Research Articles

Intimate Partner Violence

Prevalence, Types, and Chronicity in Adult Women
Robert S. Thompson, MD, Amy E. Bonomi, PhD, MPH, Melissa Anderson, MS, Robert J. Reid, MD, PhD, Jane A. Dimer, MD, David Carrell, PhD, Frederick P. Rivara, MD, MPH Background: Most intimate partner violence (IPV) prevalence studies do not examine the relationships between IPV types and the chronicity and severity of abuse. Objectives: Design: Delineate prevalence, chronicity, and severity of IPV among adult women. Retrospective cohort study conducted by telephone survey. Data were collected in 2003 to 2005 and analyzed contemporaneously.

Participants: English-speaking women (n 3568) aged 18 to 64 years enrolled in a U.S. health maintenance organization for 3 or more years. Response rate was 56.4%. Main Exposure: Results: Physical, psychological, and sexual IPV were assessed using ve questions from the Behavioral Risk Factor Surveillance Survey and ten items from the Womens Experience with Battering (WEB) scale. Most (3429) of the respondents had at least one intimate partnership as an adult. Of these, 14.7% reported IPV of any type in the past 5 years, and 45.1% of abused women experienced more than one type. Prevalence was 7.9% in the past year, while during a womans adult lifetime, it was 44.0%. Depending on IPV type, 10.7% to 21.0% were abused by more than one partner; duration was 1 year to 5 median years; while in 5% to 13% of the instances, IPV persisted for 20 years. IPV rates were higher for younger women, women with lower income and less education, single mothers, and those who had been abused as a child.

Conclusions: The high prevalence of IPV across womens lifetimes in the previous 5 years and the previous year are documented. The present investigation provides new information of IPV chronicity, severity, and the overlap of IPV types over a womans adult life span.
(Am J Prev Med 2006;30(6):447 457) 2006 American Journal of Preventive Medicine

Introduction
ntimate partner violence (IPV) is widespread, with 25% to 54% of women reporting exposure in their adult lifetime, depending on the population sampled, denitions of IPV, and data-collection methods.112 A disproportionate number of these women had been abused as children.13,14 Women experiencing IPV are at increased risk for medical and psychosocial comorbidity1526 and use more primary care, emergency, and hospital services than non-abused women.24,25,2733 Plichtas25 recent review of the relationship of IPV to womens health and the use of health services noted that most
From the Center for Health Studies (Thompson, Bonomi, Anderson, Reid, Carrell), Department of Preventive Care (Thompson, Reid), and Department of Obstetrics and Gynecology (Dimer), Group Health Cooperative; and Harborview Injury Prevention and Research Center (Rivara), and Departments of Pediatrics and Epidemiology, University of Washington (Rivara), Seattle, Washington Address correspondence and reprint requests to: Robert S. Thompson, MD, Department of Preventive Care, 1730 Minor Ave., Suite 1600, Seattle WA 98101. E-mail: thompson.rs@ghc.org. The full text of this article is available via AJPM Online at www.ajpm_online.net.

studies used short-term follow-up and did not disentangle relationships among IPV types, chronicity, and severity of abuse, and the relationship to health status, health behaviors, and overall patterns of health service utilization. The health policy implications are potentially far-reaching for a condition that is four times more common than breast cancer, spills over to the children of the family,13,14,34 39 and incurs healthcare utilization costs twice the norm.30 The present investigation provides new information on the burden of suffering imposed by different IPV types (physical, sexual, psychological), the overlap among types, the chronicity of the problem (number of abusive partners, number of occurrences, time period the abuse encompassed), and the severity during womens lifetimes. Previous exposure to physical or sexual abuse as a child is also explored.

Methods Study Setting

This study was conducted at Group Health Cooperative (GHC), a large nonprot HMO serving approximately

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slapping (one question); forced intercourse (one question); forced sexual contact that did not result in intercourse (one question); fear due to a partners anger or threats (one question); and put-downs, name calling, and controlling behavior (one question). The BRFSS questions on IPV have Study Design, Eligibility Criteria for Subjects, not been formally validated; however, versions of these quesand Data Collection tions have been used widely since the 1990s to estimate IPV In this retrospective cohort study, IPV was identied by prevalence in U.S. counties4 and states.2,8,42,46 48 telephone survey of a random sample of English-speaking The WEB scale was used to supplement the assessment of women aged 18 to 64 years who were enrolled in GHC for 3 IPV exposure, because previous studies indicate that the WEB years in the 19912001 period. In order to preserve the safety identies additional dimensions of abuse22,43 45 that may be of those presently living with an abusive partner, the mailed missed by surveys assessing specic behavioral tactics (e.g., invitation letter described the study as the Group Health BRFSS).49 The WEB assesses a womans fear and perceived Wellness Study. In the letter and subsequently by telephone loss of power and control due to her interaction with an women were told that questions about health habits, funcintimate partner. For example, one question asks women to tional status, relationships, social support, chronic conditions, rate the degree to which my partner could scare me without and domestic violence would be asked. During the follow-up laying a hand on me. WEB items were rated on a six-point phone call, after consent was obtained and recorded, women scale ranging from 1 (strongly disagree) to 6 (strongly agree). were told to say, I dont want vinyl siding and hang up if they Summary scores 20 (range: 10 to 60) were considered perceived the need to stop the interview because of fear of indicative of abuse.49 To avoid response bias, the WEB was being overheard. Study staff subsequently re-contacted them. administered before the BRFSS. Women were paid $25 to recompense their time. The survey The WEB was adapted for administration by telephone and data were collected from 2003 to 2005 using a for use in same-sex as well as heterosexual partcomputer-assisted telephone interview program.40 nerships. WEB responses for current or most The survey was piloted with 47 women to ascertain recent intimate partner rst, and then up to two time and administration ease. The nal survey, See preceding partners were assessed. based on a second pilot (n 68), took 33.1 minWomen were exposed to IPV if they reported related utes (SD 9.9) to complete: 39.6 minutes (SD any abuse type on the BRFSS and/or their WEB Commentaries 9.7) for those experiencing abuse and 28.0 minscore for any of their three most recent partners on pages 528 utes (SD 6.6) for those who were not. was 20. 550,000 members in Washington State and northern Idaho. The study was approved by GHCs Institutional Review Board (IRB).

and 530.

Denitions
Intimate partner violence was dened as physical, sexual, or psychological violence between adults who were present and/or past sexual/intimate partners in heterosexual or homosexual relationships. Intimate partners were dened as current or former spouses, nonmarital partners, or dating partners in relationships longer than 1 week. Partnerships could include relationships without sexual involvement.41

Time Periods, Number of Occurrences, and Abusive Partners

Exposure to discrete abusive events since age 18 physical, sexual, or psychological was determined with the BRFSS questions and categorized by time of occurrence (the last year, last 5 years, adult lifetime). For each abuse type, the rst and last year, the number of times, and the number of partners who did this over time were determined. For women with positive WEB scores, the rst year the respondent felt this way for longer than 1 week and the time period the feelings persisted were assessed, and prevalence estimates for the past year and past 5 years constructed.

Establishing an Intimate Partner Relationship History

To establish partnership history and to construct time periods of abuse exposure, women were asked whether they had an intimate partner since age 18, the gender and number of partners, the current status of the partnership(s), and the beginning and ending years (if ended). For operational practicality, this information was obtained for a womans three most recent partners, after which respondents were asked to estimate total adult lifetime partners. Using the three most recent partners data, relationships were determined for 98.7% of women over the last 5 years.

Chronicity of Severity of IPV

Various aspects of IPV chronicity are described: number of abusive partners, number of times a particular type of abuse occurred, and the time period encompassed. Intimate partner violence severity was assessed by asking a woman to rate her collective experience (i.e., across multiple episodes of abuse and partners) for each type of abuse using a four-point scale from 1 did not consider it violent to 4 extremely violent.50

Survey Questions and Coding

Intimate partner violence was assessed using ve questions from the Behavioral Risk Factor Surveillance Survey (BRFSS)2,4,8,42 and the ten-item Womens Experience with Battering (WEB) scale.22,43 45 The BRFSS questions assessed exposure to physical abuse such as hitting, kicking, and

History of Child Abuse or Witnessing IPV as a Child

Questions from Bensley et al.13 were used to measure exposure to physical or sexual abuse before age 18 years, age at occurrence, number of times it occurred, and whether the

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woman ever witnessed or heard physical abuse between her parents.

Table 1. Characteristics of female respondents aged 18 to 64 years Sample respondents (n 3429) Demographics Age (years) 1824 2534 3544 4554 5564 Household income $25,000 $25,000$49,999 $50,000$74,999 $75,000 Employed (at least part-time) No Yes Education High school graduate or less At least some college Race/ethnicity White African American Asian American Indian Multiracial Other Hispanic origin No Yes Number in household (mean, standard deviation) Children in home for whom respondent is guardian No Yes Currently a single parent for children <18 years No Yes Intimate partner relationship status In past, but not current Current HISTORY OF ABUSE AS A CHILD Physically abused as a child No Yes Sexually abused as a child No Yes Physically or sexually abused as a child No Yes Witnessed intimate partner violence as a child No Yes n 271 359 690 1157 952 366 912 870 1169 662 2765 429 2998 2826 87 183 119 114 93 % 7.9 10.5 20.1 33.7 27.8 11.0 27.5 26.2 35.2 19.3 80.7 12.5 87.5 82.6 2.5 5.4 3.5 3.3 2.7

Demographic Information
Sociodemographic information was obtained using questions modeled after the U.S. Census survey.51

Data Analysis
Data analysis was performed from 2003 to 2005. IPV prevalence 1 year, 5 years, and womens lifetimes was estimated. For examination of IPV types and IPV risk factors, the 5-year IPV exposure estimates were used. This period was chosen since it provides a robust and relatively current sample for risk factor information. Descriptive statistics were used to characterize the study cohort for demographic factors, history of child abuse, prevalence of IPV, and time period of occurrence, severity, and chronicity. The probability of IPV as an exponential function of the risk factors was modeled and nonlinear least squares estimation was used to obtain asymptotically unbiased estimates of the relative risk of IPV exposure. HuberWhite sandwich estimates for standard errors were used to compute 95% condence intervals (CIs) for the association between IPV and demographic risk factors and exposure to abuse as a child.

Results Sample Characteristics and Respondent Burden

Contacts were attempted for 6666 women meeting eligibility criteria for age and enrollment period. A total of 345 were excluded from the denominator because sampling error (209), death (3), being too ill (15), or language or hearing problems (118) precluded their participation. This resulted in a denominator of 6321. There were 1829 active refusals (28.9%). There were 539 passive refusals (women located but not interviewed), and 385 who could not be located after 20 phone attempts or for whom the time window for calling had expired. Employing standard procedures,52 surveys were completed on 3568 women. The resulting response rate was 56.4% (3568/6321). Of the 3568 women, 139 were excluded from the numerator later because they never had an intimate partner.49 This resulted in an analytic sample of 3429. Respondents were older than nonrespondents, with a mean age of 45.3 (standard deviation [SD] 12.5) versus 43.1 (SD 13.1) years. Women in the sample were older, of higher income levels, and more highly educated with 87.5% having at least some college compared to 51.8% for the United States and 66.2% for Washington State (Table 1). The study population was 82.6% white, compared to 75.1% for the United States and 88.3% for Washington State residents.13 Hispanic women comprised 4.1% of the sample. The mean number of household members was 2.95 (SD 1.46), slightly higher than the U.S. average
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3287 95.9 139 4.1 2.95 1.46

2281 1147 3291 137 606 2823 2936 470 2448 929 2261 1153 2785 622

66.5 33.5 96.0 4.0 17.7 82.3 86.2 13.8 72.5 27.5 66.2 33.8 81.7 18.3

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Table 2. Prevalence of IPV, by instrument of detection and time period Last 12 months Women aged 18 to 64 (n 3429) Any IPV (BRFSS or WEB ) IPV by any positive on BRFSS IPV positive on WEBa Neither (BRFSS , WEB ) BRFSS only (BRFSS , WEB ) WEB only (BRFSS , WEB ) Both (BRFSS , WEB )
a

Last 5 years n 504 401 278 2925 226 103 175 Prevalence 14.7 11.7 8.1 85.3 6.6 3.0 5.1

n 272 197 138 3157 134 75 63

Prevalence 7.9 5.8 4.0 92.1 3.9 2.2 1.8

WEB was dened as positive if the WEB summary score is 20 and the woman reported having those feelings for more than 1 week in duration. BRFSS, Behavioral Risk Factor Surveillance Survey; IPV, intimate partner violence; WEB, Womens Experience with Battering scale.

(2.59). Similar to national estimates, 33.5% of respondents lived in homes with children for whom they were responsible. Four percent were single parents; 82.3% had a current partner. Among the respondents, 13.8% and 27.5% of women reported physical or sexual abuse, respectively, as a child, with 33.8% experiencing either. Nearly one in ve respondents (18.3%) reported witnessing physical IPV as a child. Women were asked about their reactions to the survey. One third agreed or strongly agreed that they had gained something positive from completing the interview, and 87% said that they would have agreed to do the interview even if they had known in advance what it would be like for them. These responses did not differ signicantly by abuse status. Women reporting IPV found taking the survey to be more upsetting than expected compared to non-abused women (18.5% vs 3.6%, p 0.001).

tial proportion (20.4%, 103/504) experienced abuse only as measured by the WEB survey. The WEB detected a large portion (55.2%, 278/504) of all abuse (Table 2). One-year, 5-year, and adult lifetime prevalence estimates for the different IPV types delineated by the BRFSS are shown in Table 3. Forty-four percent of the women reported IPV during their adult lives, and 11.7% reported IPV in the past 5 years. The 5-year prevalence of physical abuse (physical, forced sex, and/or sexual contact) among all women was 5.1% and 10.2% for non-physical abuse (threats, anger, and/or controlling behavior). Past-year IPV was 5.8% for any IPV, 1.6% for physical/sexual abuse, and 5.1% for non-physical abuse. While these data indicate the current commonality of IPV, lifetime prevalence (44.0% for any IPV, 34.1% physical/sexual, and 35.1% nonphysical) indicates its pervasiveness over time.

Co-occurrence of Different Types of IPV Prevalence of IPV

Prevalence by the BRFSS and WEB is shown in Table 2. Over 14% of the women reported IPV of any type in the past 5 years, and 7.9% in the past year. Although most women reporting IPV in the past 5 years were positive (79.6%, 401/504) on the BRFSS questions, a substanMany women reported more than one IPV type (Table 4 and Figure 1). For example, among the 138 women (Table 4) with physical abuse (not sexual) in the past 5 years, 28 (20.3%) experienced physical abuse only, while 79.7% also experienced other types. As shown in Figure 1, of the 138 women reporting physical abuse, 84

Table 3. Prevalence of IPV by type as delineated by the BRFSS in 3429 women aged 18 to 64 years Last 12 months n Any BRFSS BRFSS Physical abuse Physical Forced sex Sexual contact Nonphysical abuse Threats/anger Controlling behavior
a b

Last 5 years n 401 176 138 45 43 350 163 307 Prevalence 11.7 5.1 4.0 1.3 1.3 10.2 4.8 9.0 n 1509 1170 1038 382 204 1212 814 1047

Adult lifetimea Prevalence 44.0 34.1 30.3 11.1 6.0 35.4 23.7 30.5

Prevalenceb 5.8 1.6 1.1 0.4 0.3 5.1 1.7 4.5

197 55 39 13 11 175 59 154

Adult lifetime is 18 to 64 years. Prevalence within categories of violence represent overlapping tactics used. BRFSS, Behavioral Risk Factor Surveillance Survey; IPV, intimate partner violence.

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Table 4. Women experiencing IPV: overlap between different types delineated by BRFSS in 3429 women aged 18 to 64 years Last 12 months (n % only this abuse 39 13 11 59 154 30.8 30.8 36.4 32.2 64.3 70.0 30.0 197) % with other abuse 69.2 69.2 63.6 67.8 35.7 Last 5 years (n % only this abuse 20.3 15.6 20.9 22.1 45.6 54.9 45.1 401) % with other abuse 79.7 84.4 79.1 77.9 54.4 Adult lifetime (n % only this abuse 18.2 10.5 10.8 7.7 17.7 33.1 66.9 1509)a % with other abuse 81.8 89.5 89.2 92.3 82.3

n Physical abuse Physical violence Forced sex Sexual contact Nonphysical abuse Threats/anger Controlling behavior One type of IPV Multiple types of IPV
a

n 138 45 43 163 307

n 1038 382 204 814 1047

Adult lifetime is ages 18 to 64 years. BRFSS, Behavioral Risk Factor Surveillance Survey; IPV, intimate partner violence; WEB, Womens Experience with Battering scale.

(60.9%) experienced a total of two to three types of IPV, and 26 (18.8%) experienced four to ve types. For the 307 women reporting controlling behavior, 140 (45.6%) experienced controlling behavior only, a notable difference from the pattern for other types, while 141 (45.9%) reported a total of two to three, and 26 (8.5%) a total of four to ve types. As womens exposure time increased, the proportion experiencing multiple types of abuse increased.

Chronicity of IPV
As shown in Table 5, 10.7% (100% 89.3% for threats/anger) to 21.0% of abused women reported abuse by two or more partners. Approximately 14% to 18% experienced 20 episodes of physical or

sexual abuse, while for fear due to a partners threats/anger and controlling behavior the percentages were 26.5% and 50%, respectively. The repetitive nature of forced sex as a form of IPV is noteworthy; 13.8% of women reported the occurrence of 20 episodes. Mean duration of IPV ranged from 3.9 years (SD 6.9) for forced sex to 8.2 years (SD 8.9) for controlling behavior, with median durations of 1 year and 5 years, respectively. From the frequency distributions of duration for different types of IPV a picture emerges of relatively brief episodes: 33% to 50% of women experienced physical, sexual, or threat forms of abuse for 1 year; however, 5% to 9% were abused for 20 years. Controlling behavior as a form of abuse follows a different pattern, with more evenly distributed occurrences and more years of abuse.

Severity of IPV
The proportion of women with IPV rating it as moderately to extremely violent was 61% for physical violence, 45% for sexual intercourse, 36% for forced sexual contact, 63% for fear due to a partners threats/anger, and 31% for controlling behavior (Table 5).

Risk Factors for IPV

With women aged 55 to 64 years as the reference group, Figure 1. Percent of women reporting single or multiple types of abuse in past 5 years. IPV, the prevalence rate ratio (RR) for any IPV in the preceding 5 intimate partner violence.
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Table 5. Adult lifetime: chronicity and severity of IPV by type in 3429 women aged 18 to 64a Physical abuse n 1038 Number Number of different abusive partners 1 2 3 3 Number of different occurrences of abuse 1 2 35 610 1120 2150 50 Years encompassed by IPVc 1 year 1 year 2 years 35 years 610 years 1115 years 1620 years 20 years Years of abuse Mean (standard deviation) Median Severity of abuse Not violent Slightly violent Moderately violent Extremely violent
a b c

Forced sexual intercourse n 382 % 86.5 9.9 2.6 1.0 32.5 14.4 21.3 9.4 7.2 6.3 8.9 44.9 8.6 8.5 11.5 9.6 7.0 4.1 5.8 n 321 34 11 7 176 46 61 28 15 26 26 201 24 23 31 36 27 7 18 % 86.1 9.1 3.0 1.9 46.6 12.2 16.1 7.4 4.0 6.9 6.9 54.8 6.5 6.3 8.5 9.8 7.4 1.9 4.9

Forced sexual contact n 204 n 158 26 10 6 53 22 51 12 27 18 19 70 18 15 31 21 17 7 17 % 79.0 13.0 5.0 3.0 26.2 10.9 25.3 5.9 13.4 8.9 9.4 35.7 9.2 7.7 15.8 10.7 8.7 3.6 8.7

Threats/ anger n 814 n 723 56 18 13 128 91 182 109 84 80 134 261 88 65 117 102 65 40 57 % 89.3 6.9 2.2 1.6 15.8 11.3 22.5 13.5 10.4 9.9 16.6 32.8 11.1 8.2 14.7 12.8 8.2 5.0 7.2

Controlling behaviorb n 1047 n 912 99 19 15 31 48 141 120 153 177 369 185 113 78 182 151 122 65 134 % 87.3 9.5 1.8 1.4 3.0 4.6 13.6 11.6 14.7 17.0 35.5 18.0 11.0 7.6 17.7 14.7 11.8 6.3 13.0

n 891 102 27 10 334 148 219 97 74 65 91 456 87 86 117 97 71 42 59

4.6 (7.2) 1 72 329 371 255 7.0 32.0 36.1 24.8

3.9 (6.9) 1 106 101 103 66 28.2 26.9 27.4 17.6

5.8 (8.2) 2 66 64 49 24 32.5 31.5 24.1 11.8

5.6 (7.5) 2 93 204 328 185 11.5 25.2 40.5 22.8

8.2 (8.9) 5 446 262 225 109 42.8 25.1 21.6 10.5

BRFSS only. Controlling behavior includes controlling behavior, put-downs, and name calling. Years encompassed by IPV computed to the nearest year, so 1 year indicates a period of BRFSS, Behavioral Risk Factor Surveillance Survey; IPV, intimate partner violence.

12 months.

years decreased with older age groups of women (Table 6). The same pattern was maintained across more specic types (e.g., physical) of abuse. An exception to the general pattern was seen in women aged 25 to 34 years, where generally lower rates were delineated except for physical abuse. The RRs in the group aged 18 to 24 years were the highest across all IPV types, ranging from 3.51 for positive WEB scores to 16.29 for physical abuse (BRFSS). Intimate partner violence risk was higher for women with lower income (Table 7). For example, the RR for any form of abuse (last column in Table 7) in the $25,000 income group was 2.54-fold that of women with income $75,000, a trend consistent across all IPV types. Race/ethnicity was generally not associated with IPV risk. Low educational achievement (high school or less) was associated with a 1.3 to 1.6 RR for non-physical or physical abuse (BRFSS). Having a child in the home was not associated with IPV. Single parents of children
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aged 18 years were at higher risk (RRs 2.57 to 3.87) for all IPV types. Exposure to any form of abuse as a child or witnessing IPV as a child was uniformly associated with increased IPV risk as an adult (RRs range from 1.55 to 3.02).

Discussion
The present investigation focusing on intimate partner violence prevalence in a cohort of insured, employed, educated, English-speaking, U.S. women provides new knowledge on the high prevalence, several dimensions of chronicity, severity, and the interrelatedness of IPV types. It is the rst study to document IPV across womens lifetimes, in the past 5 years, and past year using the BRFSS and the WEB. The pervasiveness of IPV previously documented in the United States is attested to by the 44% percent of women reporting any IPV in their adult lifetime (34.1% physical/sexual and 35.4% non-physical). The results
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Reference group. BRFSS, Behavioral Risk Factor Surveillance Survey; CI, condence interval; IPV, intimate partner violence; RR, prevalence rate ratio; WEB, Womens Experience with Battering scale.

WEB

95% CI

2.415.12 1.152.72 1.352.75 1.012.01

of the present investigation are generally congruent with and add to the emerging literature on the prevalence of IPV.112 The ndings on non-physical abuse help to ll in this picture.33,53,54 The linkages of nonphysical IPV to health status, and health outcomes are beginning to emerge, as Coker et al.55 have reported that women experiencing psychological abuse only (positive on the WEB only and negative on physical abuse measures) reported a wide range of physical symptoms and diagnoses similar in magnitude to those for people positive for physical abuse only. Thus, it appears that the impacts of non-physical abuse are measurable and signicant. Findings on IPV chronicity and overlap between IPV types were striking: approximately 15% of abused women were abused by two or more partners, 14% to 53% of women with IPV experienced 20 or more occurrences, and the years in an adult womans life encompassed by IPV ranged from a mean of 3.9 to 8.2, while the medians were less than 1 year to 5 years. Fully 45% of women with any IPV in the last 5 years experienced multiple types. Approximately 33% to 50% of women with IPV experience a single episode or brief period of physical abuse or threats, while for 5% to 9% it encompassed more than 20 years. This nding of a 1.55- to 3.02-fold increased risk for IPV for those women experiencing physical or sexual abuse as a child or observing IPV between adults adds to the literature13,14,32,34 39 linking child abuse with a propensity for IPV as adults. The ndings that younger age, lower income, and single parent status are associated with higher risk for IPV are similar to those from a multistate analysis of BRFSS data.47

Nonphysical BRFSS

95% CI RR % 95% CI RR % 95% CI RR %

Physical BRFSS

Any IPV (BRFSS or WEB )

29.9 16.2 17.5 14.1 8.5 14.7

3.51 1.90 2.06 1.66 1.00

2.664.63 1.392.60 1.582.68 1.292.13

18.8 6.7 6.2 4.1 1.2 5.1

16.29 5.79 5.39 3.52 1.00

8.6130.81 2.8611.69 2.8010.38 1.836.74

21.0 11.4 12.5 9.9 5.4 10.2

3.93 2.13 2.33 1.86 1.00

2.765.59 1.443.16 1.673.24 1.352.55

RR

3.51 1.77 1.93 1.42 1.00

Limitations
One study limitation is the relatively low response rate (56.4%). New Health Insurance Portability and Accountability Act rules in the United States may have led to concern on the part of potential interviewees about privacy issues and about access to medical records, points that have been noted by others.56 It should be noted that GHCs IRB prevented the authors from accessing any information on nonrespondents besides their age and years of enrollment. The study response rate must be viewed against a background of declining rates over recent years in population surveys and cohort studies.57 Published response rates on population surveys for IPV have ranged from a high of 77%49 to a low of 12%,24 while Bensley et al.13 in our home state of Washington reported response rates for state BRFSS surveys on IPV of 61% (1999) and 54% (2001), quite similar to two other very recent reports.58,59 This response rate may have led to an under- or over-reporting bias, but it is about what one could reasonably expect in a large-scale population-based survey on IPV.
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Table 6. IPV prevalence by age strata in previous 5 years

% Any BRFSS 95% CI RR % Age (years) n

1824 2534 3544 4554 5564a Total

271 359 690 1157 952 3429

27.3 12.8 14.2 11.1 5.8 11.7

4.73 2.22 2.46 1.91 1.00

3.436.52 1.533.22 1.793.37 1.412.60

17.7 8.9 9.7 7.2 5.0 8.1

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454 American Journal of Preventive Medicine, Volume 30, Number 6 www.ajpm-online.net Table 7. Relationship between demographic characteristics or history of child abuse and IPV (previous 5 years) BRFSS nonphysical Demographic factors Household income $25,000 $25,000$49,999 $50,000$74,999 $75,000 Race/ethnicity Caucasian African American Asian/Pacic Islander American Indian Multiracial Otherb Not employed Education: high school graduate or less One or more children in the home for whom respondent is guardian Respondent is currently a single parent for children aged <18 years History of abuse as a child Physically abused as a child Sexually abused as a child Physically or sexually abused as a child Witnessed IPV as a child
b

BRFSS physical RR 3.78 3.24 1.55 1.00 1.00 1.28 0.56 1.24 1.45 2.44 0.96 1.63 1.21 3.87 3.04 1.87 2.57 2.05 95% CI 2.306.23 2.055.14 0.912.66 0.592.76 0.251.24 0.602.54 0.872.44 1.444.13 0.671.37 1.172.27 0.911.61 2.715.51 2.274.06 1.382.53 1.943.41 1.522.76 RR 2.57 2.01 1.47 1.00 1.00 1.21 0.71 0.96 1.24 1.42 0.92 1.30 1.12 2.57 2.20 1.70 2.14 1.71

BRFSS any 95% CI 1.933.44 1.552.61 1.111.96 0.732.00 0.451.13 0.571.61 0.851.83 0.912.23 0.721.16 1.021.64 0.931.35 1.973.34 1.812.68 1.412.06 1.792.56 1.402.08 RR 3.92 3.11 1.74 1.00 1.00 1.35 0.66 1.36 0.83 1.27 0.73 1.32 0.98 3.67 2.41 1.57 2.16 1.54

WEB 95% CI 2.685.73 2.214.38 1.182.57 0.752.43 0.371.19 0.812.30 0.461.52 0.702.31 0.531.01 0.981.77 0.781.24 2.754.89 1.893.08 1.241.99 1.722.70 1.191.99

Any WEB or BRFSS RR 2.54 2.14 1.46 1.00 1.00 1.18 0.71 0.98 1.17 1.20 0.87 1.23 1.06 2.72 2.19 1.64 2.06 1.57 95% CI 1.963.30 1.702.69 1.131.88 0.761.85 0.471.06 0.631.53 0.821.67 0.781.85 0.701.08 1.001.52 0.891.24 2.193.37 1.852.60 1.391.93 1.762.41 1.311.87

RRa 2.67 1.97 1.51 1.00 1.00 1.27 0.66 0.92 0.90 1.43 0.94 1.30 1.10 2.63 2.27 1.73 2.21 1.60

95% CI 1.953.66 1.492.62 1.112.05 0.752.15 0.391.10 0.521.62 0.541.49 0.882.32 0.731.21 1.011.69 0.901.35 1.973.52 1.842.82 1.412.13 1.822.69 1.292.00

Other race examples: human, Heinz 57, Cajun, Celtic, Middle Eastern. a All RRs adjusted for age only. BRFSS, Behavioral Risk Factor Surveillance Survey; CI, condence interval; IPV, intimate partner violence; RR, Prevalence rate ratio; WEB, Womens Experience with Battering scale.

The requirement that women be insured by GHC for at least 3 years during the 19912001 period, while helpful for forthcoming utilization studies, resulted in a selection bias here. In a sample (N 118) of women enrolled for less than 3 years who did not differ from the main study sample by demographic characteristics, the prevalence of any IPV was 25% higher than the main study sample. Therefore, these prevalence estimates are conservative. The adaptations of the WEB for this study have not been formally validated. The clustering of generally higher responses for IPV duration at 3 to 5 years in the frequency distributions by IPV type implies that some recall bias may be present in the data. While the sociodemographic characteristics of the study cohort may temper generalizability for some, the ndings are important in helping to establish that prevalence is very high in educated, employed U.S. women with healthcare coverage, which indicates that IPV is a problem for the entire population, not just certain subgroups. The results are associational, as causal inferences cannot be drawn from observational study designs. This study has important implications for healthcare providers and policymakers. From the present work, a picture emerges of both physical and non-physical IPV as very common, chronic, intergenerational, and present in highly overlapping forms. These data, coupled with information on its association with deaths,25,60 multiple forms of medical morbidity,1523 and increased medical care utilization and costs,2731 constitute cause enough to mount and evaluate major interventional best-practice efforts for IPV in day-today medical practice as has been proposed.23,61 63 These efforts should employ universal routine questioning in health history questionnaires (too many risk factors to do otherwise) by computer64 or paper65,66 along with links to institutional or community resources, so that the practitioners fear of opening Pandoras box67 is adequately addressed. Concerns about the potential negative effects of asking about IPV are quite overblown in our opinion. The present work suggests that women want to answer questions about IPV. Furthermore, we aver that the risks of not asking about a major underlying condition that affects nearly half of womens lives are far greater than the risk of asking. We ask the reader to consider, if there were a major risk factor for coronary heart disease that affected approximately 50% of the adult population, would you not want to know about it? As a clinician, of course you would! Rigorous program evaluation with longitudinal follow-up must be integral to major initiatives for IPV identication and management in medical care. We and others have advocated for this in the past.25,68,69 The American Medical Associations National Advisory Council on Violence and Abuse is pushing ahead with a policy initiative (Resolution 438:A-04) promoting
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these goals. In conclusion, a cause of major morbidity and mortality, which is fourfold more common than breast cancer, cannot be ignored.
We would like to thank Cynthia Sisk, Louis Grothaus, Julia Anderson, Tara Beatty, Eve Adams, Marcella Clement, Gwendolyn Davis, Scharisha Johnson, and the Survey Program of the Center for Health Studies, Group Health Cooperative; Jacqueline Campbell of The Johns Hopkins University; Brigid McCaw of Northern California Kaiser Permanente; Louise Ann McNutt of the State University of New York-Albany; Linda Saltzman of the Centers for Disease Control and Prevention; Lillian Bensley, Washington State Health Department, Ofce of Epidemiology; and Diane Gordon and Ward Hinds of the Snohomish County Washington Health Department. This study was funded by the Agency for Health Research and Quality (grant R01 HS10909). Other than oversight, the agency played no further role in the research performed. No nancial conict of interest was reported by the authors of this paper.

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