousand Oaks, CA: Sage. Stephens, M. A., Franks, M. M., & Townsend, A. L. (1994). Stress and rewards in women’s multiple roles: The case of women in the middle. Psychology and Aging, 9(1), 45–52. Straus, M. A. (1979). Measuring intrafamily conflict and violence: The Conflict Tactics (CT) Scales. Journal of Marriage and the Family, 38, 75–88. Stronks, K., Van De Mheen, H., Van Den Bos, J., & Mackenbach, J. P. (1997). The inter- relationship between income, health and employment status. International Journal of Epidemiology, 26(3), 592–600. Sullivan, C. M. (1991). The provision of advocacy services to women leaving abusive partners: An exploratory study. Journal of Interpersonal Violence, 6(1), 41–54. Sullivan, C. M. (2000). A model for effectively advocating for women with abusive partners. In J. P. Vincent & E. N. Jouriles (Eds.), Domestic violence: Guidelines for research informed practice (pp. 126–143). London: Jessica Kingsley. Sullivan, C. M., Basta, J., Tan, C., & Davidson, W. S., II. (1992). Brief report. After the crisis: A needs assessment of women leaving a domestic violence shelter. Violence and Victims, 7(3), 267–275. Sullivan, C. M., & Bybee, D. I. (1999). Reducing violence using community-based advocacy for women with abusive partners. Journal of Consulting and Clinical Psychology, 67(1), 43– 53. Sullivan, C. M., Parisian, J. A., & Davidson, W. S., II (1991). Index of Psychological Abuse: De- velopment of a measure. Paper presented at the 99th Annual Convention of the American Psychological Association, San Francisco. Sutherland, C., Bybee, D., & Sullivan, C. (1998). The long-term effects of battering on women’s health. Women’s Health: Research on Gender, Behavior, and Policy, 4(1), 41–70. Swett, C., & Halpert, M. (1993). Reported history of physical and sexual abuse in relation to dissociation and other symptomatology in women psychiatric patients. Journal of Interper- sonal Violence, 8(4), 545–555. Talley, N. J., Fett, S. L., & Zinsmeister, A. R. (1995). Self-reported abuse and gastrointestinal disease in outpatients: Association with irritable bowel-type symptoms. The American Journal of Gastroenterology, 90(3), 366–371. Thoits, P.A. (1982). Life stress, social support, and psychological vulnerability: Epidemiological considerations. Journal of Community Psychology, 10, 341–362. P1: GXB/GYQ/GDP American Journal of Community Psychology [ajcp] pp545-ajcp-376934 July 2, 2002 17:57 Style file version June 4th, 2002

636 Sutherland, Bybee, and Sullivan

U. S. Department of Commerce, Bureau of Census. (1996). General population characteristics [online]. Available: Von Korff, M., & Simon, G. (1996). The relationship between pain and depression. British Journal of Psychiatry, 168(Suppl. 30), 101–108. Winﬁeld, I., George, L. K., Swartz, M., & Blazer, D. G. (1990). Sexual assault and psychiatric disorders among a community sample of women. American Journal of Psychiatry, 147, 335–341.