Cumulative lifetime violence, social determinants of health, and cannabis use disorder post-cannabis legalization in a community sample of men: An intersectional perspective.

Despite Canada having the highest disease burden globally for cannabis use disorder (CUD) and violence being ubiquitous in men's lives, little is known about how intersections among social determinants of health (SDOH) and cumulative lifetime violence severity (CLVS) influence CUD in men post-cannabis legalization. Using data collected in a survey with a national community sample of 597 men who self-identified as having experienced violence, we conducted a latent profile analysis using 11 subscales of the CLVS-44 scale and explored differential associations between CLVS profiles and CUD considering SDOH covariates. Four profiles were distinguished by intersections among CLVS-44 subscale severity and roles as target and perpetrator. CLVS profiles were significantly associated with CUD in the unadjusted model and in the adjusted model where age, adverse housing, and education were significant covariate controls. In the adjusted model, CUD was differentially associated with CLVS profiles and significantly higher in Profile 4 (highest severity target and perpetrator) than in Profile 1 (lowest severity target, no perpetration). Chi-square tests showed significant intersection between adverse housing, younger age, Profile 4 CLVS, and moderate to severe CUD among cannabis users. These results reveal the importance of understanding simultaneous intersections among indicators of CLVS in determining profiles of lifetime violence. Also critical are intersections among CLVS profiles and significant covariates as a basis for trauma- and violence-informed care for CUD that prioritizes men most disadvantaged by this convergence and attends to individual and structural health disparities at practice and policy levels.

Cumulative lifetime violence severity, social determinants and anxiety in a national sample of Canadian men.

BACKGROUND: Despite anxiety disorders being the ninth leading cause of disability and associated with social inequities, little attention has been given to how intersections among social determinants of health and chronic stressors such as cumulative lifetime violence affect the likelihood of experiencing anxiety disorders. Our purpose was to explore the relationships among cumulative lifetime violence severity as target and perpetrator, social determinants of health and generalized anxiety disorder in Canadian men. METHODS: Using a community sample of 592 Canadian men who self-identified as having experienced violence, we developed and tested an evidence-based model of generalized anxiety disorder including indicators of cumulative lifetime violence, gender, social location, socio-economic disparity, personal resources and other chronic stressors using logistic regression. RESULTS: Most men (76.4%, n = 452) reported experiences as both target and perpetrator. The model accounted for 50.8% of the variance in anxiety severity χ2 (8) = 264.43, p = .000). The prevalence of probable generalized anxiety disorder was 30.9%, a rate higher than that found among Canadian men in general in the same period. Remarkably, the likelihood of generalized anxiety disorder increased by a factor of 5.30 for each increase of 1 in cumulative lifetime violence severity, and six-fold for feeling overwhelmed by demands of everyday life (aOR = 6.26). Masculine discrepancy stress, having been born in Canada, unemployment, and food insecurity also contributed significantly to increasing the likelihood of generalized anxiety disorder. Both social support and mastery had significant aORs < 1, suggesting possible protective effects. Together these findings delineate characteristics and social determinants that may heighten vulnerability to generalized anxiety disorder and influence its progression among men who have experienced lifetime violence. CONCLUSIONS: These findings are the first evidence that Canadian men with lifetime violence histories are a sub-group disproportionately affected by chronic stressors and socio-economic disparities and that together the presence and/or severity of these factors increases their vulnerability to generalized anxiety disorder. Our results highlight the importance of strengths-based trauma- and violence-informed approaches to care, including practical resources to reduce the stress of everyday life, improve social support, and reinforce personal control and choice.

Cumulative Lifetime Violence Severity and Chronic Pain in a Community Sample of Canadian Men.

OBJECTIVE: To create a descriptive profile of chronic pain severity in men with lifetime cumulative violence histories, as a target and/or a perpetrator, and investigate how chronic pain severity is associated with and predicted by lifetime cumulative violence severity and known determinants of chronic pain. METHODS: Analysis of variance and binary logistic regression were performed on data collected in an online survey with a community convenience sample of 653 men who reported experiences of lifetime violence. RESULTS: The prevalence of high-intensity / high-disability pain in men with lifetime violence was 35.8%. Total Cumulative Lifetime Violence Severity-44 (CLVS-44) scores were significantly associated with high-intensity / high-disability chronic pain measured by the Chronic Pain Grade Scale (odds ratio= 8.40). In a model with 10 CLVS-44 subscale scores, only psychological workplace violence as a target (adjusted odds ratio [aOR]= 1.44) and lifetime family physical violence as a target (aOR= 1.42) significantly predicted chronic pain severity. In a multivariate model, chronic pain severity was predicted by CLVS-44 total score (aOR= 2.69), age (aOR= 1.02), injury with temporary impairment (aOR= 1.99), number of chronic conditions (aOR= 1.37), and depressive symptoms (aOR= 1.03). CONCLUSION: The association between lifetime cumulative violence severity and chronic pain severity in men is important new information suggesting the need for trauma- and violence-informed approaches to assessment and intervention with men. This is the first analysis using CLVS-44 subscales to understand which configurations of lifetime cumulative violence may be most predictive of chronic pain severity; further investigation is needed to confirm these findings.

Cumulative lifetime violence severity scale: development and initial testing among men.

BACKGROUND: Knowledge of the relationship between men's health and violence is flawed by narrow and faulty conceptualization and measurement of violence that often results in attribution of health problems to one form or type of violence without consideration of other exposures. Our purpose is to describe the development and initial testing of the Cumulative Lifetime Violence Severity scale designed for use in health research to measure men's perceptions of the severity of their cumulative lifetime violence. METHODS: We framed the dimensions of violence severity as: type (physical, psychological, sexual), timing (childhood, adulthood), focus (perpetrator, target), context, frequency, and degree of distress. Items reflecting these dimensions were vetted by local experts including individuals who identified as men, with particular attention to meaningful language for men. The measure was pretested, revised to 64 items, and tested for test-retest reliability prior to use in a study of 685 English-speaking Eastern Canadian men, ages 19 to 65 years. We used Principal Components Analysis to illuminate the underlying dimensionality of the items. RESULTS: Principal Components Analysis yielded a 44-item 11 component solution that accounted for 64.06% of variance with good model fit and a Cronbach's alpha of .92. All dimensions of our conceptualization of violence severity were reflected in the components, except Adult Target Sexual Violence. Convergent validity between the Cumulative Lifetime Violence Severity-44 Scale and a global lifetime violence rating scale was r = .750 (p < .001) and concurrent validity was moderate and significant between the Cumulative Lifetime Violence Severity-44 scale and measures of mental health problems commonly experienced by people with violence histories. CONCLUSIONS: The Cumulative Lifetime Violence Severity-44 scale shows promise as the first comprehensive measure of cumulative lifetime violence for health research that considers gender, individual distress and experiences as both perpetrator and target. Next steps include further exploratory analysis with a more diverse sample of men and confirmatory factor analysis.

Longitudinal impacts of an online safety and health intervention for women experiencing intimate partner violence: randomized controlled trial.

BACKGROUND: Responding to intimate partner violence (IPV) and its consequences is made complex by women's diverse needs, priorities and contexts. Tailored online IPV interventions that account for differences among women have potential to reduce barriers to support and improve key outcomes. METHODS: Double blind randomized controlled trial of 462 Canadian adult women who experienced recent IPV randomly were assigned to receive either a tailored, interactive online safety and health intervention (iCAN Plan 4 Safety) or a static, non-tailored version of this tool. Primary (depressive symptoms, PTSD symptoms) and secondary (helpfulness of safety actions, confidence in safety planning, mastery, social support, experiences of coercive control, and decisional conflict) outcomes were measured at baseline and 3, 6, and 12 months later via online surveys. Generalized Estimating Equations were used to test for differences in outcomes by study arm. Differential effects of the tailored intervention for 4 strata of women were examined using effect sizes. Exit survey process evaluation data were analyzed using descriptive statistics, t-tests and conventional content analysis. RESULTS: Women in both tailored and non-tailored groups improved over time on primary outcomes of depression (p < .001) and PTSD (p < .001) and on all secondary outcomes. Changes over time did not differ by study arm. Women in both groups reported high levels of benefit, safety and accessibility of the online interventions, with low risk of harm, although those completing the tailored intervention were more positive about fit and helpfulness. Importantly, the tailored intervention had greater positive effects for 4 groups of women, those: with children under 18 living at home; reporting more severe violence; living in medium-sized and large urban centers; and not living with a partner. CONCLUSION: This trial extends evidence about the effectiveness of online safety and health interventions for women experiencing IPV to Canadian women and provides a contextualized understanding about intervention processes and effects useful for future refinement and scale up. The differential effects of the tailored intervention found for specific subgroups support the importance of attending to diverse contexts and needs. iCAN is a promising intervention that can complement resources available to Canadian women experiencing IPV. TRIAL REGISTRATION: Clinicaltrials.gov ID NCT02258841 (Prospectively Registered on Oct 2, 2014).

Modeling lifetime abuse and cardiovascular disease risk among women.

BACKGROUND: Cardiovascular disease (CVD) is one of the most significant health challenges facing women today. Abuse is a serious gendered issue also affecting the health of women. Despite beginning evidence that abuse may increase the risk of CVD among women, causal pathways linking abuse to CVD have received little attention. Our purpose was to test Scott-Storey's conceptual model showing direct and indirect pathways through which lifetime abuse severity may affect women's CVD risk. METHODS: Using data collected from a community sample of 227 Canadian women who had left an abusive partner, we conducted structural equation modeling with latent growth curve analysis using a phantom variable approach to test the direct effects of severity of lifetime abuse on CVD risk (indicated by measures of systolic and diastolic blood pressure) as well as its indirect effects through CVD risk behaviors and through women's initial level of depressive symptoms and the observed rate of change in their depressive symptoms over time. RESULTS: Women in this sample had above average CVD risk factors (i.e., smoking, overweight/obesity, depressive symptoms, high blood pressure) in comparison to women in the general population. Further, CVD risk behaviors increased with severity of lifetime abuse and remained present long after leaving the abusive relationship. Results of the tested model provide preliminary evidence supporting many of the hypothesized pathways by which severity of lifetime abuse can increase CVD risk among women; the model fit the data reasonably well explaining 41% of the variance in CVD risk. CONCLUSIONS: Findings support the growing recognition of the long-term effects of lifetime abuse on cardiovascular health, suggest important implications for clinicians working with women, and provide a novel approach for studying the concept of cumulative lifetime abuse through the use of a phantom variable.

A tailored online safety and health intervention for women experiencing intimate partner violence: the iCAN Plan 4 Safety randomized controlled trial protocol.

BACKGROUND: Intimate partner violence (IPV) threatens the safety and health of women worldwide. Safety planning is a widely recommended, evidence-based intervention for women experiencing IPV, yet fewer than 1 in 5 Canadian women access safety planning through domestic violence services. Rural, Indigenous, racialized, and immigrant women, those who prioritize their privacy, and/or women who have partners other than men, face unique safety risks and access barriers. Online IPV interventions tailored to the unique features of women's lives, and to maximize choice and control, have potential to reduce access barriers, and improve fit and inclusiveness, maximizing effectiveness of these interventions for diverse groups. METHODS/DESIGN: In this double blind randomized controlled trial, 450 Canadian women who have experienced IPV in the previous 6 months will be randomized to either a tailored, interactive online safety and health intervention (iCAN Plan 4 Safety) or general online safety information (usual care). iCAN engages women in activities designed to increase their awareness of safety risks, reflect on their plans for their relationships and priorities, and create a personalize action plan of strategies and resources for addressing their safety and health concerns. Self-reported outcome measures will be collected at baseline and 3, 6, and 12 months post-baseline. Primary outcomes are depressive symptoms (Center for Epidemiological Studies Depression Scale, Revised) and PTSD Symptoms (PTSD Checklist, Civilian Version). Secondary outcomes include helpful safety actions, safety planning self-efficacy, mastery, and decisional conflict. In-depth qualitative interviews with approximately 60 women who have completed the trial and website utilization data will be used to explore women's engagement with the intervention and processes of change. DISCUSSION: This trial will contribute timely evidence about the effectiveness of online safety and health interventions appropriate for diverse life contexts. If effective, iCAN could be readily adopted by health and social services and/or accessed by women to work through options independently. This study will produce contextualized knowledge about how women engage with the intervention; its strengths and weaknesses; whether specific groups benefit more than others; and the processes explaining any positive outcomes. Such information is critical for effective scale up of any complex intervention. TRIAL REGISTRATION: Clinicaltrials.gov ID NCT02258841 (Registered on Oct 2, 2014).

The process, outcomes, and challenges of feasibility studies conducted in partnership with stakeholders: a health intervention for women survivors of intimate partner violence.

Feasibility studies play a crucial role in determining whether complex, community-based interventions should be subject to efficacy testing. Reports of such studies often focus on efficacy potential but less often examine other elements of feasibility, such as acceptance by clients and professionals, practicality, and system integration, which are critical to decisions for proceeding with controlled efficacy testing. Although stakeholder partnership in feasibility studies is widely suggested to facilitate the research process, strengthen relevance, and increase knowledge transfer, little is written about how this occurs or its consequences and outcomes. We began to address these gaps in knowledge in a feasibility study of a health intervention for women survivors of intimate partner violence (IPV) conducted in partnership with policy, community and practitioner stakeholders. We employed a mixed-method design, combining a single-group, pre-post intervention study with 52 survivors of IPV, of whom 42 completed data collection, with chart review data and interviews of 18 purposefully sampled participants and all 9 interventionists. We assessed intervention feasibility in terms of acceptability, demand, practicality, implementation, adaptation, integration, and efficacy potential. Our findings demonstrate the scope of knowledge attainable when diverse elements of feasibility are considered, as well as the benefits and challenges of partnership. The implications of diverse perspectives on knowledge transfer are discussed. Our findings show the importance of examining elements of feasibility for complex community-based health interventions as a basis for determining whether controlled intervention efficacy testing is justified and for refining both the intervention and the research design.

Cumulative Effects of Multiple Forms of Violence and Abuse on Women.

Little is known about how patterns of workplace bullying contribute to the negative effects of lifetime violence. Analysis of longitudinal data from a study of women's health after separating from an abusive partner revealed that 76% of 229 women had experienced workplace bullying. Workplace bullying was associated with child sexual abuse, adult sexual assault, and ongoing partner abuse. Timing was critical, with those experiencing past workplace bullying having poorer health and fewer personal and social resources than those experiencing none, ongoing, or past and ongoing bullying. Lifetime sexual harassment (54%) was associated with higher posttraumatic stress disorder symptomology and greater likelihood of leaving workplaces and physical bullying (16%) with poorer health and personal, social, and economic resources. These findings highlight the importance of including bullying in studying lifetime violence.

Prevalence and characteristics of sexual functioning among sexually experienced middle to late adolescents.

INTRODUCTION: Little is known about problems in sexual functioning among young people, despite the high rates found in adult samples. It is unclear which problems are most prevalent or how common sexual distress is for young people experiencing problems. AIMS: This study aims to assess the prevalence, range, and correlates of sexual problems and distress among a sample of adolescents (16-21 years). METHODS: Participants (mean age 19.2) were recruited from community and area high schools. Male adolescents (n = 114) completed online the International Index of Erectile Function (IIEF) and Premature Ejaculation Diagnostic Tool (PEDT). Female adolescents (n = 144) completed the Female Sexual Function Index (FSFI). Both completed the Female Sexual Distress Scale (FSDS) and the measures of background, relationship characteristics, and sexual histories. MAIN OUTCOMES MEASURES: Clinical cutoff scores on the IIEF, PEDT, FSFI, and FSDS were used to determine whether there was a significant sexual problem. RESULTS: Adolescents reported extensive sexual experience, most in relationship contexts. Half of the sample (51.1%) reported a sexual problem; 50.0% reported clinically significant levels of distress associated with it. Similar rates of problems and distress were found among male and female adolescents. For the most part, adolescent characteristics, backgrounds, and experience were not associated with adolescents' sexual problems. CONCLUSION: Sexual problems are clearly prevalent among adolescents, and distressing to many who experience them, emphasizing a strong need to develop programs to address this issue.

Cumulative Lifetime Violence, Gender, Social Determinants of Health and Mental Health in Canadian Men: A Latent Class Analysis.

Purpose: Among men, violence is pervasive and associated with poor mental health, but little is known about which men are most vulnerable. Our purpose is to address this gap by exploring mental health and social determinants of health (SDOH) including gender role conflict (GRC) in heterogenous groups of men with distinct patterns of cumulative lifetime violence (CLV) as target and perpetrator. Methods: Latent class analysis was conducted using means of 64 indicators of CLV severity collected from a community sample of 685 eastern Canadian men, ages 19 to 65 years. Class differences by SDOH, and depression, anxiety, and posttraumatic stress disorder (PTSD) were explored with Chi-square and analysis of variance. Results: A 4-class solution was optimal. Class 1 had the lowest CLV severity; were more likely to be better educated, employed, and have little difficulty living on their incomes; and had better mental health than other classes. Class 2, characterized by moderate psychological violence as both target and perpetrator, had mean depression and PTSD scores at clinical levels, and more difficulty living on income than Class 1. Classes 3 and 4 were typified by high severity CLV as target but differentiated by Class 4 having the highest perpetration severity, higher GRC, and being older. In both classes, mean mental health scores were above cut-offs for clinical symptomology and higher than Classes 1 and 2. Conclusion: This is the first evidence that distinct patterns of CLV severity among men intersect with GRC and SDOH and are uniquely associated with mental health.

Cumulative Lifetime Violence, Gender Role Conflict, and Cardiovascular Disease Risk in Eastern Canadian Men.

Despite violence being a chronic stressor that negatively affects health through allostatic overload and potentially harmful coping behaviors, the relationship between cumulative lifetime violence severity (CLVS) and cardiovascular disease (CVD) risk in men has received little attention and the role of gender has not been considered. Using survey and health assessment data from a community sample of 177 of eastern Canadian men with CLVS as target and/or perpetrator, we developed a profile of CVD risk measured by the Framingham 30-year risk score. We tested the hypothesis that CLVS measured by the CLVS-44 scale has direct and specific indirect effects through gender role conflict (GRC) on 30-year CVD risk using parallel multiple mediation analysis. Overall, the full sample had 30-year risk scores 1.5 times higher than their age-based Framingham reference normal risk scores. Men classified as having elevated 30-year CVD risk (n = 77) had risk scores 1.7 times higher than reference normal. Although the direct effects of CLVS on 30-year CVD risk were not significant, indirect effects of CLVS through GRC, specifically Restrictive Affectionate Behavior Between Men, were significant. These novel results reinforce the critical role of chronic toxic stress, particularly from CLVS but also from GRC, in influencing CVD risk. Our findings highlight the need for providers to consider CLVS and GRC as potential antecedents to CVD and to routinely use trauma- and violence-informed approaches in the care of men.

Trajectories of Depression, Post-Traumatic Stress, and Chronic Pain Among Women Who Have Separated From an Abusive Partner: A Longitudinal Analysis.

This longitudinal study explored changes in women's health after separation from an abusive partner by characterizing the trajectories of their mental health (depression and post-traumatic stress disorder [PTSD]) and physical health (chronic pain) over a 4-year period. We examined how the severity of intimate partner violence (IPV) affected these trajectories, controlling for selected baseline factors using 5 waves of data collected from a community sample of 309 English-speaking, Canadian women. IPV severity was measured using the Index of Spouse Abuse where women were asked to consider the entire period of their partner relationship up to present at wave 1 and to rate their IPV experiences in the previous 12 months at waves 2-5. Mental health was measured using established self-report measures of depression (CESD) and PTSD (Davidson Trauma Scale), while chronic pain was measured using the Chronic Pain Grade Scale. Trajectories were estimated using MLM techniques with severity of IPV and selected co-variates (time since separation, age, financial strain) included. Our results show that women's health improved significantly over time, although significant levels of depression, PTSD symptoms and disabling chronic pain remained at the end of wave 5. Regardless of time since separation, more severe IPV was associated with higher levels of depression, PTSD, and disabling chronic pain, with IPV having a stronger effect on these health outcomes over time, suggesting cumulative effects of IPV on health. The results of this study contribute to quantifying the continuing mental and physical health burdens experienced by women after separation from an abusive partner. Increased attention to the long-term effects of violence on women's health beyond the crisis of leaving is critically needed to strengthen health and social services and better support women's recovery and healing.

Modeling the effects of past relationship and obligation on changes in the health and health promotion of women caregivers of family members with dementia.

Wuest's (1998, 2001) caregiving theory was tested with 282 women self-identified as caregivers of family members with dementia to examine how quality of past relationship within caregiving dyads and sense of obligation to care affected their health outcomes and health promotion over 9 months, using latent growth curve analysis. The model explained 62% of the variance in women's health (Time 4). Health was affected positively by past relationship and negatively by obligation. Health promotion was positively affected by health (Time 1) and by obligation. Change observed in health promotion was nonlinear and positively affected health (Time 4). Findings suggest past relationship and obligation to care predict health outcomes for caregivers and that interventions to increase caregivers' health promotion may improve health outcomes.

Are we there yet? Positioning qualitative research differently.

Almost two decades ago, Janice Morse launched this conference, and QHR as a venue for qualitative health research scholarship. The health research climate was then resistant to qualitative research methods. Qualitative scholars portrayed the rigor of their work in traditional scientific language and justified qualitative approaches in opposition to quantitative approaches. Emphasis on difference expanded as we embraced paradigm debates and argued about location of particular research approaches. Increasingly, I have been challenged to reconsider the boundaries between and among research methods and paradigms as I struggled to answer my most pressing emerging questions. The focus of this presentation is consideration of how the position of qualitative research has shifted over the past 20 years. Based on my program of women's health research, I will discuss the appeal and pitfalls of concrete distinctions, the challenges of flexibility and convergence, and the necessity of moving beyond difference toward a complete research toolbox that is useful for improving health.

Reflections on methodological approaches and conceptual contributions in a program of caregiving research: development and testing of Wuest's theory of family caregiving.

Caregiving by family members, particularly women, is a societal expectation that is intensifying in the context of an aging population and health care restructuring. Our program of caregiving research spans two decades, moving from inductive theory development using grounded theory methods to deductive theory testing. In this article, we reflect on the serendipitous development of this program of research methodologically and conceptually. We summarize the key conceptual contributions that the program has made to caregiving knowledge, particularly with respect to the past relationship between care recipient and caregiver, obligation to care, caregiver agency, and relationships between caregivers and the health care system.

Attributing selected costs to intimate partner violence in a sample of women who have left abusive partners: a social determinants of health approach.

Selected costs associated with intimate partner violence were estimated for a community sample of 309 Canadian women who left abusive male partners on average 20 months previously. Total annual estimated costs of selected public- and private-sector expenditures attributable to violence were $13,162.39 per woman. This translates to a national annual cost of $6.9 billion for women aged 19­65 who have left abusive partners; $3.1 billion for those experiencing violence within the past three years. Results indicate that costs continue long after leaving, and call for recognition in policy that leaving does not coincide with ending violence.

The Mental Health Effects of Cumulative Lifetime Violence in Men: Disruptions in the Capacity to Connect with Others and Finding Ways to Reengage.

We report qualitative findings of our Men's Violence Gender and Health Study, a multiple method study using a sequential design in which we explored the mental health manifestations of cumulative lifetime violence in men. Survey results revealed that higher cumulative lifetime violence scores were significantly associated with higher scores on depression, post-traumatic stress disorder, and anxiety in a community sample of men (n = 685) living in Eastern Canada. To obtain a deeper understanding of men's scores, we used an interpretive description approach to analyze data derived from 32 participant interviews. The main mental health manifestation of cumulative lifetime violence is perceptual interference, a sense of being disconnected or detached from others. This is managed by rectifying detachment, a process that includes efforts to gain connections with others. Findings suggest mental health needs in men with cumulative lifetime violence contradict gender role expectations to be stoic. Implications for nurses are explored.

A theoretical understanding of sickness absence among women who have experienced workplace bullying.

Historically, we have assumed that workplaces, where employed individuals spend approximately one third of their days, provide safe and supportive environments and opportunities to enhance women's capacities. Unfortunately, workplace bullying and consequent sickness absence are prevalent and costly realities that significantly influence women's health. In this study, sickness absence among 18 Canadian women who were targets of workplace bullying was explored using a grounded theory secondary analysis. Findings show that although sickness absence is critical in attenuating the health consequences of being bullied, it is a partial solution because rehabilitation and successful return to work is challenged when working conditions remain unchanged. This problem is addressed using is a three-stage process of discerning a path that involves gaining space, making sense, and moving forward. Organizational support is critical to all stages of the process; it can reduce the risk of declines in health and sickness absence, and is essential for successful return to work.

Workplace bullying in health care affects the meaning of work.

Our purpose in this grounded theory study was to explore the impact of workplace bullying (WPB) on women working in health care. We analyzed interviews with 21 women, professionals and nonprofessionals. The women experienced a change in their meaning of work (MOW) when they had experienced WPB, and they addressed this change through a process we called the shifting meaning of work. This process has three stages. The first, developing insight, involves recognizing causes of changed MOW as external. In the second stage, resisting, women defend against changed MOW by sustaining acceptable MOW and work performances, and by confronting causes. In the final stage, rebuilding, women try to adapt and modify approaches to work by coming to terms, adjusting work attitudes, and investing in self. We identified implications of this process for managing health and work issues with women, health care providers, and employers.