Rosalind J' Wright, M'D', M'P'H'

1
Violence Across the Life Course and Womens
Health A Growing Public Health Agenda

• Rosalind J. Wright, M.D., M.P.H.
• Assistant Professor in Medicine
• Harvard Medical School
• Channing Laboratory
• Brigham and Womens Hospital
• Department of Society, Human Development and
  Health
• Harvard School of Public Health
• Boston, MA

2
Scope of the Problem
3
U.S. Statistics- Physical and Sexual Assaults by
Intimates

• 1.5 million women, 835,000 men per year (physical
  assault or rape) includes hetero or same-sex
  relationships
• 25-35 lifetime prevalence (women)
• 7.6 lifetime prevalence (men)

4
U.S. Statistics

• 1 in 7 (15) seen in primary care
• 1 in 9 women seen in ED
• 1 in 2 (54) lifetime prevalence in women seen in
  ED
• One in four women who attempt suicide
• One in twelve women who are pregnant
• More than half of the mothers of abused children

5
Violence and Pregnancy

• Violence during pregnancy may be more common
  than
• Gestational diabetes
• Neural tube defects
• Preeclampsia
• i.e., conditions for which pregnant women are
  routinely screened
• 48 of women report violence during pregnancy

6
Rate of intimate partner violence to women, by
annual household income,National Crime
Victimization Survey, 1993-98
US Department of Justice, 2000
7
Adverse Childhood Experiences (ACE) Study

• Felitti mid-1980s, obesity clinic at KP SD
• Unexpected observation successes were
  dropping out those losing most weight
• Overeating and overweight were often coping
  strategies stemming from adverse childhood
  experiences
• Led to ACE study at KP and CDC
• N17000 in first wave

8
ACE Exposures Studied

• Personal abuse
• Physical abuse
• Contact sexual abuse
• Psychological abuse
• Household dysfunction
• Violence against mother
• Substance abuse in household member
• Mental illness/suicidality in household member
• Household member ever in prison

9
ACE - Findings

• Abuse
• Psychological (by parents) 11
• Physical (by parents) 11
• Sexual (by anyone) 22
• Household Dysfunction
• Violence against mother 13

10
Health Impact

• Behavioral/Psychological
• sleep disturbances
• drug/alcohol abuse
• smoking
• chronic pain / somatization disorders
• anxiety, panic
• depression
• post-traumatic stress
• dissociation during medical procedures
• suicidal ideation or attempts

• Physical
• acute injury
• chronic sequelae of injury
• headaches
• abdominal pain/IBD
• pelvic pain
• recurrent STDs
• eating disorders
• musculoskeletal complaints
• asthma

11
Effects on Children

• 3.3 to 10 million children per year witness DV
• Developmental regression
• Fear, anxiety, depression, PTSD
• Impairment in social/emotional development
• Impairment in learning
• Risk of bystander victimization
• Risk of future victimization (dating, adult
  relationships)

12
Definition

• A pattern of purposeful coercive behaviors used
  in the context of dating or intimate
  relationships
• Adapted from Ganley A. Understanding Domestic
  Violence, Family Violence Prevention Fund, 1998

13
Definition

• Any act of gender-based violence that results
  in, or is likely to result in, physical, sexual
  or psychological harm or suffering to women,
  including threats of violence, coercion or
  arbitrary deprivation of liberty, whether
  occurring in public or private life.

14
Power Control
15
Psychoneuroimmunology Mind-Body Connections
Webster, Tonnelli and Sternberg 2002
16
What is Stress?

• Stress results when there is a threat to our
  well-being
• Stress happens when things feel beyond our
  control
• AND
• We attempt to cope and respond to defend
  ourselves from that threat

Stress
17
Violence Across the Life Course and Health
18
NHS2 Violence Questionnaire

• Violence questionnaire mailed to 91,297
• nurses across the US
• 68,518 responses (75)
• Follow-up 98 response rate in 2003

19
Domains of the Violence Questionnaire

• Prevalence of exposure to violence
• Associations of violence characteristics with
  disease risk
• physical, sexual, emotional
• developmental stage
• severity
• cumulative experience

20
Measuring Childhood and Teen Violence

• Measures
• Childhood Trauma Questionnaire
• Conflict Tactics Scale
• Sexual Abuse
• Lifestage childhood vs. adolescence
• Type physical, sexual, emotional
• Severity
• Physical None, Mild, Moderate, and Severe
• Sexual None, Touched, Forced
• Frequency None, once, more than once

21
Measuring Adult Violence

• Measures
• Emotional abuse
• Physical abuse
• Sexual abuse
• Womens Experiences of Battering Scale (WEB)
• Stalking (NVAW Survey)

22
Abuse Severity/Chronicity

• Mild Physical Abuse
• Push/shove any frequency or hit/kick/punch once
  or hit with something that hurt once
• Moderate Physical Abuse
• Hit with something that hurt a few or more times
  of physically attacked in some other way once
• Severe Physical Abuse
• Hit/kick/punch a few or more times, choke or burn
  any frequency, or physically attack in some other
  way a few or more times

23
(No Transcript)
24
Validation vs. Antidepressant Use Severity of
Physical Abuse in Childhood/Adolescence
25
Validation vs. Antidepressant Use Timing of
Physical Abuse in Childhood/Adolescence
26
(No Transcript)
27
Validation vs. Antidepressant Use Type of
Violence in Childhood/Adolescence
28
(No Transcript)
29
Validation vs. Antidepressant Use Childhood
Trauma Questionnaire
30
Smoking Initiation
31
OR of Smoking Onset at Age 13-14 by Childhood
Trauma Questionnaire
32
OR of Smoking Onset at Age 13-14 by Feeling
Special
33
Current Smoking
34
WEB Scale
My partner makes me feel unsafe even in my own
home I feel ashamed of the things my partner
does to me I try not to rock the boat because I
am afraid of what my partner might do I feel
like I am programmed to react a certain way to my
partner I feel like my partner keeps me prisoner
My partner makes me feel like I have no control
over my life, no power, no protection I hide
the truth from others because I am afraid not to
I feel owned and controlled by my partner My
partner can scare me without laying a hand on me
My partner has a look that goes straight through
me and terrifies me
35
OR of Current Smoking by WEB Score
36
Age at Menarche
37
Childhood abuse and age at menarche
38
Childhood abuse and age at menarche
39
Childhood abuse and age at menarche
40
Obesity
41
Growing Up Today Study (1996-2003)

• Prospective study of adolescent girls and boys in
  U.S. begun in 1996 and ongoing
• Children of nurses participating in the Nurses
  Health Study II
• 9039 girls and 7843 boys at baseline
• Aged 9 to 14 years at enrollment
• 96 white race/ethnicity
• GUTS mothers (1997, 1999)

42
Aim Hypothesis

• Aim To examine BMI trajectories through
  adolescence into early adulthood (ages 9 to 20)
  who differ in exposure to household intimate
  partner violence (IPV) reported by their mother
• Hypothesis Subjects exposed to household IPV in
  earlier childhood would differ in their
  developmental trajectories of BMI compared to
  those who were not exposed

43
Outcome and Predictor

• Outcome BMIs at ages 9 to 20
• Predictor Exposure to inter-parental violence
• Mothers retrospective report on intimate partner
  abuse since age 18
• Linked to the childs birth year and created
  exposure to inter-parental violence between ages
  0-17
• Onset at ages 0-5, 6-11, or 12-17 years old

44
Covariates

• Maternal factors
• Maternal BMI at age 18
• diabetes in pregnancy
• birth weight
• Infant factors
• Breast feeding
• duration of breast feeding
• Introduce solid foods (4 months)

45
Covariates (continued)

• Demographic variables
• Age at baseline (1996)
• Race (white and others vs. black and Hispanic)
• Child factors
• Age at menarche (girls)
• TV viewing time at baseline
• Psychosocial factors
• Household Income (2001)
• Family dinner together (1996,97,98)

46
4 BMI Trajectories Classes

• Normal growth (reference group)
• Normal to Obese
• Steady overweight
• High Obese

47
(No Transcript)
48
Multinomial Logistic Regression Results Boys (OR
and 95 CI)
49
Multinomial Logistic Regression Results Girls
(OR and 95 CI)
50
Adult Onset Asthma
51
RR of Adult Onset Asthma by Childhood Trauma
Multivariate RR adjusted for race/ethnicity,
parental smoking in early childhood, social
support in childhood, participant smoking, BMI at
age 18, husbands occupation, mental health index
from SF36, ETV in adulthood (ever/never).
52
Early Onset Asthma
53
DV and Early Childhood Asthma
54
DV and Asthma Influence of Mother-Child
Interactions
55
Violence and Pulmonary Function
56
(No Transcript)
57
Cardiovascular Risk
58
Association of Childhood Trauma Questionnaire
with metabolic disturbances in adult women
Hypertension Hyperlipidemia Type 2 diabetes
Odds ratio of outcome
Childhood Trauma Score
59
Associations of Child/Adolescent Abuse with CVD
events
60
Leaving and Mental Health
61
Poor mental health and WEB Score
62
Collaborative Response
Medical Community
Social Services

Shelters
Trauma/ IPV
Employers
Friends
Judges Legal Professionals
Policy Makers
Educators