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Roberta K. Lee, DrPH, RN, Vetta L. Sanders Thompson, PhD and Mindy B. Mechanic, PhD

Roberta K. Lee is with the Barnes College of Nursing & Health Studies. Vetta L. Sanders Thompson and Mindy B. Mechanic are with the Department of Psychology, University of Missouri, St Louis.

Correspondence: Requests for reprints should be sent to Roberta K. Lee, DrPH, RN, Barnes College of Nursing, University of Missouri, St Louis, 8001 Natural Bridge Rd, StLouis, MO 63121 (e-mail: bobbie_lee{at}umsl.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 

In this commentary, we focus on violence against women of color. Although African American women experience higher rates of intimate partner homicide than White women, the cumulative rates for nonfatal intimate partner violence are similar and do not vary between urban and rural locations (though access to services may vary by location).

Much of the research about intimate partner violence is based on women with low socioeconomic status and on interventions that were developed by and for White women. Current primary prevention strategies focus on violence that is perpetrated by strangers rather than their primary perpetrators—intimate partners.

We recommend the development and rigorous evaluation of prevention strategies that incorporate the views of women of color and attention to primary prevention.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
THE DELETERIOUS IMPACT OF intimate partner violence (IPV) has been documented along a number of health-related dimensions, including acute injuries, somatic health complaints, diminished psychological functioning, and decrements in other social role domains, including occupational, interpersonal, and parental functioning.

Before 1980, there were only a few national studies of IPV in the United States.^1–3 These studies used survey methods that were criticized as biased because of the approaches used to recruit and interview participants. During the 1980s, a national strategic plan for health promotion was released and since 1990, reducing rates of IPV has been an objective. During the 1980s, the number of journal articles about IPV increased, although many studies used small convenience samples of women who either were residents of women's shelters or attended public prenatal clinics. Those studies primarily focused on women in poverty. Recently, after efforts to broaden case finding, studies have been conducted in emergency departments and in the practices of primary care providers; victims of IPV were found in these settings.

Increased attention to IPV during the 1990s resulted in the publication of an integrative review of IPV,⁴ passage of the Violence Against Women Act in 1994, and establishment of a National Advisory Council on Violence Against Women. Currently, we observe unprecedented levels of collaboration and cooperation between federal, state, and local agencies that provide services or funds for research and services to victims of IPV and their families. One of the Healthy People 2010 objectives is to reduce the rate of physical assault by current or former intimate partners.⁵

Coercive control underlies the multidimensional expressions of IPV, which can include physical violence and injuries in the form of homicide; emotional, verbal, or psychological abuse; sexual coercion; rape; and stalking.⁶ Many studies have focused on a single expression of violence, such as physical assault, without examining the interrelationships among various expressions of coercive control.

This commentary provides a review of the epidemiology of IPV, including current prevention efforts. We focus especially on the scope and magnitude of this problem among women of color and their responses to current prevention initiatives. We then suggest areas for further research as well as implications for public health and social policy to reduce the high toll of IPV.

	INTIMATE PARTNER VIOLENCE MORTALITY

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
In the United States, the source for information about IPV mortality is the Federal Bureau of Investigation's Uniform Crime Reporting⁷ and Supplemental Homicide Report programs.⁸ The Uniform Crime Reporting program is estimated to capture information for more than 95% of homicides, and the identity of the perpetrator is known for most IPV cases.⁹ When a woman is murdered, the perpetrator is 5 times more likely to be a spouse or intimate partner than to be a stranger.¹⁰ While IPV homicide rates have declined during the past 20 years, the rate for African American women is more than double that observed for White women.¹¹

	NONFATAL INTIMATE PARTNER VIOLENCE

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
In 1995, using state-of-the-art technology and procedures to protect confidentiality, the US Institute of Justice and the Centers for Disease Control and Prevention collaborated to conduct the National Violence Against Women Survey¹² of the incidence and prevalence of nonfatal violence against women. Because of the design of this survey, these findings are the best current source of information about IPV. Key findings are summarized in Table 1.

Because the National Violence Against Women Survey is based on a probability sample of US telephones, we consider it the best available source of information about IPV. It thus appears that the prevalence of IPV is similar between African American and White women and between urban and rural women. Although data are limited, analysis of IPV in the American Indian community consistently suggests higher rates than those found in other communities. The National Violence Against Women Survey data on rape in Asian/Pacific Islander communities is also consistent in that rates are lower than those found among other ethnic groups; however, rates of physical assault are higher than those reported in general crime statistics.

	STALKING AS A RISK FACTOR FOR SEVERE AND LETHAL VIOLENCE

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
Stalking and morbid jealousy were identified as risk factors for severe and lethal violence in several studies.^14–18 Recent studies have found that severe stalking was associated with more frequent and more severe forms of concurrent partner physical violence, emotional abuse, and physical injuries. Stalking and emotional abuse were both significant predictors of lethal harm. Former partners were more likely than current partners to perpetrate stalking. Women who asked their partners to leave were at high risk of physical violence when their partners refused to leave or threatened to kill them if they left, or if the women themselves left and refused to return. In the National Violence Against Women Survey, White and non-White women experience similar rates of stalking. Among non-White women, American Indians/Alaska Natives report significantly more stalking, although this is based on small numbers, and further research is needed.¹⁹

These compelling data underscore stalking as a critical component of intimate partner abuse that may have implications for battered women's risk of concurrent, future, and lethal violence. The implications of these findings for screening are obvious: stalking should be included in risk assessments routinely conducted on battered women.

	HEALTH CONSEQUENCES OF INTIMATE PARTNER VIOLENCE

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
Many studies of IPV document a variety of chronic somatic and physical health complaints and disproportionate use of primary health care services.^20–25 The health care costs alone associated with IPV are estimated to be $67 billion (1993 dollars) per year.²⁶ Diminished physical health, poor health care behaviors, and increased use of harmful tension reduction behaviors have been unequivocally demonstrated as consequences of IPV. Several studies of violence-related acute injuries among women presenting to hospital emergency departments and clinics have been published.^27–31 In case–control studies of IPV resulting in injury (with half of these cases being African Americans), increased risk of injury was associated with partners who were alcohol or drug users, were unemployed, had less than a high school education, had prior arrests, or were former or estranged partners. When the violence was perpetrated by a former partner, the risk of injury increased 3.5-fold; when the woman was living with the former partner, the risk was 8.9 times greater.

Of women injured by IPV, fewer than half sought care for the injury. African American³² and American Indian^33,34 women have been reported to experience more severe injuries and to more often have weapons used against them³⁵; African American and Hispanic women reportedly experience greater mental health consequences.^36,37

Hispanic women seek medical services but not at the time of the assault,³⁸ or they present with general complaints; few voluntarily disclose the abuse or recall being asked about it by providers. Reportedly, Hispanic, Asian, and American Indian women prefer medical and other service providers to ask directly about IPV.^39,40 Because of the opportunity for case finding and referrals, efforts have been made to improve detection in emergency and health services.⁴¹

Few studies examine IPV in rural communities.⁴² Although higher rates for women of color have been reported, the samples were very small. Further research comparing rural communities and rural communities of color is needed.

	INTIMATE PARTNER VIOLENCE AND PREGNANCY

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
The literature on IPV during pregnancy^43–48 is voluminous and allows comparisons among many racial/ethnic groups of women. Recent integrative reviews^49,50 have found that these studies generally produce mixed results, with most reporting lower rates of IPV during pregnancy among Hispanics.^51,52 In another study, Cuban and Central American women reported lower rates of IPV during pregnancy, while Puerto Rican and African American women reported higher rates.⁵³ The literature on abuse during pregnancy has not sufficiently addressed Asian or American Indian women.

	CULTURAL CONTEXT AND PERCEPTIONS

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
The experience of IPV is shaped by the social and cultural context of a woman's life.^54,55 This context is a powerful lens through which the experience of IPV is viewed and interpreted. It also shapes perceptions of the viability of various options for responding to IPV. The most consistent finding according to current data is that context varies by race/ethnicity.⁵⁶

Contextual factors include potential for retaliation by the abuser, available economic resources, potential for child abuse, personal emotional strengths, and perception of available social support. Racial/ethnic communities have different cultural norms regarding intimate partner roles, the acceptability of IPV, the importance of the family as an intact unit, and the appropriateness of seeking community services. Decisions about how, whether, and in what manner to respond to IPV are strongly influenced by beliefs and expectations about the impact of those choices on the woman, her children, and her extended community. While our information about IPV in communities of color or rural areas is limited, even fewer studies evaluate the service needs and preferences of communities of color.^57,58

	PREVENTION, INTERVENTION, AND IPV SERVICES

TOP ABSTRACT INTRODUCTION INTIMATE PARTNER VIOLENCE... NONFATAL INTIMATE PARTNER... STALKING AS A RISK... HEALTH CONSEQUENCES OF INTIMATE... INTIMATE PARTNER VIOLENCE AND... CULTURAL CONTEXT AND PERCEPTIONS PREVENTION, INTERVENTION, AND... References

 
In the United States, there is an enormous array of IPV services.^59,60 These include shelters for women and their children, legal measures such as orders of protection and court interventions, establishment of specialized family violence police teams using IPV policing strategies,^61,62 advocacy services, psychological and social service counseling, and others.^63,64 Evaluations of these services and their effectiveness are emerging in the literature.^65–67 Findings suggest that different types of IPV require different types of services; short-term counseling services are often desired and seem to provide at least some benefit, and postshelter services may provide some benefits and assist women who do not wish to return to abusive relationships. Longer follow-up and a greater variety of programs and program components must be evaluated.

There are few rigorous intervention studies that include women of color.^68–70 Most existing IPV studies are largely qualitative and involve small convenience samples. Knowledge of cultural, social, and economic influences on help-seeking patterns suggests that when negative outcomes are expected to result from accessing traditional sources of help—such as contacting the police or going to a battered woman's shelter—or from the loss of social support (or from blame) related to leaving the abusive partner, women's choices about intervention are affected. In addition, cultural and social context may influence the timing, sequencing, and presentation of services offered in communities of color.

Ethnic differences in the source of aid that is sought have been noted.^71–73 Perhaps because of language barriers, Hispanic women are more isolated than African American and European American women in terms of seeking help. Hispanic women reportedly are least likely to contact a friend or a social service agency in response to IPV. Contrary to what has been noted with IPV, African American women are less likely than their White counterparts to report instances of rape to anyone. White women are more likely than ethnic minority women to call a psychotherapist or lawyer. Several studies note cultural issues that are associated with Asian women's degree of willingness to leave abusive relationships; cultural prescriptions for what makes a "good wife" and rigid gender roles that contribute to male dominance are noted.^74–77 Among Asian women, the support of elders may be important in assisting a woman to leave or to cope with a violent relationship.

In terms of shelter services, a model program designed for women of Mexican descent⁷⁸ was bilingual and included counseling, transportation, legal services, and assistance with job training. African American women wanted appropriate food and grooming aids and reported a need for more material and financial support.⁷⁷ The ability to accommodate larger families, language barriers, and citizenship requirements have also been noted as issues among women of color.

In 1995, in response to an evaluation,³⁴ the Department of Justice began funding STOP Violence Against Women Grants in American Indian/Alaska Native communities.⁷⁹ These initiatives allow, among other things, a focus on traditional spirituality and culture as a part of the healing process and a way to reclaim one's identity and strength.

Perhaps because of the potential for serious physical harm and the limitations of our self-report measures, physical violence has received significantly more research attention than other forms of abuse. More inclusive measurement of multiple expressions of IPV is evident in recent IPV studies that find that emotional and sexual abuse can be as deleterious as physical injuries.^80–82 More thorough understanding of the nature and impact of IPV demands the inclusion of multiple dimensions of IPV and measures that account for cultural and ethnic variation in the experience, meaning, and impact of partner violence on women's lives.

It is clear that research on IPV among women of color is sparse. Evidence about the impact of programs in general—and on women of color in particular—is needed. There is a significant need to improve communication and collaboration between researchers, and community service providers, and governmental agencies.^83,84 We note the absence of a cost–benefit appraisal of one of the very common IPV program strategies—orders of protection—and the relative absence of programs that focus on reducing IPV but potentially retaining the relationship.⁸⁵ We urgently need data on emerging issues such as effects on child witnesses and concurrent child abuse,^86,87 specific treatment and intervention needs not only for women but also for their abusers,^88,89 and culturally specific program evaluation. Finally, there is a significant need to focus on primary prevention.⁹⁰

	Footnotes

 
Peer Reviewed

Accepted for publication November 29, 2001.

	References

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