1. Correlates of Medical and Legal Help-Seeking among Women Who Have Experienced Intimate Partner Violence Erin E Duterte Amy E Bonomi, Ph.D., MPH Mary A Kernic, Ph.D., MPH Melissa Schiff, MD, MPH Group Health Cooperative Center for Health Studies and University of Washington’s Department of Health Services, Maternal and Child Health Program

2. Objective To describe the relationship between IPV type, severity, and duration and self-reported use of medical and legal services among a large population-based sample of abused women To describe the relationship between IPV type, severity, and duration and self-reported use of medical and legal services among a large population-based sample of abused women

3. Factors related to seeking medical and legal help Self-reported severity of all IPV types and IPV-related injury positively associated with medical and legal help- seeking Self-reported severity of all IPV types and IPV-related injury positively associated with medical and legal help- seeking Women with physical or sexual IPV were 1.5 times as likely to visit the doctor >10 times in the past year compared to other women, (Coker, et al. 2000). Women with physical or sexual IPV were 1.5 times as likely to visit the doctor >10 times in the past year compared to other women, (Coker, et al. 2000). Women who experienced severe physical IPV, severe psychological IPV, or IPV-related injuries were 1.7, 1.8, and 1.9 times as likely to call the police, respectively, compared to other abused women, (Bonomi, et al. year). Women who experienced severe physical IPV, severe psychological IPV, or IPV-related injuries were 1.7, 1.8, and 1.9 times as likely to call the police, respectively, compared to other abused women, (Bonomi, et al. year).

4. Hypothesis It was hypothesized that physical and sexual IPV exposure, higher levels of perceived severity of IPV, and longer duration of IPV would be positively associated with a woman’s propensity to seek medical and legal help. It was hypothesized that physical and sexual IPV exposure, higher levels of perceived severity of IPV, and longer duration of IPV would be positively associated with a woman’s propensity to seek medical and legal help.

5. Subjects and data collection 3,429 randomly sampled adult women from Group Health Cooperative (GHC) membership files 3,429 randomly sampled adult women from Group Health Cooperative (GHC) membership files Cross-sectional telephone survey Cross-sectional telephone survey Study dates from July, 2003 through August, 2005 Study dates from July, 2003 through August, 2005 Response rate 57.5% Response rate 57.5% Any lifetime IPV according to the Behavioral Risk Factor Surveillance System (BRFSS) Any lifetime IPV according to the Behavioral Risk Factor Surveillance System (BRFSS)

6. Intimate partner violence exposure groups Women N=3,429 Any IPV in adult lifetime n=1,509 Non-physical IPV only n=339 Sexual IPV n=454 Physical IPV n=1,038 Sev. Dur. Sev. Dur. Sev. Dur. Excluded No IPV in adult lifetime n=1,838

7. Outcome Medical or legal help Medical or legal help Medical help Medical help Hospital, physician, dental, ambulance, urgent care, physical therapy, mental health counseling Hospital, physician, dental, ambulance, urgent care, physical therapy, mental health counseling Legal help Legal help Ever sought a protection order Ever sought a protection order Called the police because of physical abuse or forced sex in the past five years Called the police because of physical abuse or forced sex in the past five years

8. Statistical Methods Bivariate analysis Bivariate analysis to examine socio-demographic and abuse factors that could be associated with help-seeking status to examine socio-demographic and abuse factors that could be associated with help-seeking status Binary outcomes: Multiple Poisson regression was used Binary outcomes: Multiple Poisson regression was used to calculate RR and 95% CI for IPV types associated with medical and legal help-seeking to calculate RR and 95% CI for IPV types associated with medical and legal help-seeking Model 1: Medical or legal (45%) Model 1: Medical or legal (45%) Model 2: Medical (35%) Model 2: Medical (35%) Model 3: Legal (19%) Model 3: Legal (19%) in a sub-analysis to examine the contribution of IPV severity and duration in a sub-analysis to examine the contribution of IPV severity and duration Model 1: physical IPV Model 1: physical IPV Model 2: sexual IPV Model 2: sexual IPV Model 3: non-physical IPV Model 3: non-physical IPV

9. Characteristics of Abused Women by Help-Seeking Status Sought help for IPV N = 673 Did not seek help for IPV N =836 Age (%) 18-2526-3536-45 46 + 3.7 3.7 9.7 9.724.861.8 6.6 6.610.322.161.0 Race/Ethnicity (%) CaucasianAfrican-AmericanAsian/PI American Indian Multi-racial/OtherOther82.6 2.8 2.8 2.1 2.1 5.7 5.7 3.9 3.9 2.9 2.983.8 3.6 3.6 2.8 2.8 3.6 3.6 2.6 p≤0.05 2.6 p≤0.05

10. Characteristics of Abused Women by Help Seeking Status Sought help for IPV N = 673 Did not seek help for IPV N =836 Education (%) High school or less Some education post high school College graduate Post graduate 12.8 12.8 51.4 51.4 20.5 20.5 15.3 15.3 12.9 12.9 44.3 44.3 19.6 19.6 23.2 p≤0.001 23.2 p≤0.001 Experienced physical or sexual abuse as child (%) 50.2 50.2 41.5 p≤0.001 41.5 p≤0.001 Witnessed IPV as a child (%) 25.4 25.4 23.1 23.1 Children witnessed IPV (%) 62.1 62.1 37.9 p≤0.001 37.9 p≤0.001

11. Medical or legal help seeking by IPV type* Did not seek help (%) Sought help (%) Relative Risk (95% CI) Model 1: Medical or Legal Help Non-physical IPV only (reference) PhysicalSexual26.762.023.617.277.238.21.0 1.5 (1.3-1.7) 1.3 (1.2-1.5) *Adjusted for age, race/ethnicity, educational level, physical/sexual abuse as a child, witnessed IPV as a child, and children witnessed IPV

12. Medical help seeking by IPV type* Did not seek help (%) Sought help (%) Relative Risk (95% CI) Model 2: Medical Help Non-physical IPV only (reference) PhysicalSexual24.765.424.818.675.139.41.0 1.2 (1.0-1.4) 1.3 (1.2-1.5) *Adjusted for age, race/ethnicity, educational level, physical/sexual abuse as a child, witnessed IPV as a child, and children witnessed IPV

13. Legal help seeking by IPV type* Did not seek help (%) Sought help (%) Relative Risk (95% CI) Model 3: Legal Help Non-physical IPV only (reference) PhysicalSexual25.664.026.79.588.544.11.0 3.2 (2.2.-4.5) 1.6 (1.3-1.9) *Adjusted for age, race/ethnicity, educational level, physical/sexual abuse as a child, witnessed IPV as a child, and children witnessed IPV

14. Medical or Legal Help Seeking by IPV Severity and Duration* Did not seek medical or legal help (%) Sought medical or legal help (%) Relative Risk (95% Confidence Interval) Model 1: Physical IPV 518 (62.0%) 520 (77.2%) Severity Not severe Not severe Slightly Slightly Moderate Moderate Extreme Extreme Duration (years) 0-2 0-2 3-10 3-10 >10 >1011.540.535.412.771.716.112.22.523.636.837.052.326.021.71.0 1.4 (1.3 -1.5) 1.9 (1.6-2.2) 2.5 (2.0-3.2) 1.0 1.1 (1.0-1.2) 1.2 (1.1-1.4) *adjusted for age, race/ethnicity, educational level, physical/sexual abuse as a child, witnessed IPV as a child, and children witnessed IPV

15. Medical or Legal Help Seeking by IPV Severity and Duration* Did not seek medical or legal help (%) Sought medical or legal help (%) Relative Risk (95% Confidence Interval) Model 2: Sexual IPV 197 (23.6%) 257 (38.2%) Severity Not severe Not severe Slightly Slightly Moderate Moderate Extreme Extreme Duration (years) 0-2 0-2 3-10 3-10 >10 >1035.632.222.210.171.012.816.220.124.033.222.755.724.919.51.0 1.1 (1.0-1.2) 1.1 (1.0-1.2) 1.2 (1.0-1.4) 1.2 (1.0-1.4) 1.3 (1.0-1.7) 1.3 (1.0-1.7)1.0 1.0 (0.9-1.1) 1.0 (0.9-1.3) *adjusted for age, race/ethnicity, educational level, physical/sexual abuse as a child, witnessed IPV as a child, and children witnessed IPV

16. Medical or Legal Help Seeking by IPV Severity and Duration* Did not seek medical or legal help (%) Sought medical or legal help (%) Relative Risk (95% Confidence Interval) Model 3: Non-physical IPV only 223 (26.7%) 116(17.2%) 116(17.2%) Severity Not severe Not severe Slightly Slightly Moderate Moderate Extreme Extreme Duration (years) 0-2 0-2 3-10 3-10 >10 >1058.725.114.41.848.231.919.950.426.115.77.847.827.025.21.0 1.2 (1.0-1.4) 1.4 (1.0-1.9) 1.6 (1.0-2.6) 1.0 1.0 (0.8-1.2) 0.9 (0.6-1.4) *adjusted for age, race/ethnicity, educational level, physical/sexual abuse as a child, witnessed IPV as a child, and children witnessed IPV

17. Summary Physical and sexual IPV associated with medical or legal help-seeking Physical and sexual IPV associated with medical or legal help-seeking ‘Dose-response’ effect with increasing severity of physical IPV associated with greater likelihood of seeking medical or legal help ‘Dose-response’ effect with increasing severity of physical IPV associated with greater likelihood of seeking medical or legal help Longer duration of IPV associated with increased help-seeking efforts Longer duration of IPV associated with increased help-seeking efforts

18. Comments Cannot assess temporality Cannot assess temporality Legal help-seeking restricted Legal help-seeking restricted IPV exposure did not include related injury IPV exposure did not include related injury Large population-based sample of women Large population-based sample of women Broad definition of IPV exposure Broad definition of IPV exposure

19. Significance First study to empirically determine that longer duration of physical IPV was associated with help-seeking in medical and legal venues First study to empirically determine that longer duration of physical IPV was associated with help-seeking in medical and legal venues Additional efforts must be mounted to improve women’s agency and improve the health care system’s and legal system’s response to IPV Additional efforts must be mounted to improve women’s agency and improve the health care system’s and legal system’s response to IPV

20. Acknowledgements Thesis Committee Thesis Committee Amy E Bonomi, Ph.D., MPH Amy E Bonomi, Ph.D., MPH Mary A Kernic, Ph.D., MPH Mary A Kernic, Ph.D., MPH Melissa Schiff, MD, MPH Melissa Schiff, MD, MPH Agency for Healthcare and Research Quality (AHRQ), Robert S. Thompson, 1 RO1HS/MH 10909-01A1, Long tem healthcare effects of domestic violence, Group Health Cooperative. Agency for Healthcare and Research Quality (AHRQ), Robert S. Thompson, 1 RO1HS/MH 10909-01A1, Long tem healthcare effects of domestic violence, Group Health Cooperative. This work was funded in part by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration's Maternal and Child Health Bureau (Title V, Social Security Act), grant #T76MC00011-21-00. This work was funded in part by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration's Maternal and Child Health Bureau (Title V, Social Security Act), grant #T76MC00011-21-00. Family and friends Family and friends