Soc Indic Res (2008) 86:497–509 DOI 10.1007/s11205-007-9182-7
Health-Related Quality of Life Among Abused Women One Year After Leaving a Violent Partner Kjersti Alsaker Æ Bente E. Moen Æ Kjell Kristoffersen
Accepted: 20 August 2007 / Published online: 6 September 2007 Springer Science+Business Media B.V. 2007
Abstract This is the first follow up study measuring quality of life among abused women who have left their abusive partner. The women (n = 22) answered a questionnaire while staying at women’s shelter and one year later. The aim was to examine long-term effects of intimate partner violence against women on health-related quality of life. Health-related quality of life was measured using the SF-36 Health Survey and the WHOQOL-BREF. The meantime for living in a violent partnership was 11 years, most of the women had children under 10 years living with them, low income and were on sickness absence or disability pension. About half of the women had experienced threats of violence and 6 had experienced violent acts after leaving their partner. SF-36 scores after one year were significantly better in vitality (t-test, P \ 0.001), mental health (t-test P \ 0.001) and social domains (t-test, P \ 0.04). WHOQOL-BREF scores did not change significantly from baseline, showing that the SF-36 showed more responsiveness in this population. Regression analysis showed that serious physical violence reported at baseline predicted significantly less improvement in physical and mental health and role-emotional in the SF-36 and in social relationships and environmental health in the WHOQOL-BREF. High psychological violence at baseline predicted significantly less improvement in mental health in the SF-36 and in social relationships and environmental health in the WHOQOLBREF. Keywords Intimate partner violence Follow-up study Quality of life after separation SF-36 WHOQOL-BREF
K. Alsaker (&) Department of Postgraduate Studies, Faculty of Health and Social Sciences, Bergen University College, Møllendalsveien 6, Bergen 5009, Norway e-mail:
[email protected] B. E. Moen K. Kristoffersen Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, Bergen 5018, Norway
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1 Introduction The most dangerous period for homicide and injuries is within the first year after separation from a violent relationship (Campbell 2002; Helweg-Larsen and Kruse 2003; Wilson and Daly 1993). In a study from Spain (Ruiz-Perez et al. 2006), the large majority of women who had experienced intimate partner violence were not passive victims of abuse but tried to solve their problem by separating from the partner. Predictors of re-victimization by ex-partners are found to be the level of prior abuse and threats, the ex-partners level of jealousy and whether he lived in the same city as the survivor (Bybee and Sullivan 2005). This risk has been described to be lower if the women are employed, report higher quality of life and have social support (Bybee and Sullivan 2005), but few have studied these issues. Intimate partner violence has been documented as a worldwide problem with great social, economic, health and individual consequences (Desjarlais et al. 1995; Watts and Zimmerman 2002). In international surveys, 10–69% of women report being physically assaulted by an intimate partner at some point in their lives (Garcia-Moreno et al. 2006; Krug et al. 2002). Intimate partner violence is defined as a systematic pattern of abusive acts showing repeated physical, psychological and sexual violence taking place over time. Various types of violence coexisting in the same relationship is often called abuse or maltreatment (Krug et al. 2002). Both female and male partners carry out intimate partner violence, also in homosexual relationships (Balsam et al. 2005). The social and cultural impact of gender roles and attitudes in intimate partner violence (Dobash and Dobash 2004; Kimmel 2000) is therefore not as clear as earlier presumed. Most studies confirm that men’s violence against women has far more serious consequences than women’s violence against men (Balsam et al. 2005; Dobash and Dobash 2004; Ehrensaft et al. 2006; Hjemmen et al. 2002; Haaland et al. 2005; Paul et al. 2006). A longitudinal study found that mental disorders pose a risk for involvement in abusive relationships among both sexes and were a source of mental disorders among women but not among men (Ehrensaft et al. 2006). A 5-year follow-up study from Sweden showed that abused women continued their hospital contact much more often than the average women at the same age (Bergman and Brismar 1991). The group of 117 battered women had both significantly more need for somatic hospital care and psychiatric care than the control group. However those were included in the study when seeking aid for acute injuries, and may only partially be representative for all battered wives in Sweden. They also had more psychosocially problems than other populations of battered women. They differ from our population of women at Norwegian women’s shelters as many of the respondents had alcoholism as a problem. Alcohol or drugs are not allowed at the shelters in Norway where our responders were collected. Despite the growing research since the international women’s movement focused on intimate partner violence against women in the early 1970s, little is known about the life situation and the risk for long-term health problems among women who leave their abusive partner (Anderson and Saunders 2003). The first women’s shelter in Scandinavia started in Oslo, Norway, in 1978. Today the 50 women’s shelters in Norway spread throughout the country are the most important community-based refuges for abused women and their children. The shelters give help and protection as long as women stay there, and some shelters also offer follow-up in conversation groups. In a national report from Norway in 2005, Amnesty International (2005) found that 95% of the local governments did not have any plan of action to prevent men’s violence against women or any intervention plan for those exposed to intimate partner violence (2005). Women exposed to intimate partner violence are more likely to suffer multiple physical health problems than women not exposed (Sutherland et al. 2002).
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Measuring quality of life (QOL) explains well-being in life as a whole based on selected items. It is often used as a generic label to describe an assortment of physical and psychological variables. Two studies show impaired QOL among women exposed to intimate partner violence (Bonomi et al. 2006; Laffaye et al. 2003), and the measure seems to be good indicator of the life situation of abused women. In our baseline study, a crosssectional study among all the women’s shelters in Norway (Alsaker et al. 2006b), we found health-related QOL (HRQOL) very low and below (P \ 0.001) the norm for the female population in Norway in all dimensions. The very low scores can have a cultural impact as the individual’s thoughts and feelings with reference to herself as abused may make her feel even more left out alone in a society where equality between men and women tends to be more common, as in Norway (Carr et al. 2001). Few researchers have focused on the mental well-being of survivors of abuse (Anderson and Saunders 2003), and no known research has focused on the relationship between abuse and long-term HRQOL outcomes. This follow-up study examined the long-term effects of intimate partner violence on HRQOL. We studied whether HRQOL among women who left their violent partner changed one year after leaving and whether the degrees of experienced serious physical and psychological violence predict the HRQOL one year after leaving a violent partner. In addition, we wanted to describe these women’s home situations, the existence of threats, acts of violence and the police protection from their violent partner.
2 Method 2.1 Participants and Procedure A cross-sectional baseline study was performed at all women’s shelters in Norway. The inclusion criteria in the study period were;understanding Norwegian and staying in the shelter for at least 1 week as a result of violence from an intimate partner. All 50 shelters agreed to participate, and 42 had residents who met the inclusion criteria in the data collection period from October 2002 to May 2003: We gave information about the project to women’s shelters through lectures about this study at a national congress meeting. We also sent an information letter to each shelter and gave one to every participant. Women who arrive at a women’s shelter often do not know where they will be living in the future, especially if they want to leave their partner. We therefore asked the participants to fill out a separate note giving us their personal identification number and permission to search for them in the National Population Registry and contact them for re-examination. We gave each participant a separate envelope with a prepaid postage stamp and the address of the principal investigator for this permission note. One year later we searched for the participants in the National Population Registry and phoned the women we found. If they still wanted to participate in the follow-up study and if it was safe, we sent a questionnaire to their home address. One woman said that she felt that receiving a mailed questionnaire would be too dangerous, so we conducted the interview by the phone.
2.2 Questionnaire Both the baseline and the follow-up study comprised questions about demographic data and HRQOL measured using the SF-36 Health Survey and the WHO Quality of Life Index—BREF (WHOQOL-BREF). In addition, in the follow-up study we asked what kind
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of help they had received from the police, health and social services and whether they had experienced threats or physical violence in the past year and from whom. Eight questions about threats and acts of physical violence, based on the types of violence which were most common experienced in the baseline study, were asked for as well. We used both the SF-36 and the WHOQOL-BREF for measuring the quality of life. The SF-36 was selected because of the strong health dimension in the SF-36 and the WHOQOL-BREF because the more psychological basis. Several studies have validated and tested for reliability the SF-36, which consists of 36 items divided into eight scales (Ware et al. 2000). The scales are physical functioning, role limitations due to physical problems, role limitations due to emotional problems, bodily pain, social functioning, vitality, mental health and general health. The raw scores for each scale range from 0 to 100, and the adjusted median scores range from 0 to 50, with lower scores reflecting poorer functioning. This study used the standard Norwegian version (Loge et al. 1998), asking about health situations in the past 4 weeks. Assessments with more than 50% data missing were discarded. Goals, expectations, standards and concerns are important in the WHOQOL-BREF (Skevington et al. 2004b). It includes 26 items in four domains (Hanestad et al. 2004; Skevington et al. 2004a): • physical health: pain and discomfort, energy and fatigue, sleep and rest, dependence on medication, mobility, activity of daily living and working capacity; • psychological health: positive feelings, negative feelings, enjoyment of life, meaningful life, concentration, body image and appearance; • social relationships: personal relationships, sexual activity and practical social support; and • environment: financial resources, information and skills, recreation and leisure activities, home environment, access to health and social care, safety in daily life, physical environment and transport. All items are rated on a five-point scale (1–5). The mean of the answered items was substituted if one or two (but not more than 20%) items were missing within a domain. We used the mean-range 4–20, and higher scores indicate better QOL.
2.3 Statistical Analyzes We examined whether the participants differed from the baseline by using a chi-square test for comparing categorical data (education, employment situation and place of residence in Norway) and t-test for age and the continuous data in the nine different categories of violence in Severity of Violence Against Women Scale (SVAWS) (Marshall 1992) and the Psychological Maltreatment of Women Index (PMWI) (Tolman 1989). The follow-up and the baseline SF-36 results were adjusted for age according to the general female population of Norway, such that the mean for the general population is 50 and 1 standard deviation (SD) is 10 (Loge et al. 1998). The changes from baseline to follow-up in scores of both the SF-36 and WHOQOL-BREF domains were examined using t-tests, and the effect sizes were also measured (follow-up score minus baseline score divided by the standard deviation at baseline). We used regression analysis to study the relationship between serious violence at baseline (SVAWS), the mean sum of psychological violence (PMWI) at baseline and the difference in HRQOL outcome. We used only one of the nine categories in SVAWS; the category serious violence. The mean sum of psychological violence was
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calculated as the mean of the 58 items with opportunity 1 as never and 5 as very frequently. We excluded participants from this analysis for whom more than 20% of the items were missing. We adjusted the results by baseline scores from the domains in the WHOQOLBREF and the SF-36. The results were adjusted by baseline scores from the different domains in WHOQOL-BREF and SF-36. The dependent variable was the change in score (follow-up score minus baseline score) in all domains. We conducted the analysis using SPSS 13.0 for Windows. We set the significance level at P \ 0.05. The Regional Committee for Medical Research Ethics for Western Norway and the Norwegian Data Inspectorate approved the project. We obtained informed written and oral consent from all participants.
3 Results 3.1 Respondents and Non-respondents In the baseline study, 87 women participated and 57 volunteered for the follow-up study. We could not find three of these 57 after one year because their personal code was changed in Norway’s National Population Registry; probably because they were on protection (code 6), which mean that their address was classified as strongly confidential so that neither private nor public authorities have access to their address. Another three had not given their complete personal code in the note, so we did not find them. Twenty did not have a phone or did not answer the phone. One did not want to participate. Thirty agreed to participate. However, we received 2 unanswered questionnaires, and 4 had put in an unknown code for identification and had to be excluded from the study. Of the remaining 24 participants, 2 had not left their partner, leaving 22 participants for this follow-up study. The respondents (n = 22) and the non-respondents (n = 63) did not differ significantly in; place of residence, age, employment, experiences of physical or psychological violence and QOL measured by SF-36 and WHOQOL-Bref measured at baseline.
3.2 Life Situation The 22 women had left a shelter 11 months (median 11, SD = 3.5) previously and had been in the violent partnership 11 years (median 8, SD = 9.1). Their mean age was 40 years (range 19–64). Most of the mothers had children 0–10 years old, and 15 of 22 had children living with them. Five had paid work and 16 had sickness absence from work or received disability pension. Three were under education, and some of these had both paid work and education or paid work and disability pension. Most had low income; only two earned more than NOK 300,000 (about €37,500) a year. Most had a temporary residence; only two had their own dwelling. Most rented small flats 10–70 m2. Six had living space of more than 80 m2.
3.3 Protection and Help The police had offered 12 of the 22 women a restraining order for visits by the partner; seven had accepted. Nine had been offered a security alarm, and five still had this one-year after leaving their partner. Fourteen had received help from the health services and most of them from a psychologist.
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3.4 Violence Twelve of the 22 women had experienced some threat of violence in the past year, and most of these were from their previous partner. A new partner threatened two women, and a son threatened one woman. The threats for more than half these participants were related to being hurt, killed or having the children taken away from them. Six of 22 had experienced serious acts of violence after they had left their partner, such as beating (3), strangulation (5), forced to have sexual intercourse against their will (4) and violence to their head (3) (Table 1).
3.5 Change in the Quality of Life All the QOL domains of the SF-36 except vitality were still significantly lower than the female population in Norway at the same age one year after leaving a violent partner (Fig. 1). The QOL measured using the SF-36 improved significantly in three of eight domains, whereas none of the four domains in WHOQOL-BREF changed significantly compared with baseline results (Table 2). The effect sizes in mental health and vitality in the SF-36 were especially high (Table 2).
3.6 Physical Violence Predicting Change in the Quality of Life The regression analysis (Table 3) showed that high serious violence reported at baseline predicted significantly less improvement in the WHOQOL-BREF in social relationship and environmental health domains. Further, high physical violence predicted significantly higher change on the SF-36 physical functioning subscale but significantly less improvement in the role–emotional and the mental health subscales. Table 1 Experiences of threats and acts of violence among the abused women in the past year after leaving their partner Yes (n)
No (n)
Threats to hurt you
10
12
Threats to kill you
8
12
Threats to hurt your children or others for whom you care
3
17
Threats of violence
Threats to take the children away from you
7
7
12
9
Acts of violence
6
16
Violence against the head
3
13
Beat you up
3
13
Choked you
5
17
Forced you to have sexual intercourse against your will
4
17
Other acts of violence
3
16
Other threats Acts of violence
Some of the questions had missing values
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Fig. 1 Mean age-standardized (The mean score of the general female population of Norway is 50, and the standard deviation is 10 for all scales) score and 95% confidence interval (CI) for the eight SF-36 dimensions among abused women at baseline (baseline score) and 1 year after leaving their violent partners. (score 1 year after leaving a violent partner) PH: physical health. RP: role–physical. BP: bodily pain. GH: general health. VT: vitality. SF: social functioning. RE: role–emotional. MH: mental health
Table 2 Change in quality of life scores from baseline a to one year after leaving a violent a partner Instruments and scoring range
Baseline (n = 87)
WHOQOL-BREF Mean range 4-20 Mean values
SD
One year after (n = 22) Mean SD values
95% confidence P interval
Effect size
Physical domain
11.6
2.3
11.4
3.0 –0.88–1.2
0.77
–0.1
Psychological domain
11.1
2.4
11.9
3.1 –2.2–0.7
0.27
0.3
Social domain
13.2
3.4
12.9
3.2 –1.3–1.7
0.78
–0.1
Environmental domain
12.7
2.3
12.7
2.4 –1.07–1.0
0.94
0
0.1
SF-36 adjusted score mean range 0–50 Physical health
40.4
11.2
41.2
10.9 –4.9–3.1
0.65
Role–physical
35.3
8.7
37.2
10.7 –6.8–3.0
0.43
0.2
Bodily pain
38.4
11.5
37.6
14.0 –3.0–4.5
0.65
–0.1
General health
39.8
12.2
38.4
4.8 –4.0–6.8
0.59
–0.1
Vitality
34.2
9.5
48.4
4.7 –19.1–9.3
0.001 1.5
Social functioning
27.6
15.7
35.9
3.8 –16.2–0.4
0.04
0.5
Role–emotional
29.0
8.3
29.9
0.74
0.1
Mental health
19.7
10.9
39.1
a
10.8 –6.7–4.8 6.8 –24.8–14.1
0.001 1.8
One week after arriving a women’s shelter in Norway
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Table 3 Regression analysis of the relationship between SF-36 and WHOQOL-BREF scores and experiences of serious violencea Change scores in quality of life
WHOQOL-BREF baseline
Mean serious violence
Adjusted R2
Domains WHOQOL-BREF
Standard beta
P
Standard beta
Physical health
–0.170
0.48
–0.048
P 0.84
0%
Psychological
–0.464
\0.03
–0.286
0.15
19%
Social relationship
–0.545
\0.01
–0.443
\0.01
47%
Environmental health
–0.395
\0.02
–0.545
\0.003
44%
SF-36 domains—SF-36 baseline Physical health
–0.020
0.94
0.605
\0.03
32%
Role–physical
–0.132
0.60
0.462
0.07
24%
Bodily pain
0.236
0.55
0.306
0.43
0%
General health
–0.940
\0.001
–0.068
0.47
84%
Vitality
–0.901
\0.001
–0.113
0.30
80%
Social function
–0.983
\0.001
0.032
0.56
95%
Role–emotional
–0.666
\0.001
–0.391
\0.04
40%
Mental health
–0.815
\0.001
–0.304
\0.03
72%
a
Serious violence = mean score of the category serious violence in SVAWS
Table 4 Regression analysis of the relationship between SF-36 and WHOQOL-BREF scores and experiences of psychological violencea Change scores in quality of life
WHOQOL-BREF baseline
Mean serious violence
Adjusted R2
Domains WHOQOL-BREF
Standard beta
P
Standard beta
Physical health
–0.156
0.49
–0.184
P 0.42
0
Psychological
–0.431
\0.04
–0.229
0.25
16%
Social relationship
–0.426
\0.01
–0.529
\0.003
47%
Environmental health
–0.410
\0.03
–0.446
\0.02
34%
SF-36 domains—SF-36 baseline Physical health
–0.362
0.15
–0.146
0.55
12%
Role–physical
–0.597
\0.01
–0.401
0.07
25%
Bodily pain
–0.044
0.92
–0.051
0.90
0
General health
–0.940
\0.001
–0.062
0.51
84%
Vitality
–0.900
\0.001
–0.962
0.35
80%
Social functioning
–0.978
\0.001
–0.294
0.77
95%
Role–emotional
–0.570
\0.005
–0.277
0.14
32%
Mental health
–0.083
\0.001
–0.033
\0.02
74%
a
Psychological violence = mean score on all items in PMWI
3.7 Psychological Maltreatment Predicting Change in the Quality of Life The regression analysis (Table 4) showed that high psychological violence reported at baseline predicted significantly less improvement in the mental health domain in the SF-36 and in the WHOQOL-BREF social relationship and environmental health domains.
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4 Discussion The baseline study found clinically significantly low scores in both the SF-36 and the WHOQOL-BREF (Alsaker et al. 2006b). The significant changes in the follow-up study in mental health, vitality and social functioning in the SF-36 one-year after arriving at a women’s shelter show that leaving their abusive partner improved these women’s quality of life. The degree of violence reported at baseline predicted some changes. Those who reported the most serious physical and psychological abuse at baseline also reported significantly less improvement in some QOL domains in both the SF-36 and the WHOQOLBREF. Few follow-up studies have been performed on women staying at a women’s shelter. In one such study from Michigan 141 women were interviewed immediately after shelter exit, 10 weeks after, and then after 6 and 12-month follow-up intervals. After a 6-months they found that those who had reported higher rates of abuse also reported higher levels of stress, depression and physical health problems than those who had reported lower rates of abuse (Sutherland et al. 1998). A 5-year follow-up study of 117 battered women from a hospital emergency department in Sweden (Bergman and Brismar 1991) found more frequent need for somatic and mental health care among battered women than among the general population of non-abused women. None of these studies distinguished between abused women who stayed with their abusive partner and those who left. This creates difficulty in comparing these studies with our study. Another follow-up study from South Australia (Mertin and Mohr 2001) analyzed 100 women when they arrived at a women’s shelter and 59 of these 12 months later. One year later, anxiety and depression declined significantly and the incidence of post-traumatic stress disorders was lower than at baseline. Another American study that focused of changes in depression among 129 women staying at a women’s shelter over a 6 month period (Campbell et al. 1995) distinguished between those who had left the partner and those who had not found that depression declined significantly more among those who had left the partner. This is in accordance with our findings. The possibility to recover after leaving a violent partner may be affected by the culture acceptability of domestic violence in general. In a study within 15 countries in EU, Gracia and Herrero found that there are still widespread attitudes such as blaming the victim for the violence (Gracia and Herrero 2005). The individual’s thoughts and feelings with reference to herself as abused may make her feel even more left out alone in a society where equality between men and women tends to be more common, as in Norway (Carr et al. 2001). Our study participants had left their violent partners, but many still experienced threats of violence and acts of violence in the past year. Few of the women in our study had a security alarm or a restraining order from the police on visits by the partner one year after leaving the violent partner. The reasons for this may include that the women had to reapply for this protection after 3 months or that they did not need one. Other studies also found experience of threats and acts of violence among women after they had left a violent partner (Bybee and Sullivan 2005; Ekbrand 2006; Sullivan et al. 1994; Wilson and Daly 1993). In a sample from of 124 women in USA who had sought refuge in a battered women’s shelter 3 years earlier, 19% had been assaulted by ex-partner or current partner at least once 2 and 3 years after the shelter exit (Bybee and Sullivan 2005). The follow-up study (Mertin and Mohr 2001) from South Australia found that safety and the presence of social support were the most important factors for recovery from depression and anxiety. Physical and mental safety and security are prerequisites for any other form of intervention among women and children exposed to intimate partner violence according to Stover’s
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review of many studies in the United States the past 20 years (Stover 2005). In a telephone interview among 3429 women in USA those 1591 who reported any IPV in their adult lifetime were divided into four exposure groups according to how recent they had experienced IPV. Those who had experienced physical and sexual IPV the last 5 years had quality of life scores (SF-36) roughly half a standard deviation lower than women with no IPV. Those who had experienced remote IPV had higher quality of life scores than those who had recent experiences of IPV, but lower than those who had not experienced any IPV (Bonomi 2006). Longer duration of IPV was associated with worse health. The mean time for staying in abusive relationship in our study was 11 years, and the SF-36 results were also lower than found in Bonomi’s study. In our follow—up study all SF-36 domains except vitality were more than one standard deviation below the general female population in Norway at the same age. Only 40% of the participants in our baseline study were employed. Even more women were unemployed in the follow-up study. Tolman & Wang (Tolman and Wang 2005) showed that intimate partner violence significantly affected women’s work activities in USA. Compared with women with the same mental and physical status, intimate partner violence alone reduced their work time by 137 h per year. A 3-year follow-up study among women from a domestic violence shelter in Michigan (Bybee and Sullivan 2005) found that women who did not have a supportive social network or lacked financial resources were more vulnerable to being physical assaulted than were women with stronger social support and socioeconomic status. Being employed protects against further violence and is important for the QOL. Other studies confirmed (Hjemmen et al. 2002; Jonassen 2004; Tolman and Wang 2005) the low incomes we found among most women. Women’s income was the best predictor of women leaving their abusive partner (Anderson and Saunders 2003), and issues concerning jobs and children are important (Tutty 1998). Abused women’s energy is almost totally absorbed in practical concerns such as securing permanent housing for them and their children and financial support (Anderson and Saunders 2003) after leaving a violent relationship. Intrusion in the partner relationships and isolation are common acts in psychological abuse. Most of the women in this follow-up study had children staying with them. Intrusion is also the key problem for a family’s health promotion after leaving an abusive partner. Ex-partners often control the women through the children many years after separation (Wuest et al. 2003). The QOL scores measured by WHOQOL-BREF did not change significantly 1 year after the baseline measurement, as the SF-36 did. This shows that the SF-36 had the best responsiveness in this population (Fayers and Machin 2000). The SF-36 correlated better than the WHOQOL-BREF with physical and psychological intimate partner violence in this population in the baseline study as well (Alsaker et al. 2006a). Many ethical and safety considerations apply to obtaining information from battered women for research purposes. A partner or ex-partner seriously threatens the lives of these respondents, and researchers must pay attention to this in the research planning and give this priority in data collection (Sullivan and Cain 2004). This follow-up study had few participants; one reason was the population’s special situation, providing limited possibilities for contact. In the follow-up study in Australia mentioned earlier, 59 participants of the 100 at baseline participated, and those who were unavailable for follow-up believed significantly more than the others that their spouse or partner could kill them (Mertin and Mohr 2001). Follow-up studies (Elliott et al. 2002) that have higher response rates (85– 93%) have offered payment for participating and/or intervention programmes and collected
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the participants in the same community or from the same shelter. Our follow-up study had participants from women’s shelters across the whole country. The low participation rate, however, does not have the same implications in the follow-up study as in the crosssectional baseline survey. As the respondents in our follow-up study did not differ significantly from the participants in the baseline study (who were women who have stayed one week at women’s shelters in Norway) in any way, we can assume that the results can be generalized to these baseline participants. But the results might not be generalized to the population of abused women in general. Because of the few participants in this follow-up study it may be considered as a pilot study for future a more extensive study.
5 Conclusion The women at women’s shelters in Norway who had left their abusive partners improved their QOL measured using the SF-36 one-year after leaving the perpetrator. However, the QOL scores were still low compared with the general Norwegian female population. A high degree of serious physical and psychological violence reported at baseline predicted significantly less improvement in some of the SF-36 and the WHOQOL-BREF domains. Together all these findings show the need for preventing violence and supporting abused women also after they have left their violent partner.
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