Inhibiting and facilitating factors to end a violent relationship: patterns of behavior among women in Spain.

The objective of this study are (a) to explore the factors, which facilitate or inhibit women's responses to intimate partner violence (IPV) and their ability to leave a violent relationship; (b) to identify patterns of behavior in abused women based on their perception of the violence and the actions they take to find help or a solution to the problems derived from IPV. Semistructured interviews were carried out. The critical path is defined as the sequence of decisions and actions taken by affected women to address the violence they experienced. Based on this concept, we identified several factors that affect women's responses to violence, and categorized them into inhibiting and facilitating factors. We also identified three patterns of behavior: the first one is theoretically as the ideal critical path, whereas in the third pattern the process is less like the ideal critical path.

Strategic responses to intimate partner violence against women in Spain: a national study in primary care.

BACKGROUND: Research on women''s responses to intimate partner violence (IPV) has largely been limited to women who have been exposed to severe physical violence with scarce generalisation. This study aimed to analyse how Spanish abused women from different backgrounds and with different IPV characteristics respond to violence. METHOD: Women experiencing IPV before the previous year (1469) were selected from a large cross-sectional national survey of adult women recruited during 2006-7 among female patients seeking medical care for whatever reason in primary healthcare services. The outcome variables were women's responses to IPV and the predictor variables were personal and social resources profiles and characteristics of the abuse (type, duration and women's age at onset). Stepwise logistic regression models were fitted. RESULTS: 87.5% of abused women took some kind of action to overcome IPV. Significant differences on personal and social profile and type and duration of the abuse were detected between the three strategic responses: distancing, in process and inhibition. The probability of a woman responding with a distancing strategy (seeking outside help or leaving temporarily) is almost three times greater if she is employed, was young when the abuse began, had experienced physical and psychological abuse and when the abuse was under 5 years. CONCLUSIONS: The results of this study show that personal and social resources and the specific circumstances of the abuse should be taken into account to understand women's responses to IPV. Well-validated interventions targeted at abused women's needs and the circumstances of IPV remain a priority.

The relationship between reproductive work and sociodemographic and psychosocial factors in regard to psychological distress in men and women in Spain.

Studies have shown that some sociodemographic factors, such as marital status, employment status or social class, can affect mental health in different ways for each gender. However, up until now, few research projects have tried to ascertain if the role that reproductive work or psychosocial factors play in mental health is different for men and women. The aim of this study is to assess the differences between men and women in terms of how reproductive work, sociodemographic and psychosocial factors are linked to psychological distress in Spain. A cross-sectional study of 29,478 male and female adults using data gathered for the Spanish National Health Survey 2006 was carried out. Psychological distress was measured using the GHQ-12. The independent variables analyzed were: sociodemographic, psychosocial (family functionality and functional social support) and those related to reproductive work (living with or being in charge of different types of people needing care and number of hours devoted to caregiver tasks). Different independent logistic regression models were developed for men and women. In general, with the exception of men who were more prone to psychological distress if they were signed off work for 3 months or more, no major differences were observed regarding the effect of sociodemographic and psychosocial characteristics on psychological distress. With regard to reproductive work, the likelihood of psychological distress doubles in both sexes when the person lives with someone who needs care. In women, a greater number of hours devoted to caring for another person is associated with an increase in distress. Men play a less frequent role in caregiving, but the impact on psychological distress is similar to that in women. Women experienced more psychological distress when they had to live with or be in charge of a disabled person or different types of persons needing care, while men were not affected by this. Major differences have been identified in terms of psychological distress in women and men in several aspects of reproductive work to date unexplored.

The assessment of intimate partner violence in Spanish women: the index of spouse abuse.

We aimed to analyze the internal consistency and construct validity of the Spanish version of the Index of Spouse Abuse (ISA) in a representative sample of 8,995 women attending general practice in Spain in 2006-2007. The factor structure analysis shows that the ISA measures four intimate partner violence (IPV) dimensions: emotional, physical, and sexual abuse, and controlling behavior. Cronbach alpha ranges from .82 (sexual factor) to .94 (emotional). Construct validity analysis shows that IPV is associated with poorer self-perceived health, higher psychological distress, and lower tangible social support. The ISA can help make more visible forms of gender violence in the intimate relationship that sometimes are not recognized as such, like sexual violence or controlling behavior. This can contribute to the development of specific interventions for women experiencing IPV, considering the specificities of the violent acts experienced.

[Mental disease, existence of diagnostic, use of psychotropic medication: differences by autonomous communities under the national health survey 2006]. / Morbilidad psíquica, existencia de diagnóstico y consumo de psicofármacos: Diferencias por comunidades autónomas según la encuesta nacional de salud de 2006.

BACKGROUND: Most of the studies on psychological distress in Spain have been conducted in small geographical areas or specific population groups. However, there are no studies that provide representative data for each Autonomous Community (AC). The objectives of this paper are to determine, both in Spain and in the AC, the prevalence of psychological distress, diagnosis, use of psychoactive medication, social support and self-perceived health, as well as to study the association between psychological distress and the rest of the variables. METHODS: Cross-sectional study, using data from the 2006 National Health Survey, that was completed by 29,478 persons. VARIABLES STUDIED: sociodemographics, psychological distress (GHQ-12), self-perceived health, mental disorder diagnosis, functional social support (Duke) and use and prescription of psychoactive medication. RESULTS: The prevalence of psychological distress in Spain was 20,1%; the highest prevalence was found in Canary Islands (28,2%) and the lowest in La Rioja (12,2%). Among those who presented psychological distress, 62,4% had never received a mental disorder diagnosis, and 71,6% had not used psychoactive medication in the last year. The highest prevalences of non-diagnosed cases (81,8%) and cases non-treated with psychoactive medication (83,1%) were found in La Rioja, whereas the lowest prevalences were found in Asturias. Eight percent of the persons who presented psychological distress had low social support and 63,8% reported bad self-perceived health. CONCLUSIONS: Psychological distress is a prevalent phenomenon, and more than half of the persons who suffer it receive neither a diagnosis nor psychoactive medication. Moreover, there are considerable differences between the AC.

Identifying sociodemographic differences in Intimate Partner Violence among immigrant and native women in Spain: a cross-sectional study.

OBJECTIVES: To analyze whether sociodemographics and social support have a different or similar effect on the likelihood of Intimate Partner Violence in immigrants and natives, and to estimate prevalences and associations between different types of IPV depending on women's birthplace. METHODS: Cross-sectional study of 10,048 women (18-70 years) attending primary healthcare in Spain (2006-2007). OUTCOME: Current Intimate Partner Violence (psychological, physical and both). Sociodemographics and social support were considered first as explicative and later as control variables. RESULTS: Similar Intimate Partner Violence sociodemographic and social support factors were observed among immigrants and natives. However, these associations were stronger among immigrants, except in the case of poor social support (adjusted odds ratio natives 4.36 and adjusted odds ratio immigrants 4.09). When these two groups were compared, immigrants showed a higher likelihood of IPV than natives (adjusted odds ratios 1.58). CONCLUSION: Immigrant women are in a disadvantaged Intimate Partner Violence situation. It is necessary that interventions take these inequalities into account.

Partner violence and psychological well-being: buffer or indirect effect of social support.

OBJECTIVES: To determine the effect of two kinds of intimate partner violence (IPV) (physical and psychological) in the previous 12 months (current) and before the previous 12 months (past) on psychological well-being among women aged 18 to 70 years who attend primary healthcare centers in Spain; and to analyze the effect of the duration of lifetime IPV and social support on psychological well-being. METHODS: A cross-sectional survey was carried out among 10,322 women randomly recruited in primary healthcare centers in Spain. Outcome variables were three indicators of psychological well-being (psychological distress, psychotropic drug use, and self-perceived health). Predictor variables were the different types of IPV, IPV timing (current and past), duration of lifetime IPV, and social support. Logistic regression models were fitted. RESULTS: Both types of IPV increased the probability of worse psychological well-being in both IPV timings (current and past). Longer duration of lifetime IPV, friends network size, and tangible support were independently associated with worse psychological well-being. However, an interaction between current IPV and family network size was found. The probability of poor self-perceived health status was reduced by 29% among women exposed to current IPV who had a large family network (odds ratio, 0.71; 95% confidence interval, 0.54-0.94). CONCLUSIONS: Psychological well-being was independently affected by IPV (types and duration) and social support (friends network size, tangible support). Only family network size mitigates the negative consequences of IPV on self-perceived health status.

[Geographical variability in violence against women in Spain]. / Variabilidad geográfica de la violencia contra las mujeres en España.

OBJECTIVES: To describe the prevalence of intimate partner violence and non-partner violence against women in Spain overall and by autonomous regions, as well as the characteristics of this violence, and to study the association between the prevalence of intimate partner violence and the frequency of formal complaints and deaths. METHODS: A cross-sectional survey was performed through a self-administered questionnaire in 11,475 women attending primary care from 2006 to 2007. Multistage stratified sampling was carried out in a representative sample in each autonomous region. Data on intimate partner and non-intimate partner violence, formal complaints to the police and deaths due to intimate partner violence were gathered. A descriptive analysis was conducted. Correlations between the prevalence of intimate partner violence and police reports and deaths from this cause were determined through Pearson's correlation coefficient. RESULTS: A total of 24.8% (23.4%-26.3%) of the sample reported having experienced intimate partner violence at some time. The highest prevalence of intimate partner violence was found in Ceuta and Melilla (40.2%) and the Balearic Islands (32.5%) and the lowest in Cantabria (18%). Fifteen percent of the sample reported having experienced non-partner violence at some time, and the most frequent type was that committed by a relative. Again, the highest prevalence of non-partner violence was found in Ceuta and Melilla and the Balearic Islands and the lowest in Cantabria. A significant positive linear correlation was found between intimate partner violence in the previous year and the rate of reports of intimate partner violence in the autonomous regions (r=0.398; p=0.005). CONCLUSIONS: The prevalence of intimate partner violence varies from one autonomous region to another. The reasons for this variation should be further explored in future studies.

[Gender-based violence against immigrant and Spanish women: scale of the problem, responses and current policies]. / Violencia de género en mujeres inmigrantes y españolas: magnitud, respuestas ante el problema y políticas existentes.

OBJECTIVE: To compare the prevalence of gender-based violence among immigrant and Spanish women. To describe their responses to this problem and the possible differences. To identify specific interventions to deal with gender-based violence in immigrant women in Spain. METHODS: We performed a cross-sectional survey through a self-administered questionnaire in 10,202 women attending primary care in Spain (2006-2007). A content analysis was performed of the follow-up report of law 1/2004 of integral protection measures against gender violence sent by each Spanish region (2005) and the most recent regional laws and acts. RESULTS: The prevalence of gender-based violence was 14.3% in Spanish women and 27.9% in immigrant women. The likelihood of gender-based violence was higher in immigrant (odds ratio adjusted: 2.06; 95% confidence interval: 1.61-2.64). Immigrant women more frequently reported that they had denounced their intimate partners and that they did not know how to manage the situation. Some Spanish regions have already started interventions to overcome access barriers to social and health services, but only three have provided data on the number of immigrant women who received economic and occupational help up to 2005. CONCLUSIONS: Inequalities were observed in the prevalence of gender-based violence according to country of origin, with immigrant women being more frequently affected. Immigrant women more frequently denounce their intimate partners than Spanish women but this action does not guarantee effective results. Other specific interventions have been identified in some autonomous regions of Spain but these interventions need to be evaluated to ensure that they benefit immigrant women.

Validation of the Spanish version of the Index of Spouse Abuse.

BACKGROUND: Partner violence against women is a major public health problem. Although there are currently a number of validated screening and diagnostic tools that can be used to evaluate this type of violence, such tools are not available in Spain. The aim of this study is to analyze the validity and reliability of the Spanish version of the Index of Spouse Abuse (ISA). METHODS: A cross-sectional study was carried out in 2005 in two health centers in Granada, Spain, in 390 women between 18 and 70 years old. Analyses of the factorial structure, internal consistency, test-retest reliability, and construct validity were conducted. Cutoff points for each subscale were also defined. For the construct validity analysis, the SF-36 perceived general health dimension, the Rosenberg Self-Esteem Scale and the Goldberg 12-item General Health Questionnaire were included. RESULTS: The psychometric analysis shows that the instrument has good internal consistency, reproducibility, and construct validity. CONCLUSIONS: The scale is useful for the analysis of partner violence against women in both a research setting and a healthcare setting.

Risk factors for fibromyalgia: the role of violence against women.

The objectives of the study were to analyse the association between fibromyalgia (FM) and violence against women and to explore the association between FM and sociodemographic factors, social support and psychological distress. A case-control study was conducted in a Spanish hospital. Cases were women diagnosed with FM, with no signs of any other type of inflammatory rheumatic disorder, who were seen at the Rheumatology Department of the hospital. Controls were women not diagnosed with FM who were seen at the Ear, Nose and Throat Department of the same hospital. A self-administered anonymous questionnaire was used to gather data on sociodemographic characteristics, violence, social support and psychological distress. Uni-, bi- and multivariate logistic regression analyses were conducted; 287 cases and 287 controls were recruited. The multivariate analysis showed that the probability of presenting FM increased with age (odds ratios (OR) = 1.06; CI95% = 1.03-1.09); that employed women and housewives were more likely to have the syndrome than unemployed women or students (OR = 4.97; CI95% = 1.45-17.02, and OR = 3.47; CI95% = 0.98-12.22, respectively); that the lower the educational level, the higher the probability of having FM; and that psychological distress was positively associated with the syndrome (OR = 4.62; CI95% = 2.68-7.97). Although abuse was more prevalent in cases than in controls, the differences were not statistically significant. However, frequency of abuse was positively and significantly correlated with FM. Although the aetiology of FM is still uncertain, it seems that certain psychosocial factors may be associated with the syndrome. Therefore, an interdisciplinary approach to the treatment of patients affected with this syndrome should be considered.

[The protective role of social support and intimate partner violence]. / Apoyo social como factor protector frente a la violencia contra la mujer en la pareja.

OBJECTIVE: To describe the relationship between the presence of social support and overall support from different sources and intimate partner violence in women attending primary care centers irrespective of reason. METHOD: We performed a cross-sectional survey in 1,402 women aged 18 to 65 years old, randomly selected from 23 primary health practices in the autonomous communities of Andalusia, Madrid and Valencia (Spain) in 2003. The information on sociodemographic characteristics, physical, psychological and sexual intimate partner violence, and social support was gathered using an anonymous, self-administered questionnaire. RESULTS: Thirty-two percent of the women stated they had been abused by a partner (physically, psychologically or sexually) at some time in their lives. Women who reported having social support had a 89% lower probability of having been abused by a partner at some time than women who reported not having social support (odds ratio [OR] = 0.11; 95% confidence interval [95%CI]: 0.06-0.20). Among women who reported abuse by a partner in the past, those who stated they had social support had a lower probability of being abused again by a different partner than those who had no social support (OR = 0.14; 95%CI: 0.05-0.37). CONCLUSIONS: The cross-sectional design of this study does not allow us to determine whether lack of social support increases women's vulnerability to being abused, or whether social isolation is a consequence of partner abuse. Nevertheless, interventions in women experiencing abuse by their partners should aim to reestablish their social networks.

[Validation of the short version of the Woman Abuse Screening Tool for use in primary care in Spain]. / Validación de la versión corta del Woman Abuse Screening Tool para su uso en atención primaria en España.

OBJECTIVE: To examine the criterion validity of the Spanish short version of the Woman Abuse Screening Tool (WAST) to identify battered women among those attending primary health care services in Spain. MATERIAL AND METHODS: We performed a cross-sectional study in two primary care centers in Granada. A total of 390 women between 18 and 70 years old were studied. The Index of Spouse Abuse (ISA) was used as the gold standard. RESULTS: Two score criteria were used. Using the first criterion, 132 women (33.8%) scored positively. The sensitivity was 91.4%, specificity was 76.2%, positive predictive value 40.2% and negative predictive value was 98.1%. Five women with a negative WAST score obtained a positive ISA score (false negatives). Seventy-nine women obtained a positive score in the WAST, with a negative score in the ISA (false positives). CONCLUSIONS: These results coincide with the sensitivity and specificity values obtained in the validation of the instrument in Spanish-speaking women in the USA, which also recommend the use of the first criterion. The Spanish short version of the WAST is a suitable instrument to be used by health professionals for the early detection of gender violence in the healthcare context of Spain. However, because of its low specificity, this instrument should be used with caution.

Analysis of the impact of fibromyalgia on quality of life: associated factors.

We analysed the impact of fibromyalgia (FM) on the functional capacity of patients suffering this syndrome and identified factors that are associated with greater disease impact. We performed a cross-sectional descriptive telephone survey on all patients diagnosed with fibromyalgia during 2003 in a university hospital in Spain. Variables studied were socio-demographic, job, clinical, health and psycho-social characteristics of patients diagnosed with FM and impact of FM on them. Disease impact was measured by means of the Fibromyalgia Impact Questionnaire (FIQ). The rest of variables were collected by means of an expressly designed questionnaire. The relation between FIQ score and the other variables was performed with a bivariate analysis, using several tests depending on the variables involved. To analyse the factors associated with greatest disease impact, a multivariate linear regression model was designed. The average FIQ score for the sample was 63.6. Having a larger number of children, being tired and being in a depressed mood were the symptoms that most affected activities of daily living. A diagnosis of any mental illness, reference to repercussion on the family environment, a lower self-rated health and having consulted more specialists before FM diagnosis were associated with a higher impact after adjusting according to all the variables in the model. It can be confirmed that the FIQ is a useful instrument for measuring the impact of FM on quality of life. Identifying factors that determine the extent of its impact will enable more effective therapeutic strategies to be designed.

Methodological issues in the study of violence against women.

The objective of this paper is to review the methodological issues that arise when studying violence against women as a public health problem, focusing on intimate partner violence (IPV), since this is the form of violence that has the greatest consequences at a social and political level. The paper focuses first on the problems of defining what is meant by IPV. Secondly, the paper describes the difficulties in assessing the magnitude of the problem. Obtaining reliable data on this type of violence is a complex task, because of the methodological issues derived from the very nature of the phenomenon, such as the private, intimate context in which this violence often takes place, which means the problem cannot be directly observed. Finally, the paper examines the limitations and bias in research on violence, including the lack of consensus with regard to measuring events that may or may not represent a risk factor for violence against women or the methodological problem related to the type of sampling used in both aetiological and prevalence studies.

Physical health consequences of intimate partner violence in Spanish women.

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.

[Publications on women, health and gender in Spain (1990-2005)]. / Publicaciones sobre mujeres, salud y género en España (1990-2005).

BACKGROUND: The studies on women, gender and health are increasingly more frequent in Spain. This research is aimed at ascertaining the topics dealt with in these publications, the disciplines studying said topics, the sex of the leading author and whether these topics have been approached from a gender-related standpoint. METHODS: A search was conducted for published studies in Biomedicine, Sociology, Nursing, Anthropology and Psychology databases. The main key words used were [women or gender] and [health] and [Spain]. Original articles, reviews and monographic studies, both national and international, published within the 1990-2005 period were included. The variables taken into consideration were the topic of study, field of expertise, gender focus and sex of those publishing the work. A total of 298 works were included. RESULTS: The topics dealt with the most were sexual and reproductive health (39.2%) and mental health (12.4%). A total of 58.7% of the works were authored by a woman as the leading author and 47.3% had no gender focus. A total of 85.3% of the publications on sexual and reproductive health do not incorporate the gender standpoint, whilst 94.1% of the works on productive and reproductive work did however include this standpoint. A total of 80.4% of the works in Biomedicine have no gender focus. CONCLUSIONS: Even though they are scarce, the works having a gender focus are signed mostly by women as the leading authors. In the material studied, women's health continues to be confined to reproduction, it being necessary for other factors having a direct bearing on women's health to be included.

[Questionnaire to evaluate health web sites according to European criteria]. / Cuestionario para evaluar sitios web sanitarios según criterios europeos.

OBJECTIVES: To design a questionnaire to evaluate compliance with quality criteria on health web sites and to analyse its reliability. DESIGN: A descriptive study on the reliability of a questionnaire. PARTICIPANTS: Twenty web sites on health topics. SETTING: Internet. MAIN MEASUREMENTS: The questionnaire was based on analysis of content of the criteria of the e-Europe 2002 code of conduct, comparing these with the criteria underlying the AMA, the Summit code and the e-Health Code of Ethics regulations and current directives. The dimensions studied were transparency, absence of conflicts of interest, authorship, data protection, updating, accountability, and accessibility. A preliminary questionnaire was drawn up for a pilot test conducted by 3 researchers for 20 web sites, its reliability was appraised, adjustments were made and the definitive questionnaire was designed. Reliability was evaluated again for 26 web sites evaluated by 3 researchers. To evaluate concordance in the answers of the participants, Cohen's Kappa index with a 95% confidence level was used. RESULTS: All the quality directives of e-Europe 2002, the European regulations and relevant points from other questionnaires were included in the questionnaire designed. Reliability was acceptable (kappa > or = 0.60) for 12 of the 18 quality criteria included. The least concordant aspects of the questionnaire were information update (kappa = 0.310) and accessibility (search for contents and access for persons with disability). CONCLUSIONS: Reliability of the questionnaire designed was acceptable.

Women's response to intimate partner violence.

The responses of women to a situation of abuse by their partner has hardly been addressed in the literature. Using a self-administered, anonymous questionnaire, 400 women attending three practices in a primary health care center in Granada (Spain) were studied. The women's response to abuse was used as a dependent variable. Sociodemographics, intensity, duration, and combination of the types of abuse were used as independent variables. Lifetime prevalence of any type of partner abuse was 22.8%. Of abused women, 68% showed an active response, attempting to resolve the situation mainly through separation (58.2%). The factors independently associated with a woman's active response were being separated, widowed, or divorced; reporting a greater intensity of abuse; and being younger than age 35 years. The results of this study show that a large majority of abused women in Spain try to resolve their situation, and that they are not passive victims.

Women's autonomy and the evaluation of the information available on the Internet on hormone therapy after menopause.

This study was designed to examine the information in Spanish, provided by different Web sites, related to hormone therapy and climacteric symptoms. Web sites evaluated included those belonging to government and scientific institutions and to a miscellaneous group. In Web sites in Spanish, there was more extensive information on the benefits of hormone therapy than there were on other items. The Web sites of governmental institutions provided significantly more information on the risks (P < .01) and benefits (P = .02) of hormone therapy than did the other sites. Governmental institutions from the United States, unlike those from Spain, did not make recommendations regarding when hormone therapy should be considered and instead emphasized the woman's decision. The variability of information in Spanish on hormone therapy and postmenopausal symptoms presented on the Internet is related to the organization responsible for the Web site. Besides, cultural differences in the concept of patient autonomy could partly explain the differences in emphasis made on women's role in the decision-making process.