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The Women's Health Effects Study

Toward a Better Understanding of the Real Costs of Intimate-Partner Violence Against Women

Colleen Varcoe

Chronic neck and back pain; arthritis; frequent headaches and migraines; visual problems; unexplained dizziness and fainting; sexually transmitted infections; unwanted pregnancies; chronic pelvic pain; gynecological symptoms; hypertension; viral infections such as colds and flu; peptic ulcers; and functional or irritable bowel disease. These are the chronic physical health conditions that researchers have linked with intimate-partner violence (IPV). (Letourneau, Holmes, and Chasedunn- Roark, 1999:115-20; Ratner, 1995: 31-46; Campbell and Lewandowski, 1997: 353-74; Coker, et al, 2000: 451- 7, 553-9).

These conditions may be life long, persisting even after women have left abusive partners. However, policy and practice in health care in relation to IPV is typically based on concern with acute physical injuries that occur when women are in abusive relationships. The Women’s Health Effects Study is designed to provide greater understanding of the full range of health effects of IPV, and a stronger basis for health policy and practice, particularly regarding women who have left abusive relationships.

Women’s mental and physical health after leaving abusive relationships is often affected by their economic status, and the costs of violence against women are significantly underestimated. However, economic and social-welfare policies are usually set independent of consideration of the dynamics of violence against women. Thus, this study is also designed to provide better understanding of how IPV affects women’s financial status and use of health and social services, and to provide a better basis for linking such understanding to economic and social policy.

In the Women’s Health Effects Study, an interdisciplinary team of researchers is recruiting 300 women who have left abusive partners in the six months to three years prior to beginning their participation in the study. Women have been recruited from New Brunswick and Ontario; recruitment is continuing in BC. Women have been recruited through newspaper ads, posters, and word-of-mouth, so that, unlike many studies, the women are not only those who have used formal anti-violence services such as shelters. Each year for the next four years, the women will complete structured interviews that include established instruments to measure physical, emotional, and mental health as well as their access to personal, social, and economic resources that support health. The women will also undergo a physical assessment to measure such things as hearing, balance, mobility, weight, and blood pressure. In addition, the participants are providing information that will permit costing estimates of their health and socialservices use, estimates of their financial strain, and changes in their economic status over time.

BACKGROUND RESEARCH

Research conducted over the past 15 years has identi.ed extensive health effects of IPV. The World Bank Report (Heise, Pitanguy, and Germain, 1994) identi.ed IPV and rape as signi.cant causes of morbidity and mortality for women aged 15 to 44 worldwide. The most common physical injuries experienced by known IPV victims are multi-site contusions and soft tissue injuries to the face, head, back, neck, thorax, breast, and abdomen. (Muellman, Lenaghan, and Pakieser, 1996: 468-92) Even though these physical injuries are well documented in relation to IPV, our understanding of the Health problems can persist for many years after leaving an abusive partner— in some cases, a lifetime. impact of these consequences on healthcare utilization is limited and largely based on the US experience. One study (Humphreys, Parker, and Campbell, 2001: 275-306) found that less than half of American women injured as a result of IPV sought health care for their injuries; however, these women frequently used hospital emergency and primary-care health services for chronic health concerns associated with IPV.

Mental health is of particular concern for women who have been abused, both because rates of mental-health problems are signi.cantly higher for women who have been abused, and because of their potential to disable an individual. For example, uni-polar depression “ranks number one among the leading causes of disability worldwide,” (Murray and Lopez, Ed’s, 1996) and is one of the most common conditions seen in primary-care settings. (Coyne, Fechner- Bates, and Schwenk, 1994: 267-76)

Women currently living with an abusive partner and those who have left in the past year experience higher rates of: clinical depression; acute and chronic symptoms of anxiety; protracted disabling sleep disturbances; symptoms consistent with Post-Traumatic Stress Disorder (PTSD); substance use and dependence; and thoughts of suicide (Eby, et al, 1995: 563-76; Fischbach and Herbert, 1997: 1161-76; Humphreys, et al, 1999: 319-32) than their nonabused counterparts. IPV has also been associated with an increase in suicidal tendencies, particularly when the ‘pre-battering phase’ of women’s lives is compared post abuse. (Hoff: 1990) However, how women’s mental health is affected over time after leaving an abusive relationship has not been studied.

The extensive health, social, and economic costs of violence against women in Canada have been estimated by researchers such as Day, (1995) Greaves, Hankivsky, and Kingston- Riechers, (1995) and Kerr and McLean. (1996) However, these and studies in other countries (such as VicHealth, 2004, and Stanko, et al, 1998) have been based on analyses of data previously collected for other purposes. (Yodanis, Godenzi, and Stanko, 2000: 263-76) Because the data available tend to be state data, and because costing approaches use such biased estimates as gendered averagewage estimates, estimates have built-in biases. Consequently, the Women’s Health Effects Study uses a gender- and diversity-sensitive approach to costing (Hankivsky, et al, 2004: 257-82) and prospective, longitudinal data collection, as well as expanding the type of data being collected to include non-state costs.

WOMEN’S HEALTH EFFECTS STUDY

This quantitative analysis of the health, economic, and social costs of IPV against women is being undertaken to address significant gaps and limitations in knowledge. The accuracy and depth of information about women’s mental- and physical-health status is limited by dependence on self-report measures. Reliance on both clinical and shelter populations challenges the ability to generalize study findings. Furthermore, the use of cross-sectional and retrospective designs makes it difficult to identify patterns of chronic mental- and physical-health problems attributable to abuse and experienced over time.

Although no longitudinal studies of the health effects of abuse have been conducted in Canada, results of the few longitudinal studies of the health effects of IPV that have been conducted in the US (Eby, et al, 1995: 563-76; Campbell and Soeken, 1999: 21-40) suggest that some aspects of both physical and mental health improve after leaving, but that patterns of effects are complex. Thus, Rollstin and Kern (1998: 387- 94) recommended studying the health effects of abuse for one to five years after women have left abusive relationships. Our recent research suggests that after leaving an abusive partner, health problems are exacerbated for well beyond five years by a combination of ongoing abuse and harassment related to issues such as custody and child support, economic hardships, and the personal ‘costs’ of getting help from those in the system, including health professionals. (Wuest, et al, 2003: 597-622; Varcoe and Irwin, 2004: 77-99; Wuest and Merritt-Gray, 1999: 110-33) However, little is known about when and under which conditions specific health effects of IPV emerge, and how these health problems change over time in response to changes in women’s lives, including their access to personal, social, and economic resources.

The Women’s Health Effects Study is being conducted by researchers in NB, ON, and BC from nursing, sociology, political science, and medicine with consultants from economics and other relevant fields. The study is part of a larger New Emerging Team (NET) grant funded by the Canadian Institutes of Health Research (CIHR), and also has funding from the CIHR Gender and Health Institute. The NET grant is intended to build research capacity in the area of violence and health, and will fund additional studies, including a study that will test interventions designed on the basis of findings from the current study.

At this point, we have begun to examine the findings from the initial year of data collection. Early examination of the data suggests that the women in the sample are similar to women in earlier studies in terms of high levels of chronic illness and pain, and mental-health problems, along with high rates of prescription drug use and use of health and social services. This preliminary examination also suggests other findings of concern. For example, many of the women being studied have experienced multiple forms of abuse over their life times (such as childhood abuse and sexual assault, as well as IPV in adulthood) and most report a decreased standard of living and signi.cant levels of financial strain after leaving their partners. We anticipate having analysis of the first-year data available in the early fall of 2005.

To receive bulletins regarding the research findings, please visit http://www.women-health.ca or email women-health@uwo.ca. We are still seeking about 10 more women in the Lower Mainland of BC to participate. Interested women can email us or call our toll-free number, 1.866.661.3343.

Colleen Varcoe is an Associate Professor at the UBC School of Nursing. Her clinical background is critical care. Her research focuses on women’s health with emphasis on violence against women; and ethical practice in health care, with an emphasis on equity. She is also a member of the Board of Directors of BCIFV. Credit for the information in this article must go to the entire Women’s Health Effects Study research team.

REFERENCES

Campbell, J, and Lewandowski, L (1997) “Mental and psychical health effects of intimate partner violence on women and children,” in Psychiatric Clinics of North America, 20(2): 353-74.

Campbell, J, and Soeken, K (1999) “Women’s responses to battering over time: An analysis of change,” in Journal of Interpersonal Violence, 14(1): 21-40.

Coker, AL, et al (2000) “Physical health consequences of physical and psychological intimate partner violence,” in Archives of Family Medicine, 9(5): 451-7.

Coker, AL, et al, (2000) “Frequency and correlates of intimate partner violence by type: physical, sexual, and psychological battering,” in American Journal of Public Health, 90(4): 553-9.

Coyne, J, Fechner-Bates, S, and Schwenk, T (1994) “Prevalence, nature and comorbidity of depressive disorders in primary care,” in General Hospital Psychiatry, 16: 267-76.

Day, T (1995) The Health-related Costs of Violence against Women in Canada, London ON: Center for Research on Violence Against Women and Children.

Eby, KK, et al (1995) “Health effects of experiences of sexual violence for women with abusive partners,” in Health Care for Women International, 16(6): 563-76.

Fischbach, R, and Herbert, B (1997) “Domestic violence and mental health: Correlates and conundrums within and across cultures,” in Social Science and Medicine, 45(8): 1161-76.

Greaves, L, Hankivsky, O, and Kingston- Riechers, J (1995) Selected Estimates of Costs of Violence against Women, London ON: Centre for Research on Violence Against Women and Children.

Hankivsky, O, et al (2004) “Expanding economic costing in health care: Values, gender and diversity,” in Canadian Public Policy, 30(3): 257-82.

Heise, LL, Pitanguy, J, and Germain, A (1994) “Violence against women: The hidden health burden,” World Bank Discussion Papers, Washington DC: International Bank for Reconstruction and Development / World Bank.

Hoff, LA (1990) Battered Women as Survivors, London: Routledge.

Humphreys, J, et al (1999) “Trauma history of sheltered battered women,” in Issues in Mental Health Nursing, 20(4): 319-32.

Humphreys, J, Parker, B, and Campbell, J (2001) “Intimate partner violence against women,” in Annual Review of Nursing Research, 19: 275-306.

Kerr, R, and McLean, J (1996) Paying for Violence: Some of the costs of violence against women in BC, Victoria BC: Ministry of Women’s Equality.

Letourneau, E, Holmes, M, and Chasedunn- Roark, H (1999) “Gynecologic health consequences to victims of interpersonal violence,” in Women’s Health Issues, 9: 115-20.

Muellman, RL, Lenaghan, PA, and Pakieser, RA (1996) “Battered women: injury locations and types,” Annals of Emergency Medicine, 28(5): 468-92.

Murray, C, and Lopez, A, Ed’s (1996) The Global Burden of Disease, Cambridge MA: Harvard University Press.

Ratner, P (1995) “Indicators of exposure to wife abuse,” in Canadian Journal of Nursing Research, 27(1): 31-46.

Rollstin, AO, and Kern, JM (1998) “Correlates of battered women’s psychological distress: Severity of abuse and duration of the post abuse period,” in Psychological Report, 82(2): 387-94.

Stanko, E, et al (1998) Counting the Costs: Estimating the impact of domestic violence in the London Borough of Hakney, Middlesex UK: Brunel University.

Varcoe, C, and Irwin, L (2004) “‘If I killed you, I’d get the kids’: Women’s survival and protection work with child custody and access in the context of woman abuse,” in Qualitative Sociology, 27(1): 77-99.

VicHealth (2004) The Health Costs of Violence: Measuring the burden of disease caused by intimate partner violence, Carlton South Victoria, Au: Victorian Health Promotion Foundation.

Wuest, J, and Merritt-Gray, M (1999) “Not going back: Sustaining the separation in the process of leaving abusive relationships,” in Violence Against Women, 5(2): 110-33.

Wuest, J, et al (2003) “Intrusion: The central problem for health promotion among children and single mothers after leaving an abusive partner,” in Qualitative Health Research, 13(5): 597-622.

Yodanis, C, Godenzi, A, and Stanko, E (2000) “The bene.ts of studying costs: A review and agenda for studies on the ecomomic costs of violence against women,” in Policy Studies, 21(3): 263-76.