The European Journal of Public Health Advance Access published online on January 23, 2007
The European Journal of Public Health, doi:10.1093/eurpub/ckl280
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Physical health consequences of intimate partner violence in Spanish women
Isabel Ruiz-Pérez, Juncal Plazaola-Castaño and María del Río-LozanoPublic Health Research Area, Andalusian School of Public Health, Granada, Spain
Correspondence: Isabel Ruiz-Pérez, Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio 4, Apartado 2070, 18080 Granada, Spain, tel: +34 958 02 75 10, fax: +34 958 02 75 03, e-mail: isabel.ruiz.easp{at}juntadeandalucia.es
Received March 23, 2006, accepted December 21, 2006
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Abstract |
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Background: Intimate partner violence (IPV) against women can result in serious health problems. The objectives of this study are to analyse the association between the different types of IPV and women's physical health, and to examine whether this association varies depending on the intensity, duration and timing of the violence. Methods: A sample of 1402 randomly selected women attending 23 family practices in Spain responded to an anonymous self-reported questionnaire. Measures considered were exposure to physical, sexual and psychological IPV; intensity, duration and timing of such violence; chronic physical disease; number of lifetime surgical operations and number of days spent in bed in the last three months. Descriptive, bivariate and multivariate analyses were conducted. Results: Lifetime IPV prevalence was 32%. Higher prevalence of chronic disease was observed in abused women than in never abused women, as well as greater number of days spent in bed. Women who reported having experienced the three types of IPV were more likely to suffer a chronic disease (OR = 2.03; 95% CI = 1.18–3.51) and to spend more days in bed (t = 2.35; P = 0.019) than those never abused. Women abused in the past but not in the present presented a higher probability of having a chronic disease than never abused women, and women who had been abused both in the past and in the present had a higher probability of spending more days in bed. Conclusion: IPV can negatively affect physical health of the victims. It is therefore necessary to detect cases of IPV at a primary health care level.
Keywords: domestic violence, Spain, spouse abuse, women's health
Intimate partner violence (IPV) against women has been recognized as a relevant public health problem.1,2 IPV is experienced by approximately one-third of women world-wide, and each year it registers increasing incidence and mortality rates.3 Recent international studies offer IPV prevalence data that range from 24–43%.4–8 In Spain, a study conducted at a primary health care centre found that 22% of women who attended had experienced lifetime physical, psychological and/or sexual abuse by their partners.9
Many studies have shown the magnitude of the impact of IPV on women's health, although the impact on the victim's mental health has been more widely studied than the impact on physical health. It has been demonstrated that women who are physically and/or sexually abused by their partners may suffer up to 60% more physical illnesses than women who are not victims of such violence.10 Amongst the chronic health problems that can result from IPV are rheumatic pain such as chronic neck or back pain, cardiovascular complications, gynaecological problems and recurring neurological symptoms such as headaches and migraines.11–14
There also appears to be an association between IPV and a greater use of health services.15 For this reason, many studies on IPV have been conducted in the health setting. It has been shown that the rate of hospitalized women who have been abused can be as much as 50% higher than non-abused women, and that psychiatric disorders, digestive problems, injuries and diagnoses of poisoning and suicide attempts are the most common reasons for admission.16 Therefore, health services and professionals have a very relevant role to play in the prevention and care of IPV.
However, there is practically no publication of results on domestic violence in Spain. Furthermore, very few studies that analyse the impact of IPV on the physical health of the victim have taken psychological abuse into consideration.17
Considering on the one hand the great impact that IPV can have on health, and on the other, the privileged position of health services and professionals to prevent IPV, it is necessary to conduct studies to learn and show the depth of the magnitude of this problem and the serious health consequences it can have. The objective of this study is to analyse the association between the different types of abuse and women's physical health, not only taking physical and sexual abuse into account but also psychological abuse. An analysis is also conducted to examine whether the impact on physical health increases with greater intensity and duration of abuse, and how this impact varies depending on the time when such abuse occurred (in the past, present, or in both).
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Methods |
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Participants
In this cross-sectional study, participants were recruited from May to October 2003 in a convenience sample of public family practices in Spain, that were selected following accessibility criteria. A convenience list of 23 family practitioners (located in three different regions of the country) to be potentially included in the study was provided by a member of the research team, who was also a family practitioner. We invited all of them to participate in the study.
All female patients aged 18–65 years and seeking medical care in the practices were eligible for the study. Women were considered non-eligible if they were illiterate, did not understand Spanish or had severe cognitive disabilities. Following the Ethical and Safety Recommendations for Research on Domestic Violence Against Women,18 women who attended the practice with a male partner were also considered non-eligible.
Each family practitioner randomly recruited a maximum of two women a day. All physicians followed a similar randomization process, based on the time of the patient's consultation. If the woman did not meet inclusion criteria, the following one was included.
Survey instrument and measures
A self-administered structured questionnaire was specifically developed for this study. It consists of 21 closed-ended questions on IPV, demographic variables and health status, which can be answered in <15 min. The IPV questions were taken from a questionnaire used in previous studies, showing high comprehensibility and acceptability.9 They were adapted from scales used in other studies, such as the World Health Organisation Multi-Country Study on Women's Health And Life Events.19–21 Measures considered for this analysis are described below.
Measures of IPV
Each participant woman was first asked if any intimate partner in the previous year abused her physically (hit, slapped, kicked, pushed,etc.), psychologically (threatened, insulted, humiliated, been extremely jealous, scared her,etc.) and/or sexually (forced her to have sexual activities against her will). These questions had three possible responses: ‘many times’, ‘sometimes’ or ‘never’. A woman was considered to experience ‘current abuse’ if she answered ‘many times’ or ‘sometimes’ to any of these three questions. Women who had not been in an intimate relationship in the previous year were asked to leave these three questions blank, and were considered negative for current abuse. Secondly, each participant was asked if any other partner in the past had abused her physically, psychologically and/or sexually. If she answered positively to any of these three questions she was considered to have experienced ‘past abuse’. Again, women who had not been in a relationship in the past (differing from the current one) were asked to leave these questions blank and were considered negative for the past abuse. Women who had no current or past intimate relationships were excluded from the analysis.
A woman was considered to have experienced lifetime physical IPV if she answered ‘many times’ or ‘sometimes’ to any of the two questions about physical IPV, and the same applied to psychological and sexual abuse. Because there is usually considerable overlap between IPV types, we created four mutually exclusive hierarchical categories of lifetime abuse for the analysis of IPV and physical health. The first group included respondents who had ever experienced only psychological IPV. The second group included those who had ever experienced physical and psychological IPV but not sexual. The third group had experienced lifetime psychological and sexual IPV but not physical. The last group included women who had ever experienced all three types of abuse. We did not include other additional groups as categories of abuse (only physical, only sexual, and physical and sexual) because the number of women in these categories did not allow us to conduct the analysis on physical health.
The duration of the abusive experiences was also recorded. The categories considered were: no abuse, between one month and one year and more than 1 year.
Physical health indicators
In order to value the physical health status of the women three indicators were recorded, that have been used in some previous studies: chronic disease (yes/no) and type of disease if applicable (hypertension, asthma, diabetes and others); number of surgical operations in their life and number of days spent in bed in the last 3 months.
Demographics
Information on age, number of children, current marital status, employment status, education and monthly family income was obtained.
Procedures
Data were collected by the family practitioner at the end of the woman's consultation. If the patient met eligibility criteria, the physician invited her to participate in a study about women and health. The doctor explained that the questionnaire was anonymous and confidential and that she/he could help in filling it out if necessary. After giving consent for participation, the woman was handed the questionnaire, which was self-completed either in the waiting area or in a private space specifically provided for the study. Once the questionnaire was completed, the woman put it in an envelope, closed it and deposited it in a ‘questionnaire box' specifically provided for this purpose. Within the envelope, the woman was given information on available community resources for battered women in the area.
Statistical analysis
All univariate, bivariate and multivariate analysis procedures were performed with the statistical software SPSS, version 11.5.
Prevalence for the different lifetime IPV categories and for current and past IPV in our sample was first calculated. The association between IPV and physical health indicators was calculated with chi-square (
2) for the qualitative variables and with Student's t-test for the quantitative ones. Statistical significance was set at P < 0.05. Any experience of any kind of IPV was considered another category for analysis purposes and the comparison group in all analyses was comprised of never abused women. A logistic regression analysis was also conducted to control the effect of possible confounding variables (age, employment status and monthly family income). Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported.
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Results |
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The 23 family practitioners who were invited accepted to collaborate. All these practices were located in urban primary health care centres that provide services to middle class population.
A total of 1631 women were approached. Of which, 118 (7.23%) refused to participate. Seventy-two (4.76%) of the 1513 women recruited had missing data on several response variables (88.35% response rate). Of the 1441 women who completed the questionnaire, we excluded 26 who had never been in an intimate relationship, and 13 who did not meet age inclusion criteria. Therefore, 1402 women were included in the analysis.
The mean age of the sample was 39 years and 33.3% had two children. Almost 63% were married and more than half of the sample were employed (51%). Most of the women did not have a university degree (65.3%).
Physical health status of the sample
One-third of the women in the sample referred to experiencing or had experienced a chronic disease during their life. Thirty-one percent of these women have or have had hypertension, and this is the most common illness. It should also be noted that the majority of women who said they suffered a chronic disease referred to ‘other’ diseases from those stated in the questionnaire (51%). The most common were allergies, dermatitis and other skin problems, headache and migraine, thyroid related conditions and rheumatic and muscular problems. Women have undergone a mean of 1.18 operations during their life and have spent a mean of 1.27 days in bed in the last 3 months.
IPV prevalence
Thirty-two percent of the sample (n = 445) have experienced some type of IPV during their life; 14.4% (n = 198) referred to only having experienced psychological abuse, 7.2% (n = 99) have experienced physical and psychological abuse (but not sexual abuse), 2.5% (n = 35) have experienced psychological and sexual abuse (but not physical abuse), and 6% (n = 83) have experienced physical, psychological and sexual abuse. Only three women refer to experiencing sexual abuse alone, and nine have experienced physical abuse alone. Eighteen women who referred to experiencing abuse did not answer all the questions related to abuse, and therefore could not be grouped into any of the abuse categories.
IPV and physical health
Table 1 shows the association between having ever experienced any type of IPV and physical health indicators. Higher prevalence of chronic disease is observed in abused women than in women who have never been abused (36.2 vs. 30.9%), and this is the case in all illnesses studied. Similarly, the mean number of days spent in bed in the last three months is higher in abused women than in non-abused women (1.71 vs. 1.07). None of these differences were statistically significant.
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Table 2 shows the association of the different categories of abuse with physical health indicators. Women who have experienced psychological, or physical and psychological abuse are more likely to have a chronic disease than non-abused women, although this association is not of statistical significance. However, in the case of women who have experienced the three types of abuse (physical, psychological and sexual), the association between abuse and physical health is statistically significant. Thus, these women are twice as likely to suffer a chronic disease as those who have not experienced abuse (OR = 2.03; 95% CI = 1.18–3.51), and just over twice as likely to suffer ‘other diseases’ (OR = 2.57; 95% CI = 1.38–4.77) and to spend more days in bed (t = 2.35; P = 0.019).
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Experiencing abuse ‘many times’ is associated with poorer physical health, since women who have been abused more frequently, present a significantly higher probability of suffering chronic diseases than those who have not been abused, and also of spending more days in bed (table 3). The association between intensity of abuse and chronic health problems acquires statistical significance when the three types of abuse have been experienced (OR = 2.40; 95% CI = 1.29–4.45). The association between intensity of abuse and number of days spent in bed is statistically significant when abuse experienced is of ‘any type’ (t = 2.93; P = 0.003), when both psychological and sexual abuse are experienced (t = 2.44; P = 0.015), or when the three types of abuse (physical, psychological and sexual) are experienced (t = 2.63; P = 0.009).
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Analysis of the association between duration of abuse and physical health indicators offers similar results to those commented with reference to the intensity of abuse. When abuse has occurred for longer than 1 year, there is a higher probability of suffering chronic diseases or spending days in bed than in women who have never experienced abuse. Likewise, when all three types of abuse have been experienced for more than one year, this is statistically associated with chronic health problems (OR = 2.47; 95% CI = 1.34–4.57) and with a greater number of days spent in bed (t = 2.62; P = 0.009). Also, women who have experienced any type of abuse for more than one year have a significantly higher probability of spending more days in bed than those who have never experienced abuse (t = 2.52; P = 0.012) (table 4).
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Regarding the association between abuse experienced at present, in the past, and in both the past and the present, and physical health indicators, there is a similar probability of suffering chronic diseases amongst women who experience abuse at present (without having experienced abuse in the past), and those who have never experienced abuse. However, women who have been abused in the past and those who have been abused in the past and the present, do have a higher probability of suffering a chronic disease than those who have never been abused (OR = 1.38; 95% CI 0.96–2.00 and OR = 1.34; 95% CI = 0.67–2.68, respectively), although the difference is not statistically significant. However, chronic disease prevalence is higher in abused women than in non-abused women, regardless of whether they experience abuse at present, in the past, or in the past and at present. The mean number of days spent in bed in the last three months is also higher in women who have experienced abuse in the past, at present, or in the past and at present, in comparison with those who have never been abused. But it is IPV experienced in the past and at present which is statistically associated with the number of days spent in bed (t = 3.17; P = 0.002).
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Discussion |
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In the first place, the limitations of our study should be mentioned. This is a cross-sectional survey and inferences regarding causality cannot be made. Moreover, this study has the usual biases of self-reporting and certain data could have been misclassified. Additionally, we used a convenience sample of practices which may or may not be representative, and this should be considered when interpreting the prevalence data. There are also other limitations related to the exclusion criteria. On the one hand, women who attended the practice with their partners were excluded, and it could be that these women were more likely to be controlled or abused by their partners than women who attended the practice alone. On the other hand, despite the association found in previous studies between IPV and low socioeconomic levels,22 given that participants in our study were asked to complete a written questionnaire, illiterate women were excluded. All these limitations, however, could have only led to an underestimation of the real IPV associations.
Moreover, it should also be noted that Spain has a public National Health System that aims to provide universal medical care. Therefore, although data found in this study cannot by any means be generalized to the Spanish population, we should acknowledge that findings from studies in the family practice are probably the closest data we can have to the real magnitude of the problem. Furthermore, the profile of the women in this study does not differ from the demographics of the general female population in Spain.23
Thirty-two percent of women in this study sample have ever experienced some type of IPV, and this figure is consistent with findings of other international studies conducted in the health setting.4–8 Psychological abuse was the type of abuse that was experienced most frequently by abused women in the sample, and this finding also coincides with other studies.24
The results of this study show the association between IPV and poorer physical health. These results are consistent with data from other international studies.7,12–14,25–29 The majority of these studies have observed that abused women require more health care than non-abused women, and have been attended more frequently by doctors, been hospitalized more and have undergone more operations than non-abused women. Studies emphasize that abused women spend more time in bed than non-abused women and the former have a higher prevalence of chronic diseases than the latter. The results of this study coincide with the findings of these other studies, and show that there is a higher probability of abused women suffering chronic diseases and spending more days in bed than non-abused women.
Recently, some authors have stressed the need to add psychological abuse to studies on the impact of abuse on health, since this type of abuse has been neglected in the majority of literature on this subject, and yet it may have the same level of repercussion on women's health, or more so, than physical and/or sexual abuse.17,30–31 For this reason, an innovative part of this study was to incorporate the category of psychological abuse to the abuse categories that are traditionally studied. Results obtained demonstrate that the greater the number of abuse categories that are incorporated, the greater the impact on physical health. Thus, the greatest impact on chronic health problems and spending days in bed is seen when the three abuse categories (psychological, physical and sexual) are combined. These results concur with the findings of the few studies that have independently analysed the different abuse categories, and found that physical abuse has a greater impact on health than psychological abuse, whereas the impact of the latter appears to focus on psychological aspects.13,32,33
The results of this study demonstrate an association between intensity and duration of abuse, and poorer physical health. Thus, abuse of high intensity and duration appears to have a greater impact on chronic health problems and time spent in bed. These results coincide with the dose-response relation that other studies have already noted between severity of violence and the degree of physical disorders suffered by victims of such abuse.34
The study results show that women who have been abused in the past, regardless of whether or not they are abused at present, have a higher probability of suffering chronic diseases. Women who have been abused both in the past and at present have spent more days in bed in the last three months. Therefore, the results highlight the long-term consequences of IPV on the physical health of abused women.
Little research has addressed differences in health care expenditure among women who suffer IPV at present, compared with those who do not. Coker et al. reached the conclusion that women who are severely abused at present had higher medicaid expenditure than those who had never been abused,28 which demonstrates the need to detect IPV at primary health care centres, and thus reduce medical expenditure. However, more studies have focused on identifying the long-term health consequences of IPV victims. In this respect, literature repeatedly shows that there is a marked relation between IPV in the past and poorer current physical and mental health.25,27,35
Studies like this one, that highlight the consequences of IPV on the physical health of victims, enable health professionals to gain better insight into the problem, facilitating the identification of the different health care areas where women may attend for treatment. Many studies on the subject have observed that it is necessary to detect cases of IPV at a primary health care level, and take corresponding action together with the support of other health professionals.7 Early detection of abuse is therefore a number one objective for health professionals, who can help to bring abuse to an end before it has such an impact on women's health.
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We want to thank the 23 family practitioners who recruited the sample. This study was supported by a Research Grant from the Spanish Network for Research on Health and Gender (Carlos III Health Institute) (G03/042) and by a Research Grant from the Health Department of the Andalusian Government (5/04). Partial results of this study were presented at the XXIII Scientific Meeting of the Spanish Epidemiology Society, celebrated in Las Palmas de Gran Canaria, Spain, in November 2005.
Key points
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