Domestic Violence and Emotional Distress Among Nicaraguan Women

Domestic Violence and Emotional Distress Among Nicaraguan Women Results From a Population-Based Study Mary Ellsberg

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Trinidad Caldera and Andres Herrera Anna Winkvist and Gunnar Kullgren

This study aimed to measure the prevalence of emotional distress among women in Leon, Nicaragua, and to identify risk factors for emotional distress, with special reference to wife abuse. A survey was performed among a representative sample of women aged 15-49. Among ever-married women, 20% were classified as experiencing emotional distress at the time of the interview, and 52% reported physical partner abuse at some point in their lives. Women reporting abuse were 6 times more likely to experience emotional distress. An estimated 70% of all cases of emotional distress found among ever-married women were attributable to wife abuse. The study underscores the need to improve screening and care for battered women within mental health services in Nicaragua.

D

omestic violence is becoming widely recognized internationally as a serious public health problem with grave implications for the physical and psychological well-being of women and children. Although there is still a scarcity of population-based research in many countries, available research indicates that from 20%-50% of women in most countries have experienced spousal abuse at least once in their lives (Heise, Raikes, Watts, & Zwi, 1994). Domestic violence has been cited as a major risk factor for a broad range of adverse health outcomes, including injuries and mortality due to trauma (Grisso, Schwarz, Miles, & Holmes, 1996), low birth weight (Bullock & McFarlane, 1989), gynecological disorders (Schei & Bakketeig, 1989), and sexually transmitted diseases, including HIV/AIDS (Handwerker, 1993). In particular, the effects of domestic violence on women's mental health have been well-documented (Koss, 1990; Walker, 1979). Research on suicidality among women suggests that battering may be the single most important cause of female suicidality, particularly among Black and pregnant women (Stark & Flitcraft, 1996). Victims of intimate partner violence often exhibit a variety of symptoms, including cognitive disturbances, high avoidance or depression behaviors, and high arousal or anxiety disturbances, which have 30

Umed University and Autonomous University of Nicaragua—Leon Autonomous University of Nicaragua—Leon Umed University

been conceptualized as battered woman syndrome, and which meet the diagnostic criteria for post-traumatic stress disorder (National Research Council, 1996; Walker, 1994). One of the weaknesses of existing research on the links between domestic violence and women's mental health is that the majority of studies on domestic violence have been performed on nonrepresentative samples of women, usually convenience samples of women seeking help for abuse or mental health problems (Sorenson & Saftlas, 1994). Because this information is based on women who have sought help, it does not necessarily present a full picture of those women who do not seek help, either for domestic violence or mental distress. Epidemiological research in the field of mental health has consistently found gender differentials in the prevalence of a variety of psychiatric disorders. A primary example is depression, which is a major threat to health and one of the most common psychiatric disorders at the community level. Sex differences have been well-documented, with point prevalence, 12-month prevalence, and lifetime prevalence of major depression all found with greater frequency in women than in men (Culbertson, 1997; McGrath,

Mary Ellsberg, Department of Epidemiology and Public Health, Umea University, Umea, Sweden, and Department of Preventive Medicine, Autonomous University of Nicaragua—Leon, Leon, Nicaragua; Trinidad Caldera, Department of Psychiatry, Autonomous University of Nicaragua—Leon, Leon, Nicaragua; Andres Herrera, Department of Preventive Medicine, Autonomous University of Nicaragua—Leon, Leon, Nicaragua; Anna Winkvist, Department of Epidemiology and Public Health, Umea University, Umea, Sweden; Gunnar Kullgren, Department of Psychiatry, Umea University, Umea, Sweden. The research for this study was carried out with financial support from Umea University, Gruppo Voluntariado Civile, and the Swedish International Development Cooperation Agency (Sida). We gratefully acknowledge the valuable comments on earlier versions of the article, by Jerker Liljestrand, Hans Stenlund, Lori Heise, and Rodolfo Pefia, as well as the technical collaboration of the Reproductive and Child Health and Mental Health Projects of Autonomous University of Nicaragua—Leon/ Umea University funded by Sida and the Swedish Agency for Research Cooperation with Developing Countries. Correspondence concerning this article should be addressed to Mary Ellsberg, who is now at the Center for Health and Gender Equity, 6930 Carroll Avenue, Suite 910, Takoma Park, MD 20912. Electronic mail may be sent to [email protected].

January 1999 • American Psychologist Copyright 1999 by the American Psychological Association, Inc. 0003-066X/99/S2.00 Vol. 54, No. 1, 30-36


Keita, Strickland, & Russo, 1990; Nolen-Hoeksema, 1990; Weissman, Bland, & Joyce, 1993). A variety of factors have been cited as possible causes of depression, including poverty, poor working conditions, and lack of control over one's life (Brown & Harris, 1978; Kessler, McGonagle, & Zhao, 1994; Link, Lennon, & Dohrenwend, 1993). Among married women, some commonly cited risk factors for depression include role restriction, boredom, lack of economic power, low job autonomy, number of children at home, inability to communicate with the spouse, and marital discord (Lowe & Northcott, 1988; Weissman et al., 1993). To date, population-based research on mental health has not explored the extent to which domestic violence may contribute to the gender differentials in depression. Therefore, epidemiological research is needed in order to establish the effects of domestic violence on women's mental health at a community level and to determine how much domestic violence contributes to the overall prevalence of emotional distress among adult women.

The driving force behind the antiviolence movement is the Network of Women Against Violence, which brings together over 150 different groups throughout the country. The network carries out yearly public awareness campaigns against violence and has organized other activities such as a national conference on violence and educational materials for women living in violence situations. Largely as a result of the efforts of these groups, domestic violence has been identified as a key issue affecting women in Nicaragua (Ellsberg, Liljestrand, & Winkvist, 1997). The present study represents the first population-based epidemiological research on domestic violence and mental health in Nicaragua. The study had the following aims: (a) to measure the prevalence of emotional distress among women aged 15-49 and (b) to identify risk factors associated with emotional distress in women, with specific reference to physical spousal abuse.

Domestic Violence in Nicaragua

The study was carried out in the municipality of Leon, the second largest urban center in Nicaragua, with approximately 195,000 inhabitants, including urban and rural populations. A cross-sectional survey was carried out, using a representative subsample taken from a cluster sample frame used for a household survey on reproductive and child health in 1993 by the University of Leon and Umea University (Pena, Zelaya, Liljestrand, Dahlblom, & Persson, 1995). Sampling techniques are described in detail elsewhere (Ellsberg, Pena, Herrera, Liljestrand, & Winkvist, in press). The subsample included 566 women between the ages of 15 and 49, out of which it was possible to locate and interview 488 women. The remaining 78 women had either left the country or had moved without leaving forwarding addresses. No woman refused to be interviewed, although in one instance the husband of a woman refused to allow her to be interviewed in his absence, and this interview was suspended. A standardized questionnaire was used to collect information regarding demographic and socioeconomic characteristics, emotional distress, and information regarding experiences of physical spousal violence. Emotional distress was measured using a personal health survey (PHS) developed by a team of Nicaraguan and international mental health experts to detect a variety of mental health problems, including depression, anxiety, and trauma (Mezzich, Caldera, & Berganza, 1994). The PHS was developed to provide a screening tool for detecting mental health problems in a primary-care setting and has demonstrated high construct validity and reliability. The 10-item PHS is based on the 30-item Self-Reporting Questionnaire and was developed as a result of experiences with the latter in Nicaragua (Caldera, Kullgren, Penayo, & Jacobsson, 1995; Penayo, Caldera, & Jacobsson, 1992; Penayo, Kullgren, & Caldera, 1990). The PHS is scored on a 3-point subscale that measures the frequency of symptoms experienced during the last month (0 = rarely, 1 = sometimes, 2 = almost always; see Figure 1). Six items on the scale refer to somatic and psychological affective complaints (insomnia, fright, nervousness, sadness, tired-

In Nicaragua, violence against women has only been widely recognized as a significant social problem in recent years. The Sandinista revolution of the 1980s created many opportunities for women, but failed to make substantial progress in overcoming the culture of "machismo" in Nicaragua. Women still experience a high degree of subordination in economic, legal, and social spheres (Babb, 1996). The use of violence by husbands against wives for the purpose of punishment or "correction" is widely accepted, and many women view violence as an expected part of life, referring to it as yet another "cross to bear." Furthermore, the experience of a prolonged war in Nicaragua that involved most of the population in one way or another has contributed to a high tolerance in general for the use of violence for the resolution of conflicts. Finally, Nicaragua is currently in a stage of political and economic transition, which has led to high rates of unemployment and growing frustration, which seems to be associated with an overall increase in social violence. Paradoxically, Dona Violeta Chamorro's conservative government, which took over in 1990 with the aim of bringing back traditional family values and roles for women, was met by an explosion in the number and breadth of women's organizations, collectives, and alternative health centers promoting women's rights (Kampwirth, 1996; Wessel & Campbell, 1997). There are "Women's Houses" in nearly every major city that provide women with legal, health, and psychological assistance. Many other organizations carry out educational activities, such as legal literacy courses for community women in order to provide better support for women living with violence and violence-prevention activities for men. A new initiative has also been established in several major cities, called the Comisarias de la Mujer y la Ninez, or the Police Stations for Women and Children. The Comisarias are a joint effort between the Governmental Nicaraguan Women's Institute, the National Police, and the alternative women's centers to improve women's access to the justice system. January 1999 • American Psychologist

Method

31

Figure 1 The Personal Health Scale (Mezzich, Caldera, & Berganza, 1994)


How often have you experienced each of the following in the last month? O=Rarely 1 = Sometimes 2=Almost always 1. Have you had difficulty falling asleep? 2. Have you felt frightened or alarmed?

3.

Have you felt nervous or tense?

4. 5. 6. 7. 8. 9.

Have you felt sad? Have you had trouble enjoying daily activities? Have you felt tired? Have you been missing or not doing your work well? Have you had difficulty relating to your family? Have you had difficulty relating to friends and neighbors? Have you felt you had emotional problems and

10.

needed professional help? Note. From "Psychiatric Diagnosis in Primary Care and the Personal Health Scale" byJ. E. Mezzich, J. T. Caldera, and C. E. Berganza in Past, Present, and Future of Psychiatry: IX World Congress of Psychiatry, by A. Beigal, I. Lopez, and J. A. Costa e Silva (Eds.), 1994, Singapore, World Scientific Publishing. Copyright 1994 by World Scientific Publishing. Reprinted with permission.

ness, and indifference). Three items refer to functional problems (difficulties with work, family, or social relations), and a final item is a global self-evaluation, "Have you felt you had emotional problems and needed professional help?" The cut-off point for determining emotional distress was 9 points out of a possible 20 points. Women who reported having been married or in common-law union at some point in their lives were asked about experiences of physical spousal abuse. Spousal abuse was measured using the physical aggression scale of the Conflict Tactics Scales (CTS; Straus, 1979), which lists eight acts of physical aggression in order of severity, ranging from throwing objects to the use of a weapon. The CTS is used to measure current (within the last 12 months) and lifetime prevalence of physical violence, as well as severity of abuse and frequency during the previous year. Three additional incidents representing acts of verbal aggression (yelling, humiliating, threatening to hit) were included to encourage disclosure of violence, but these were not scored. A woman was considered to have experienced spousal abuse if she had experienced one or more acts of physical violence in her life on the part of a male partner with whom she was currently intimate or had been intimate. Women were also asked whether their husbands prohibited or controlled their possibilities to carry out six everyday activities (visit family or friends, receive visits, work outside the home, study, or use contraceptives). Women with children were questioned regarding behavioral, emotional, or learning problems among their children 32

and whether any of them had been physically, emotionally, or sexually abused. Finally, all women were asked about their access to social support in the form of friends, confidants, family support, and instrumental support (someone to lend money or lodging in case of need). Socioeconomic status was assessed using the method of unsatisfied basic needs, which measures family access to a series of basic services such as sanitation, education, and housing, as well as economic dependency. This method has been adapted and used for socioeconomic research in Nicaragua (Renzi & Agurto, 1998; Zelaya et al., 1996). Women living in households where one or more basic needs were unsatisfied were classified as poor. Field work was carried out between April 1995 and June 1995. All interviews were carried out in the homes of the informants by trained female interviewers. Interviews were performed in complete privacy, with special care taken to ensure the safety of both respondents and field workers. Women who reported emotional problems were offered referrals for free care at the university-run mental health clinic. The PHS was administered after the introductory questions on demographic characteristics and before discussing spousal abuse. Data were analyzed using EPI Info 6.04 (1997) software for univariate analysis, and multivariate logistic regression analysis was carried out using the Statistical Package for Social Sciences, Version 7.0 (SPSS, 1996). Population attributable risk percents were calculated as ([proportion exposed among all cases] X [relative risk — l]/relative risk). The initial results of the survey were analyzed in focus group discussions with local women activists as well as with the field workers themselves in order to contribute to the interpretation of the data.

Results Prevalence of Emotional Distress A description of the 488 women interviewed is presented in Table 1 and compared according to marital experience. The characteristics of the women with regard to educational attainment, poverty, and age groups are similar to national figures (Profamilia, 1993). The women who reported never having been married (n = 128) were significantly younger and had more years of schooling than women who had been married or in a common-law union at least once (p < .001). Out of the whole sample of women between 15 and 49 years of age, 17% scored above the cut-off point for emotional distress. When comparing ever-married with nevermarried women, the prevalence of emotional distress was 20% and 10%, respectively (p < .01).

Domestic Violence and Emotional Distress Among ever-married women of childbearing age, 52% reported having experienced violence by a spouse or intimate partner at least once in their lives, whereas 27% reported violence within the last 12 months. Of those women reporting violence, 70% had experienced acts classified as severe (including kicks, punches, beating up, blows with an object, threats, or use of a weapon). Women January 1999 • American Psychologist

Table 1 Description of the Total Sample of Women Ages 15-49 % women 15-49 (N = 488)

N

% ever-married womei (n = 360)

N

% never-married women [n = 128)

N

Age 15-24 25-34 35-49

42 31 27

204 153 131

26 39 35

94 139 127

86 11 3

110 14 4

Education None Primary (complete or incomplete) Secondary (complete or incomplete)

8 39 53

40 189 259

9 45 46

31 163 166

7 20 73

9 26 93

82 18

401 82

82 18

294 66

84 16

107 21

21 79 17

105 383 84

20 80 20

71 289 71

26 74 10

33 95 13

Variable


7rtn^

Urban Rural Poverty Not poor Poor Emotional distress Note.

Selections of women are grouped according 1to whether they have ever been married or in a common-law union.

with emotional distress were six times more likely to report lifetime spousal violence compared with women who scored below the cut-off point for emotional distress (odds ratio [OR] = 6.1; 3.1 < OR < 11.9). In comparisons of emotional distress among evermarried women according to the characteristics of abuse, women who had received severe abuse during, the last year

were more than 10 times more likely to experience emotional distress than women who had never experienced abuse (see Figure 2). Severity of abuse appeared to be a greater predictor of distress than the time period in which the abuse had taken place, because women who had experienced severe violence more than a year earlier presented more cases of emotional distress than women who had

Figure 2 Associations Between Wife Abuse and Emotional Distress Emotional distress (%) 20

30 1

40 1—

Crude Odds 50 Ratio __, (95% Cl)

No violence n = 172

1.0

Former moderate n = 27

2.3 (0.7 - 7.8)

Current moderate /7=19

3.6(1.0-12.0)

Former severe n = 64 Current severe n = 78

4.8(2.2-10.8)

27% 144%

10.3(4.9-21.6)

Note. The proportion of women experiencing emotional distress is presented, according to their experiences of wife abuse. Additionally, crude odds ratios with the corresponding 95% confidence intervals (CIs) indicate the risk of experiencing emotional distress for the different subgroups of women, compared with women in the "no violence" subgroup (n = 360 ever-married women).

January 1999 • American Psychologist

33

experienced acts of moderate violence during the previous year.


Associations Between Background Factors and Emotional Distress Multivariate logistic regression analysis was used to test the association between different background factors and the risk of emotional distress among all women interviewed (n = 488). No associations were found between emotional distress and age, educational attainment, urban-rural zone, poverty, or number of children. Although current marital status was not associated with emotional distress, women who had been married or in common-law union were significantly more likely to experience current emotional distress than women who had never been married (OR = 2.17; 1.12 < OR < 4.30). The association between emotional distress and marriage became even stronger when the model was adjusted for age and education (OR = 2.7; 1.3 < OR < 5.7). However, when spousal abuse was introduced into the model, marital status was no longer significantly associated with emotional distress. When ever-married women (n = 360) were analyzed separately for factors related to emotional distress, no associations were found between age, educational attainment, urban-rural zone, current marital status, poverty, number of children, lack of a friend or confidant, and the risk of emotional distress. However, in addition to higher levels of

spousal abuse, women reporting emotional distress were more likely to lack social networks in the form of instrumental and family support, to experience greater marital control, and to report that their children were suffering from physical, sexual, or emotional abuse. Furthermore, these women were significantly more likely to have experienced violence previously from someone other than an intimate partner and to report a history of spousal violence in either the wife's or her husband's family (see Figure 3). When these variables were analyzed together using multivariate logistic regression, only the association between spousal abuse and emotional distress remained highly significant (OR = 6.6; 2.5 < OR < 17.4), whereas all other associations became nonsignificant (95% confidence interval including 1.0). By calculating the proportion of emotional distress attributable to domestic violence, it was estimated that 70% of all cases of current emotional distress among evermarried women were explained by current or former experiences of wife abuse.

Discussion Emotional Distress and Spousal Abuse in the Community Our findings indicate that physical spousal abuse significantly increased the risk of emotional distress among the

Figure 3 Risk Factors for Emotional Distress Among Nicaraguan Women Emotional distress (%)

c

10

20

30

40

SO

I

I

I

I

i

Spousal violence Marital control8

no yes no

Crude Odds Ratio (95% Cl)

I 7% 6.1 (3.1 -11.9) 12%

yes Lack of social support1*

no yes

Child abuse0

no yes

Previous violence

14% 3.1 (1.5-6.3) 15%

3.0(1.7-5.6)

"I 16%

no

2.9(1.6-5.1)

yes Violence in wife's family

no yes

Violence in husband's family

no yes

ii

• 25%

2.5(1.4-4.6)

i j t% 2.9(1.6-5.0)

Note. Percentages of women suffering emotional distress are presented relative to the presence or absence of the above-mentioned conditions. Crude odds ratios with the corresponding 95% confidence intervals (CIs) indicate the risk of emotional distress for women with the condition, relative to women without the condition (univariate analysis; n = 360 ever-married women), "women who report that their partner prohibits them from carrying out one or more out of six possible activities (work, study, receive visits, visit family, visit friends, use contraceptives); bwomen reporting not having family and instrumental support; Svomen who report that their children have been physically, sexually, or emotionally abused by someone in the family.

34



women participating in the study, and further, it was found to be the single most important risk factor predicting emotional distress. Because the study population is similar to women of childbearing age throughout Nicaragua, at least on the Pacific Coast, it seems likely that wife abuse may account for as much as 70% of the total burden of mental health problems among adult women in Nicaragua. Marriage was also significantly associated with emotional distress at the univariate level, which is consistent with the findings in international research regarding marriage and depression among women (Weissman & Klerman, 1977). However, the fact that the association between marriage and emotional distress disappeared in multivariate analysis, whereas the association with spousal violence was strengthened, suggests that marriage acted as a proxy for spousal violence, and that psychological trauma due to domestic violence was the underlying explanatory factor for the increased levels of emotional distress among married women. The lack of social networks, together with marital control, previous experiences of nonpartner violence, a history of domestic violence in either the wife's or husband's family, and abuse of children were also identified as sources of emotional distress, although when combined in a multivariate model with spousal abuse these associations were no longer significant. This indicates that although these factors are distinct, they so frequently occur within the context of physical abuse that it is not possible to measure them independently of each other in multivariate analysis. The association between former abuse and current emotional distress indicates that psychological effects of violence may last long after the physical abuse has ended. In this regard, severity of abuse appears to be the best predictor of emotional distress. This is consistent with the conceptualization of the battered women syndrome as a result of traumatic victimization (Walker, 1994). However, it should be noted that severe physical violence was closely linked to increased emotional and sexual abuse, including controlling behavior (Ellsberg, 1997). In this sense, severe violence is likely to represent not only physical abuse but psychological and sexual abuse as well. Due to the cross-sectional nature of the study, it is not possible to infer causality in the relation between domestic violence and emotional distress. One interpretation of the findings could be that battered women are more likely to have emotional problems that precede the violent incident. However, research into the psychosocial profiles of battered and nonbattered women prior to the first reported episode of abuse indicates that battering tends to precede self-destructive behavior and psychiatric disorders, including suicidality (Stark & Flitcraft, 1996). Another possible source of error could be recall bias, in that persons suffering from depression might be more likely to disclose either greater frequency or severity of abuse than nonaffected persons. However, it is unlikely that this could account for the strength of the associations found between emotional distress and violence. January 1999 • American Psychologist

The Role of Epidemiological Research in Advocacy The preliminary results of this research were discussed extensively in Nicaragua and contributed to the public debate around the need to reform the existing Penal Code. Until recently, the Nicaraguan Penal Code, which dates back to the 19th century, did not criminalize violent acts but rather the physical injury caused by the assault. In order to be considered a criminal offense, an injury needed to be severe enough to require at least 10—15 days to heal. Because Nicaraguan law did not guarantee protection for victims of domestic violence, battered women were often reluctant to report abuse for fear of reprisals. In November 1995, the Women's Network Against Violence presented a reform bill to the National Assembly that included harsher sentences for offenders, as well as provided restraining orders to protect victims (Red de Mujeres Contra la Violencia, 1996). The preamble of the new law cited our Leon research on domestic violence in order to justify redefining the crime of injurious assault to include psychological as well as physical injuries. The Women's Network Against Violence lobbied continuously for eight months to ensure the passage of the domestic violence law and used a variety of strategies to create public support, including focus-group research, an international forum on psychological injuries, petitions, letter writing campaigns, television and radio advertisements, and direct lobbying of parliamentarians (Ellsberg et al., 1997). Largely as a result of these efforts, the law was passed unanimously and took effect in 1996. During the first years since the passage of the domestic violence law in Nicaragua, it has become evident that modifying the legal framework on domestic violence is only the first step to effective change, and transforming attitudes and practices of those involved in carrying out the law is equally essential. The next challenge is to operationalize the concept of psychological injuries and to train judges, police, and community activists so that women can use the new law effectively. Finally, efforts to incorporate routine screening and interventions for battered women within the health system, with an emphasis on women attending mental health services, are urgently needed. REFERENCES Babb, F. (1996). After the revolution: Neoliberal policy and gender in Nicaragua. Latin American Perspectives, 88, 27-48. Brown, F. W., & Harris, R. (1978). Social origins of depression: A study of psychiatric disorders in women. London: Tavistock. Bullock, L., & McFarlane, J. (1989). The battering low-birthweight connection. American Journal of Nursing, 89, 1154-1155. Caldera, J. T., Kullgren, G., Penayo, U., & Jacobsson, L. (1995). Is treatment in groups a useful alternative for psychiatry in low-income countries? An evaluation of a psychiatric outpatient unit in Nicaragua. Ada Psychiatrica Scandinavica, 92, 386-391. Culbertson, F. (1997). Depression and gender: An international review. American Psychologist, 52, 25—31. Ellsberg, M. (1997). Candies in hell: Domestic violence against women in Nicaragua. Unpublished licentiate thesis, Department of Epidemiology and Public Health, Umea University, Umea, Sweden. Ellsberg, M., Liljestrand, J., & Winkvist, A. (1997). The Nicaraguan

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