i Intimate Partner Violence (IPV), Factors Influencing IPV, and Adverse Maternal Health among Pregnant Thai Women Division of Research and Advanced Studies of the University of Cincinnati In partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing April 2012 By Treechada Punsomreung B.S.N., Boromarajonani College of Nursing Praputhabat, 1993 M.S.N., Chulalongkorn University, 2000 Committee Chair: John Schafer, Ph.D. ii ABSTRACT Background: Intimate partner violence (IPV) is recognized as a human rights violation which has taken away certain rights of women; freedom from fear and want, to move, to be safe, to be healthy, to live. IPV is of pandemic proportions because its prevalence is worldwide. In Thailand, IPV and the safety of abused women remains a prominent problem. The World Health Organization (WHO) studied women's health and domestic violence against women in several countries including Thailand. The results revealed that 41% of women in Bangkok and 47% in rural areas experienced physical or sexual violence at least once during their lifetime by an intimate partner. IPV can occur at any time over a woman’s life, including during pregnancy. IPV can lead to the risk of death for mother and unborn child. Victims of IPV, before or during pregnancy, also face more complications of pregnancy. IPV during pregnancy is associated with posttraumatic stress disorder (PTSD), depression, anxiety, increased use of cigarettes, alcohol, and drugs, as well as later entry into prenatal care. Additionally, IPV impacts health care delivery, economics, social services, the criminal justice system, and law enforcement. Objective: The purpose of this research was to test a hypothesized model by using path analysis to explain the relationships among IPV, factors influencing IPV, and adverse maternal health. Methods: The cross-sectional survey research design examined the direct effects of: a) self-esteem; b) exposure to violence; c) acceptance of violence; and d) fear of partner on IPV during pregnancy in pregnant Thai women and to examine the direct effect of IPV on adverse maternal health using path analysis. The study was conducted at the Prenatal Care Unit at Phraphutthabat Hospital, Saraburi Province, Thailand. Participants were selected by random iii selection. 304 pregnant women participated. Data were collected between June and September 2011 using one questionnaire composed of six sections. All instruments that were used in the current study were tested for empirical construct validity and reliability. There were some changes in some scales based on psychometric properties. Statistical Package for the Social Science (SPSS/PC 20.0) and Mplus version 6.12 were used for data management and data analysis. Results: The fit indices indicated that the hypothesized model was not a good initial fit to the observed data. The model needed to be modified based on theoretical reasonability and modification indices. The fit indices indicated that the final model fit the observed data well (χ² (7, N = 283) =12.865, p= .076, χ²/df = 1.84, RMSEA = .054, CFI = .980, and TLI = .941 Conclusions: Given the severe consequences and human costs and high economic costs of IPV during pregnancy, these results suggest that many factors can be used to predict IPV during pregnancy. Also, IPV during pregnancy has a huge direct effect on maternal health. Several of these factors may represent potential targets for intervention. Strategies need to be developed for effective interventions to reduce the incidence and prevalence of IPV and therefore promote maternal health. iv Copyright 2012 Treechada Punsomreung All Rights Reserved v ACKNOWLEDGEMENTS I could not have completed my journey without help from many wonderful people. Without their support, I would not have come this far and completed this journey. First, I would like to express my gratitude to my advisor and chairperson, Dr. John Schafer, for his guidance, ongoing support, intellectual challenge, statistical expertise, encouragement throughout my doctoral program, and belief in me. I also would like to express my sincere thanks to Dr. Donna Shambley-Ebron for her positive support and attention to detail that she brought to the study. Many thanks go to Dr. Bonnie Fisher for her insightful suggestions. Also, I would like to thank to Dr. Carol Deets, Dr. Jan Dyehouse, Dr. Jean Anthony, Dr. Edith Morris, Dr. Sue Davis, Dr. Yin Xu, and Dr. Susan Elek, my late previous advisor, for teaching and supporting me from the beginning of my journey. Thank you to my cohort in the doctoral program who shared this journey with brilliant discussion, especially to Dr. Kate York and Carolyn Smith. I appreciate and treasure your friendship and support. You made my stay in the U.S. so wonderful. Also, I would like to take this opportunity to thank Praputthabath Hospital where I collected the data. Special thanks go to the 304 participants, the chief nursing officer, and the staff nurses at this site for their cooperation. To my close friends, Dr. Kittiya Evans, Dr. Jinjutha Chaisena Dallas, and Sriprapai Inchaithep, thank you for your assistance with tool development, translation, data analysis, and for the warm support. Many thanks go to my Thai friends in Cincinnati – Dr. Mayom, Ple, Lynn, Kob, Toy, and Steve. It is hard to list all the names here, but thanks to everyone for being so supportive throughout all my endeavors. vi I would like to thank the Royal Thai Government and the University of Cincinnati for financial support throughout these years. I would also like to acknowledge the generous funding for my study from the Deets Dissertation Award and the Graduate Student Governance Association Award. Last, many thanks and love go to my parents for their faith, hope, and belief in me. Also, thank you to my sisters, brothers-in-law, and relatives for their support and taking care of Mom and Dad when I am far away. This dissertation is dedicated to them. vii CONTENTS Abstract …………………………………………………………………………………….. II Acknowledgements…………………………………………………………………………. V List of Tables.………………………………………………………………………………. IX List of Figures ……………………………………………………………………………… X Chapter One: Introduction................................................................................................... 1 Introduction………………………………………………………………………………… 1 Problem……………………………………………………………………………………… 3 Purpose of the Study............................................................................................................... 7 Significance for Nursing…………………………………………………………………….. 8 Hypothesized Model………………………………………………………………………… 9 Definitions of Terms................................................................................................................ 10 Intimate Partner Violence (IPV)………………………………………………………… 10 Self-Esteem……………………………………………………………………………… 10 Acceptance of Violence………………………………………………………………… 11 Fear of Partner…………………………………………………………………………… 12 Exposure to Violence…………………………………………………………………… 12 Adverse Maternal Health………………………………………………………………… 13 Research Questions and Hypotheses....................................................................................... 14 Chapter Two: Literature Review…………………………………………………………. 17 Prevalence of IPV in General Population and Pregnant Women…………………………… 17 Worldwide……………………………………………………………………………….. 17 Thailand………………………………………………………………………………….. 17 Thai Culture Influencing IPV……………………………………………………………….. 22 Family……………………………………………………………………………………. 22 Religiosity………………………………………………………………………………... 25 Media…………………………………………………………………………………….. 28 Alcohol…………………………………………………………………………………... 30 Barriers to seeking outside help…………………………………………………………. 32 Relationships between Self-Esteem, Acceptance of Violence, Exposure to Violence, Fear of Partner, and IPV………………………………………………………………………….. 34 Self-esteem and IPV…………………………………………………………………….. 34 Acceptance of Violence and IPV………………………………………………………... 38 Exposure to Violence and IPV…………………………………………………………… 42 Fear of Partner and IPV………………………………………………………………….. 45 Exposure to Violence and Fear of Partner……………………………………………… 48 Fear of Partner Mediating Exposure to Violence and IPV………………………………. 50 Relationships between Self-Esteem, Acceptance of Violence, and Exposure to Violence 51 Self-Esteem and Acceptance of Violence………………………………………………. 51 Self-Esteem and Exposure to Violence……………………………………………… 52 Acceptance of Violence and Exposure to Violence……………………………………… 53 Relationships between IPV and Maternal Health…………………………………………… 55 Pregnancy Complications……………………………………………………………… 56 Physical Health Problems………………………………………………………………... 61 Psychological Health Problems………………………………………………………... 64 viii Philosophy Underpinning the Current Study……………………………………………….. 67 Summary…………………………………………………………………………………….. 69 Chapter Three: Methodology……………………………………………………………... 70 Research Design…………………………………………………………………………….. 70 Study Setting........................................................................................................................... 70 Sample....................................................................................................................... ………. 71 Measurements......................................................................................................................... 73 Self-Esteem………………………………………………………………………………. 73 Acceptance of Violence………………………………………………………………….. 75 Exposure to Violence…………………………………………………………………….. 77 Fear of Partner…………………………………………………………………………… 79 IPV……………………………………………………………………………………….