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.

Reclaiming Our Spirits: Development and Pilot Testing of a Health Promotion Intervention for Indigenous Women Who Have Experienced Intimate Partner Violence.

Indigenous women are subjected to high rates of multiple forms of violence, including intimate partner violence (IPV), in the context of ongoing colonization and neo-colonization. Health promotion interventions for women who experience violence have not been tailored specifically for Indigenous women. Reclaiming Our Spirits (ROS) is a health promotion intervention designed for Indigenous women living in an urban context in Canada. In this paper, we describe the development of the intervention, results of a pilot study, and the revised subsequent intervention. Building on a theory-based health promotion intervention (iHEAL) showing promising results in feasibility studies, ROS was developed using a series of related approaches including (a) guidance from Indigenous women with research expertise specific to IPV and Indigenous women's experiences; (b) articulation of an Indigenous lens, including using Cree (one of the largest Indigenous language groups in North America) concepts to identify key aspects; and (c) interviews with Elders (n = 10) living in the study setting. Offered over 6-8 months, ROS consists of a Circle, led by an Indigenous Elder, and 1:1 visits with a Registered Nurse, focused on six areas for health promotion derived from previous research. Pilot testing with Indigenous women (n = 21) produced signs of improvement in most measures of health from pre- to post-intervention. Women found the pilot intervention acceptable and helpful but also offered valuable suggestions for improvement. A revised intervention, with greater structure within the Circle and nurses with stronger knowledge of Indigenous women's experience and community health, is currently undergoing testing. © 2017 Wiley Periodicals, Inc.

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.

A theory-based primary health care intervention for women who have left abusive partners.

Although intimate partner violence is a significant global health problem, few tested interventions have been designed to improve women's health and quality of life, particularly beyond the crisis of leaving. The Intervention for Health Enhancement After Leaving is a comprehensive, trauma informed, primary health care intervention, which builds on the grounded theory Strengthening Capacity to Limit Intrusion and other research findings. Delivered by a nurse and a domestic violence advocate working collaboratively with women through 6 components (safeguarding, managing basics, managing symptoms, cautious connecting, renewing self, and regenerating family), this promising intervention is in the early phases of testing.

Daughters' obligation to care in the context of past abuse.

Using theoretical sampling, we extended a previous grounded theory study of women's caring through interviews with 16 women currently giving care to parents who had abused them as children to more fully understand daughters' obligation to care in the context of past abuse. Past relationship was characterized by emotional distance, "never being good enough," degradation, control, and unpredictability. Obligation to care was grounded not only in duty to others but also in duty to self. Caregiving was seen as an opportunity for validation and reconciliation. These findings advance knowledge by illuminating how survivors of child maltreatment become caregivers for their abusers.

Pathways of chronic pain in survivors of intimate partner violence.

OBJECTIVE: To examine the roles of lifetime abuse-related injury, posttraumatic stress disorder (PTSD) symptom severity, and depressive symptom severity in mediating the effects of severity of assaultive intimate partner violence (IPV), psychological IPV, and child abuse on chronic pain severity in women survivors of IPV. METHODS: Structural equation modeling of data from a community sample of 309 women survivors of IPV was used to test partial and full theoretical models of the relationships among the variables of interest. RESULTS: The full model had good fit and accounted for 40.2% of the variance in chronic pain severity. Abuse-related injury, PTSD symptom severity, and depressive symptom severity significantly mediated the relationship between child abuse severity and chronic pain severity, but only abuse-related injury significantly mediated the relationship between assaultive IPV severity and chronic pain severity. Psychological IPV severity was the only abuse variable with significant direct effects on chronic pain severity but had no significant indirect effects. CONCLUSIONS: These findings can inform clinical care of women with chronic pain in all areas of healthcare delivery by reinforcing the importance of assessing for a history of child abuse and IPV. Moreover, they highlight the relevance of routinely assessing for abuse-related injury and PTSD and depressive symptom severity when working with women who report chronic pain.

Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence.

OBJECTIVE: To examine the role of abuse-related injury and posttraumatic stress disorder (PTSD) symptom severity in mediating the effects of assaultive intimate partner violence (IPV) severity, psychological IPV severity, and child abuse severity on chronic pain severity in women survivors of IPV. METHODS: Using data collected from a community sample of 309 women survivors of IPV, structural equation modeling was used to test a theoretical model of the relationships among the key variables. RESULTS: The theoretical model accounted for almost 38% of the variance in chronic pain severity. PTSD symptom severity was a significant mediator of the relationships of both child abuse severity (beta = 0.13) and assaultive IPV severity (beta = 0.06) with chronic pain severity. Lifetime abuse-related injury was also a significant mediator of the relationships between both child abuse severity (beta = 0.05) and assaultive IPV severity (beta = 0.06) and chronic pain severity. Child abuse severity made the largest significant contribution to the model (beta = 0.35). Assaultive IPV severity had a significant indirect effect (beta = 0.12) on chronic pain severity while psychological IPV severity had a significant direct effect (beta = 0.20). CONCLUSIONS: Management of chronic pain in IPV survivors requires attention to symptoms of PTSD, abuse-related injury, and lifetime experiences of violence. Ensuring that acute pain from injury is adequately treated and followed over time may reduce the extent of chronic pain in abused women. The results also support the importance of routine assessment for IPV and child abuse.

Modelling the effects of intimate partner violence and access to resources on women's health in the early years after leaving an abusive partner.

Although the negative health effects of intimate partner violence (IPV) are well documented, little is known about the mechanisms or determinants of health outcomes for women who had left their abusive partners. Using data collected from a community sample of 309 Canadian women who left an abusive partner, we examined whether women's personal, social and economic resources mediate the relationships between the severity of past IPV and current health using structural equation modelling. A good fit was found between the model and data for hypothesized models of mental and physical health. In the mental health model, both the direct and total indirect effects of IPV were significant. In the physical health model, the direct effect of IPV on physical health was about four times as large as the total indirect effects. In both models, more severe past IPV was associated with lower health and women's personal, social, and economic resources, when combined, mediated the relationship between IPV and health. These findings demonstrate that the health outcomes of IPV for women who have left an abusive partner must be understood in context of women's resources.

Chronic pain in women survivors of intimate partner violence.

UNLABELLED: In this descriptive study of chronic pain in a community sample of 292 women who had separated from their abusive partners on average 20 months previously, more than one-third experienced high disability pain as measured by Von Korff's Chronic Pain Grade. Beyond the usual pain locations associated with abuse, 43.2% reported swollen/painful joints. More interference in daily life was attributed to joint pain than to back, head, stomach, pelvic or bowel pain. Women with high disability pain were more likely to have experienced child abuse, adult sexual assault, more severe spousal abuse, lifetime abuse-related injuries, symptoms of depression and post-traumatic stress disorder, lifetime suicide attempts, difficulty sleeping, and unemployment. High disability pain also was associated with visits to a family doctor and psychiatrist and use of medication in more than prescribed dosages. Less than 25% of women with high disability pain were taking opioids, or prescription nonsteroidal anti-inflammatory medications. Interestingly, high disability pain was not related to smoking, use of street drugs, potential for alcohol dependence, age, income, or education. The findings add to knowledge of severity and patterns of chronic pain in abused women and support the need for further multivariate analysis of the relationships among abuse experiences, mental health, and chronic pain severity to better inform decisions regarding diagnosis and treatment. PERSPECTIVE: Understanding patterns of chronic pain in abuse survivors and their associations with abuse history, mental health symptoms, health service use, and medication is important for clinical assessment and intervention. Chronic pain persisted long after leaving abusive partners and extended beyond usual locations (back, headache, pelvic, gastrointestinal) to include swollen/painful joints.

The effects of past relationship and obligation on health and health promotion in women caregivers of adult family members.

The social expectation that women will care for family members persists despite evidence that many women have difficult or abusive past relationships with their parents and partners. Little is known about how past relationship influences the health of women caring for adult family members. On the basis of earlier grounded theory research, we tested the theory that past relationship and obligation predict health outcomes and health promotion in 236 women caregivers of adult family members. Structural equation modeling demonstrated support for the theory, with 56% of the variance in health outcomes and 11% of the variance in health promotion accounted for by the model.

Patterns of medication use among women survivors of intimate partner violence.

OBJECTIVE: Our objective was to describe patterns of medication use in a convenience sample of 309 women with a history of intimate partner violence (IPV) participating in a study of women's health after leaving an abusive partner (WHES). METHODS: Using data collected through interviews and health assessments, frequencies of past-month use of medications; abuse experienced, health problems and medical diagnoses; and selected demographics were calculated. Associations among abuse history, employment status, health problems, diagnoses, and medications were explored. Comparisons of rates of medication use in women in the WHES and the Canadian Community Health Survey (CCHS) 2.1 were calculated. FINDINGS: Almost half of participants were taking pain and/or psychotropic medications, with almost one third taking antidepressants. Child abuse history, adult sexual assault history and unemployment were associated with taking psychotropic medications. Overall rates of medication use were similar to those of Canadian women of similar age in the CCHS 2.1. However, women in the WHES were more likely to be taking antidepressants, anxiolytics and inhalants, and less likely to be taking oral contraceptives, over-the counter (OTC) pain relievers, and OTC cough and cold medications. CONCLUSION: The pattern of medication use in women who have experienced IPV differs from that in the general population. The complex associations found among health problems, employment, diagnoses, and medication use highlight the need to consider treatment patterns within the context of the impact of lifetime abuse, economic survival, and parenting demands. Medication use must be understood as only one of a range of health interventions available to assist abused women to promote their health.

Using grounded theory to generate a theoretical understanding of the effects of child custody policy on women's health promotion in the context of intimate partner violence.

Women's health is frequently influenced by social and structural factors, largely beyond women's control, and often entrenched in public policy. Although health is acknowledged to be socially determined, the ways that social conditions affect health are rarely explicated. Grounded theory is a useful method for discovering how structural conditions influence patterns of behavior. We used grounded theory to generate a theoretical understanding of how justice system policy and services related to child custody influence health promotion processes of women and their children after leaving abusive male partners/fathers. In two diverse Canadian provinces, we interviewed single mothers who had left abusive partners as well as frontline workers and policymakers in the justice system. We identified the key dimensions of policy and services that influence the ways in which women and their children promote their health in the context of varying levels of ongoing intrusion as information, eligibility, accessibility, timeliness, human resources, safety, and diversity. In this article, the interplay between theses policy and service dimensions and women's health promotion after leaving abusive partners is discussed and suggestions are made for strengthening "healthy" custody policy.

Strengthening capacity to limit intrusion: theorizing family health promotion in the aftermath of woman abuse.

Children's health is a key factor in women's decisions to leave abusive partners, yet how these families promote their health after leaving is poorly understood. In this feminist grounded theory study, the authors conducted repeat interviews with 40 single-parent families that had left abusive partners/fathers and analyzed the data using constant comparative methods. Findings reveal the central problem faced by families is intrusion, unwanted interference in everyday life that stems from abuse and its fallout. Over time, families promote their health through the basic social process of strengthening capacity to limit intrusion via four subprocesses: providing, regenerating family, renewing self, and rebuilding security. Depending on the degree of intrusion, the focus strengthening capacity shifts between practical goals of surviving and more proactive efforts directed toward positioning for the future. This theory adds to our knowledge of the long-term consequences of IPV for families and provides direction for practice and policy.

Regenerating family: strengthening the emotional health of mothers and children in the context of intimate partner violence.

Although concern for their children's well-being is pivotal in mothers' decisions to leave abusive partners, rarely is lone-parent family life after leaving framed as beneficial for family members' emotional health. In this feminist grounded theory study of family health promotion in the aftermath of intimate partner violence, we learned that families strengthen their emotional health by purposefully replacing previously destructive patterns of interaction with predictable, supportive ways of getting along in a process called regenerating family. These findings add to our knowledge of family development and how families promote their health when they have experienced intimate partner violence.

Intrusion: the central problem for family health promotion among children and single mothers after leaving an abusive partner.

Like other single-parent families, those consisting of mothers and their children who leave abusive partners/fathers are broadly viewed a deficient, high-risk structures in which children are susceptible to multiple problems. The mechanisms of strength and vulnerability in these families are poorly understood, and, consequently, their health promotion processes remain virtually unexplored. In a feminist grounded theory study of health promotion processes of single-parent families after leaving abusive partners/fathers, the authors discovered intrusion to be the basic social problem as families strive to promote health in the aftermath of abuse. The authors discuss the complex nature of intrusion, demonstrating how health is socially determined, and the challenges of health promotion in terms of the issues and dilemmas faced by study families and consider implications for health promotion knowledge and practice.

Illuminating social determinants of women's health using grounded theory.

Emphasis in health policy has shifted from curative intervention to prevention and health promotion through personal responsibility for lifestyle choices and, most recently, to the social determination of health. These shifts draw attention to and legitimize women's health research that moves beyond biomedical, epidemiological, and subjective knowledge to question previously unquestioned societal norms and structures that influence women's health. The challenge is to avoid relying solely on population-based studies that support relationships between social determinants and indicators of women's health and to find ways to illuminate the processes by which social determinants interact with the health of specific groups of women. Without such research, our knowledge of how social factors that underpin women's health interact will be faceless and will not address the interplay of health and social policy within women's lives. One research method that may be useful for exploring the interplay between such policies and women's health is grounded theory. Grounded theory is a widely used approach in women's health research. The goal of grounded theory is the discovery of dominant social and structural processes that account for most of the variation in behavior in a particular situation. Despite the usefulness of this method for capturing the interaction between social conditions and women's health experiences, many grounded theory researchers restrict themselves to women's subjective experiences as a source of data for theory development. Consequently, the resultant theory's capacity to illuminate the effects of the social determinants of health is limited. The purpose of this article is to discuss how the grounded theory method can be used in a participatory way to theoretically sample structural conditions at many levels. Using examples from completed and ongoing women's health research where data have and have not been collected primarily from women themselves, we outline the benefits and process for using grounded theory to influence health and public policy in women's health.