1. Symposium Presenters: Jacquelyn C. Campbell, PhD, RN, FAAN Gloria Callwood, PhD Marguerite B. Lucea, PhD, MPH, RN Mary Paterno, PhD(c), MSN, CNM, RN

2. Acknowledgements Research supported by a subcontract with the Caribbean Exploratory NIMHD Research Center of Excellence (CERC), University of the Virgin Islands, Grant # P20MD002286, National Institutes of Health, PI Gloria Callwood, PhD, RN, FAAN

3. Team Members United States Jacquelyn Campbell, PhD, RN, FAAN - PI Phyllis Sharps PhD, RN, FAAN – Co-I Richelle Bolyard, MHS Jamila Stockman, PhD, MPH Marguerite B. Lucea, PhD, MSN, MPH, RN Bushra Sabri, PhD, LMSW, ACSW Akosoa McFadgion, MS, MSW, PhD student Kaitlan Gibbons, PsyD(c) Mary Paterno, MSN, CNM, RN, PhD student Sharon O’Brien, PhD Sachi Mana-ay, BSN student Jessica Draughon, MSN, RN, PhD student Charmayne M. Dunlop-Thomas, MS Callie Simkoff, BSN, RN Gyasi Moscou-Jackson, MHS, BSN, RN Chris Kunselman Ayanna Johnson, MPH Ashley Chappell, BSN, RN Lucine Francis, BSN, RN Naa Ayele Amponsah, MPH Hossein Yarandi, PhD US Virgin Islands Doris Campbell, PhD, ARNP, FAAN – Co-PI Gloria Callwood, PhD, RN, FAAN – Co-I, PI of CERC Desiree Bertrand, MSN, RN Lorna Sutton, MPA Tyra DeCastro Alexandria Bradley, RN Sally Browne, RN Edris Evans, RN Yvonne Francis, RN Naomi Joseph, BSN student Jennifer King, RN Suzette Lettsome, MSPHN, RN Julie Matthew, RN Kenice Pemberton, ASN student J'Nique Smith, BSN student Jaslene Williams, MSW

4. Outline of Symposium Overview of study, settings and methods Prevalence of lifetime IPA and past 2 year IPV Mental health outcomes Relationship between substance abuse, IPV, and HIV risk behavior IPA and Reproductive Outcomes Traumatic Brain Injury and IPA Summary

5. Overarching Study Background Health disparities among African American and African Caribbean populations have been documented in national and territorial reports Intimate Partner Abuse (IPA) is related to health disparities for women of color in the US IPA is a risk factor for a variety of physical and mental health problems in US based studies (NCHS, 2000; CDC, 2000; Government of the USVI Department of Health, 2003; Campbell, 2002; Campbell et all, 2002; Coker, 2004)

6. Overarching Study Background Prevalence of IPV Affects 13 – 62% of women globally; lifetime prevalence most often estimated around 30% (Garcia-Moreno, 2006) In US, 32.9% of women experience lifetime physical IPV, 18.6% rape and 44.6% other sexual violence, with 9.4% of women reporting lifetime partner rape (Black et al, 2011) Using BRFSS data, 22.5% of women in the US Virgin Islands report lifetime IPV vs. 26.4% overall (18 states) (Breiding, Black & Ryan,2008) Gap: No data on prevalence of IPA in US Virgin Islands among women in health care settings compared to mainland US No prevalence analysis specific to the USIV No study of health consequences of IPA in USVI

7. Specific Aims of ACAAWS To determine and compare the prevalence of IPA, including emotional, sexual and physical abuse, in a sample of women from health care settings in the USVI and Baltimore, MD. To determine to what extent a history of IPA is a risk factor for other medical conditions and symptoms, including: a) mental health; b) STD's/HIV and associated risk behaviors c) reproductive outcomes; and d) traumatic brain injury (TBI)

8. Setting: USVI Unincorporated territory of the U.S. made up of 3 main islands (St. Thomas, St. Croix, St. John) and smaller islands Population (2011 est.) 109,574 76% Black, 13% White, 11% other Median household income: $41,834 4.8 immigrants/1,000 pop Most of population US citizens Official language: English

9. Setting: Baltimore, MD Population: 619,493 (2011) 64% Black, 32% White, 4% other Median household income: $23,333 Persons per household: 2.52 Foreign born: 7%

10. Study Design & Methods  Comparative case-control study (randomly selected controls)  Study period 2009-2011  Eligibility criteria  Women aged 18-55 years  Self-identify as African Caribbean or African American  Report intimate partner in the past two years  Women recruited from primary care, prenatal or family planning clinics  Questionnaire administered on a touch screen computer with optional headphones  For women who were Spanish speaking (in USVI) and of low literacy (all sites)  For sensitive information  Alerts interviewer if high score on DA or suicidality

11.  CASES = Intimate Partner Abuse (IPA)  Intimate Partner Violence (IPV - physical/sexual abuse) & psychological abuse (threats/emotional abuse/controlling behavior )  IPV assessed using the Abuse Assessment Screen (AAS, McFarlane & Helton - www.nnvawi.org) www.nnvawi.org  Pushed, slapped, hit, kicked, or physically hurt &/OR  Forced sex  Psychological abuse: <19 on WEB (Women’s Experiences of Battering – Hall-Smith)  Controlled, in fear of current/former intimate partner  Any of the above by current or former intimate partner  Past 2 Year and Lifetime IPV (Physical/Sexual)—subgroups within cases  Exclusive of emotional/controlling abuse  Reported as Lifetime and Past-two-year Study Definitions: Cases (IPA/IPV)

12.  CONTROLS = Women never abused by anyone in their lifetime  Not eligible (if meeting age, race, and language requirements)  Women experiencing abuse only from someone other than an intimate partner or ex-partner.  Women reporting no partner within 2 years prior to survey Study Definitions: Controls & Not Eligible

13. Selection of Sample from Study Population

14. Final Participants (n=901) 1579 screened from both sites n=486n=1059 169 controls 159 cases 189 controls n=553 n=461n=963 384 cases US Virgin IslandsBaltimore City, MD n=348 34 ineligible race; duplicates No partner past 2 yrs= 96 No partner past 2 yrs= 25 Didn’t meet case /control criteria = 70 Didn’t meet case /control criteria= 39 Non-selected control =329 Non-selected control = 74 Screened as case; no full survey=11 Lifetime IPA Total 621/1545=40% B’more 179/488=37% USVI 442/1059=42% Past 2-year IPV Total 382/1424= 27% B’more 119/461= 26% USVI 263/963= 26% 1315 fully eligible women

15. Education of Participants Education Levels by Site, χ 2 = 38.81, p<0.01 Percent

16. Marital Status of Participants Marital Status by Site, χ 2 = 49.21, p<0.01 Percent

17. Employed & Insured Participants χ 2 = 26.14 p<0.01 Percent χ 2 = 124.10 p <0.01 (N=901)

18. Screening-based prevalence of abuse experiences Among sample of population in healthcare setting, not limited to participants who meet restricted study definition of cases or “never-abused” controls. *Difference between sites significantly different (Chi-square p<0.01)

19. Lifetime IPA (cases) Physical Psychological 170 (31%) 89 (17%) Sexual 163 (30%) 26 (5%) 72(13%) (n=543) 5 (1%) 18 (3%)

20. Physical Psychological Recent (past 2 Year) IPV Sexual 98 (26%) 9 (2%) 79 (21%) 196 (51%) (n=382)

21. Type of abuse among cases *Difference between sites significantly different (Chi-square p<0.01)

22. Sociodemographics & Lifetime IPA BaltimoreSt. ThomasSt. Croix Children <18 years in household X (risk) Born in US/USVI (vs foreign born) X (risk) Partner born in US/USVI (vs foreign born X (risk) Having a current partnerX (protective) Variables Significantly Associated with Lifetime IPA in Bivariate Analyses, Stratified by Site (p<0.05) No significant associations in any sites between L-IPA and age, education level, employment status, insurance status, pregnancy status at time of survey.

23. Sociodemographics & Lifetime IPV BaltimoreSt. ThomasSt. Croix Children <18 years in household X (risk) Born in US/USVI (vs foreign born) X (risk) Partner born in US/USVI (vs foreign born X (risk) Having a current partnerX (protective) Variables Significantly Associated with Lifetime IPV in Bivariate Analyses, Stratified by Site (p<0.05) No significant associations in any sites between L-IPV and age, education level, employment status, insurance status, pregnancy status at time of survey.

24. Sociodemographics & Recent IPV BaltimoreSt. ThomasSt. Croix AgeX (younger >risk) Children <18 years in household X (risk) Born in US/USVI (vs foreign born) X (risk) Partner born in US/USVI (vs foreign born X (risk) Having a current partnerX (protective) Variables Significantly Associated with Lifetime IPV in Bivariate Analyses, Stratified by Site (p<0.05) No significant associations in any sites between R-IPV and education level, employment status, insurance status, pregnancy status at time of survey.

25. Lifetime IPA and Physical Health Compared to non-abused women, women reporting lifetime IPA were at higher odds for Being hospitalized (AdjOR 1.37, 95% CI 1.08 – 1.73) Having had surgery (AdjOR 1.58, 95% CI 1.08 – 2.32) Having broken bones (AdjOR 2.34, 95% CI 1.24 – 4.40) Having facial injuries (AdjOR 3.51, 95% CI 2.16 – 5.71) Having eye injuries (AdjOR 2.65, 95% CI 1.60 – 4.38) Having a broken jaw (AdjOR 4.27, 95% CI 1.32 – 13.80) When controlling for age, marital status, education, employment status, pregnancy status, and having children under 18 years of age in the household.

26. Exchange Sex – Risk of HIV – Variables in Analysis Outcome: Exchange Sex Have you had exchange male sex partners, that is, men you have sex with in exchange for food, money, shelter or drugs? (yes/no) Abuse history* Recency: No abuse, Lifetime IPA, Past 2 year IPV Based on responses to AAS, WEB, SVAWS, Danger Assessment Past Year Drug Use How often in the past year have you used drugs (street drugs, drugs that weren’t prescribed to you or were taken in a non-recommended way)? (yes if at all; no if never) PTSD (PC-PTSD) (Prins et al, 2003) Depressive symptoms(CESD-10) (Andresen et al., 1994)

27. Results: Overall Of the total sample completing the full survey (n=901), 892 women (99%) reported their participation, or not, in exchange sex and illicit drug use. 357 controls; 473 cases Of these women, 7% (n = 61) had engaged in exchange sex. 3% of controls; 10% of cases (χ 2 15.23, p<0.001) 9.3% (n=83) reported using illicit drugs 6% of controls; 12% of cases (χ 2 8.26, p<0.01)

28. Results: χ 2 Analyses Significant associations ( χ 2 p<.05 with exchange sex) Site, receipt of government aid, having children in household Recency of Abuse Drug Use, Alcohol Use, PTSD, Depressive Symptoms Non-significant associations ( χ 2 p>.10 with exchange sex): Age, Education level, Employment status, Current relationship status, Monthly income These variables were not retained for further analysis

29. Results: Predictors of Exchange Sex Unadjusted OR (95% CI)Adjusted OR (95% CI) Site Baltimore St. Thomas St. Croix (ref) 0.77 (0.43 – 1.38) 0.41(0.20 – 0.85) (ref) 0.70 (0.36 – 1.34) 0.34 (0.15 – 0.76) No Government Aid0.44 (0.21 – 0.90)0.63 (0.28 – 1.42) Children <182.07 (1.03 – 4.15)1.39 (0.65 – 2.99) Recency of Abuse None (control) Lifetime IPA Past 2 year IPV (ref) 2.03 (0.81-5.09) 4.42 (2.18-8.95) (ref) 2.03 (0.75 – 5.47) 2.95 (1.32 – 6.62) Drug Use9.26 (5.20 – 16.46)5.50 (2.86 – 10.59) Alcohol Use1.22 (1.10 – 1.37)1.04 (0.92 – 1.19) PTSD3.27 (1.83 – 5.84)1.89 (0.94– 3.80) Depressive symptoms2.69 (1.58 – 4.58)1.25 (0.67 – 2.35) OR = Odds Ratio, CI = Confidence Interval

30. Discussion of Findings Women in St. Croix were significantly less likely to engage in exchange sex than women in Baltimore (& women on St. Thomas somewhat less likely) Rates of drug use comparable to previous literature findings—significantly higher among those experiencing IPV than those non-abused women However relatively few in USVI – especially in St. Croix Few of the socio-demographics were independently related to exchange sex Recent IPV and past year drug use were both independently associated with exchange sex, a behavior linked to HIV risk. Results support influence of SAVA syndemic

31. Strategies for Early ID and Intervention Important to acknowledge risk for and assess for violence when working with women with a history of substance abuse, and vice versa When working with HIV+ or women at risk for HIV, discussion of HIV risk behaviors should encompass exchange sex it may be a substantial risk factor, compounded by substance abuse and IPV. However for most abused women – pathway to HIV is through having unprotected sex with abusive partner – b/c sex is forced or b/c she fears his abuse if she tries to “negotiate” safe sex

32. Prevalence of IPA Attitudes Community acceptance of IPAPersonal acceptance of IPA * Differences between cases and controls significant (p<0.05)

33. Influence of Community Attitudes on Lifetime IPA Women in Baltimore who feel their community is accepting of IPA are more than 4 times as likely to experience IPA than those in communities seen as not accepting of IPA (AOR 4.34, 95% CI 1.85 – 10.24) Women in St. Thomas who feel their community is accepting of IPA are nearly 3 times as likely to experience IPA than those in communities seen as not accepting of IPA (AOR 2.89, 95% CI 1.26 – 6.63) Elevated, but not significant, risk in St. Croix

34. Influence of Personal Attitudes on Lifetime IPA Women in Baltimore who personally were more accepting of IPA are more than 3 times as likely to experience IPA than those not accepting of IPA (AOR 3.06, 95% CI 1.15 – 7.48) Women in St. Thomas who personally were more accepting of IPA are nearly 13 times as likely to experience IPA than those not accepting of IPA (AOR 12.77, 95% CI 3.00 – 54.47) Elevated, but not significant, risk in St. Croix

35. Prevalence Discussion Limited number of women demonstrate a long-term separation from violence (distant IPA) Targeted interventions required to help women break the cycle of violent relationships (within the same relationship or engaging in sequential violent relationships) Influential sociodemographics vary by site- community context Some (e.g. US/USVI born partners) difficult to address indicate need for increased efforts to encourage social norms change Others (e.g. children <18 in household) could benefit from multi-pronged approach to protect women from repeated violence and to prevent multi-generational transmission of violence Younger age associated with recent IPV importance of screening and early interventions with young people regarding health relationships

36. Prevalence Discussion Physical health consequences Findings for AA and AC women support findings for broader populations Type of IPA Be sure to include psychological/controlling behaviors (in addition to physical/sexual violence) Indicated by the high rates of psychological abuse/controlling behavior in St. Croix vs. other sites Community and personal attitudes towards IPA Main drivers in elevated risk for IPA in relationships Individual based + community/societal interventions To shape attitudes about use of violence in relationship and To promote healthy relationships

37. Conclusions Reaffirms that IPA can be a significant contributing factor to women’s physical health outcomes. New Affordable Health Care Well Women’s Preventive Health care provisions – reimbursable routine screening and brief counseling for IPV in primary care – need to be implemented throughout USA including USVI Nursing & medical care in emergency and other health settings including family planning and primary care needs to include assessment for abuse Research must focus on developing and implementing culturally tailored and rigorously tested interventions for abused women of all ages